CME INDIA Case Presentation by Dr Prattay Guha Sarkar, DM, Cardiology, Assistant Professor of Cardiology at Rajendra Institute of Medical Sciences (RIMS), Ranchi.
CME INDIA Case Study
- 65year aged, BMI-32, female, presented with complains of occipital headache, giddiness, no LOC
- At admission BP was 210/100
- She was admitted in ICU and started on antihpertensive medications
- Gradually her medications were escalated
- In spite of all these medications BP continued to be high
- Home 180/100
- Office 200/110
- ABPM 24 hr 180/110
- ABPM Night 170/90
- HB 12.1, UREA 43, CREAT 1.3, NA 133, K 4.1, TSH 3.1, URINE VMA Normal, LFT Normal
- Bilateral renal arteries Normal
- Calculated eGFR 60 ML/MIN/M2
- Telmisartan 80
- Cilnidipine 20
- Eplerenone 25
- Torsemide 40
- Metoprolol 100
- Clonidine 0.3
- Minoxidil 10
- Metolazone 2.5
48 hours Holter evaluation did not reveal complete heart block or av dissociation during giddiness
She was asked to monitor k, every 3 days as gfr was 60 and she was being given telmisartan 80 + eplerenone 25
2 weeks later she comes back with SOB and LOC
- BP 210/100
- PR 30 / MIN
- K 6.9
- UREA 52, CREAT 1.4
- Potassium correction given
- She was put on temporary pacing
- Rhythm did not improve on day 2
- Urine out was >100ml/hr
- K on day 2 4.2
- Dual chamber pacemaker implanted
Now, what is the twist in this case, why BP not being controlled, even after optimal use of multiple anti-hypertensives?
History solved the mystery…
History reassess from partner H/O Day Time Somnolence or Snoring or Apneic Spells during sleep sought.
What it reveals?
- All denied, but we went ahead with sleep study in view of refractory hypertension
- In house sleep study revealed severe OSA (Obstructive Sleep Apnea)
- Spo2 as low as 75% was documented
- She was started cpap @ 12 cm h20
- 1 month later we stated tapering meds after BP got better controlled
- At 2 months, she was controlled on telmisartan 80 chlorthalidone 12.5
- She continues to be on permanent pacemaker
Summary of the Case:
CME INDIA Learning Points:
- Obstructive sleep apnea (OSA) is a prevalent sleep disorder as is hypertension (HTN) in the 21st century with the rising incidence of obesity.
- The severity of obstructive sleep apnea syndrome (OSAS) is classified based on the apnea-hypopnea index (number of apneic/hypopneic episodes per hour): 5–15, mild; 15–30, moderate; 30 or more, severe.
- Numerous studies have shown a strong association of OSA with cardiovascular morbidity and mortality. There is overwhelming evidence supporting the relationship between OSA and hypertension (HTN).
- The pathophysiology of HTN in OSA is complex and dependent on various factors such as sympathetic tone, renin-angiotensin-aldosterone system, endothelial dysfunction, and altered baroreceptor reflexes.
- The treatment of OSA is multifactorial ranging from CPAP to oral appliances to lifestyle modifications to antihypertensive drugs.
- OSA and HTN both need prompt diagnosis and treatment to help address the growing cardiovascular morbidity and mortality due to these two entities. (Volume 2017 |Article ID 1848375 | https://doi.org/10.1155/2017/1848375)
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Obstructive sleep apnea is underdiagnosed cause of resistant hypertension. It is very much prevalant in CKD patients..
A very nice case, properly worked up..an eye opener..
Excellent case summary
Most of us in practice neglect OSA evaluation which has serious implications on overall morbidity of a given patient
The case again proves that “history taking” is most important in our practice
The wonderful article dealing with OSA and Resistant
Hypertension.Every case of Resistant Hypertension must be assessed for OSA and be treated accordingly.
Signifies the significance of other corrective conditions causing hypertension resistance.
I wonder why phaeochromocytoma was not considered?
please read pont no 6 in the section “Furthur Course”. Pheochromocytoma was considered and excluded. 24 hr urine VMA was normal.