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)
Discover CME INDIA:
- Explore CME INDIA Repository
- Examine CME INDIA Case Study
- Read History Today in Medicine
- Register for Future CMEs