# Clinical Cases: Hypertension and Cardiovascular Risk

## Case 1: New Diagnosis of Hypertension

### Patient Demographics
- **Age:** 45 years old
- **Sex:** Male
- **Occupation:** Software engineer

### Chief Complaint
"My blood pressure was high at the company health screening. They said I need to see a doctor."

### History of Present Illness
Mr. David Chen is a 45-year-old man who presents after a workplace health screening revealed blood pressure of 156/98 mmHg. He has never been told he has high blood pressure before but admits he rarely sees doctors. He denies headaches, visual changes, chest pain, or shortness of breath. He reports occasional stress-related headaches that resolve with acetaminophen. He drinks 3-4 cups of coffee daily and admits to a high-sodium diet with frequent restaurant meals.

### Past Medical History
- No known medical conditions
- No prior surgeries
- Last physician visit: 5 years ago for a sinus infection

### Family History
- Father: Hypertension, had stroke at age 62, survived
- Mother: Hypertension, type 2 diabetes
- Brother: Hypertension, age 48

### Social History
- Never smoker
- Alcohol: 2-3 beers on weekends
- Married with two children
- Sedentary lifestyle, sits at desk 10+ hours daily
- High work stress, often works late

### Physical Examination
- **Vital Signs:** BP 152/96 mmHg (right arm), 148/94 mmHg (left arm), HR 78, BMI 29
- **General:** Well-appearing, mildly overweight
- **HEENT:** Fundoscopic exam normal, no AV nicking or hemorrhages
- **Neck:** No carotid bruits, no thyromegaly
- **Cardiovascular:** Regular rate and rhythm, no murmurs, PMI not displaced
- **Lungs:** Clear bilaterally
- **Abdomen:** Soft, no bruits
- **Extremities:** No edema, normal pulses

### Clinical Image
![Blood pressure measurement](case_01_image.jpg)

*Image: Proper blood pressure measurement using a sphygmomanometer and stethoscope, demonstrating the auscultatory technique essential for accurate diagnosis and monitoring of hypertension.*

**Image Source:** Wikimedia Commons
**Attribution:** Steven Fruitsmaak, CC BY-SA 3.0
**URL:** https://commons.wikimedia.org/wiki/File:Sphygmomanometer%26Stethoscope.jpg

### Outpatient Workup
- Office BP measurements (3 readings, averaged): 150/94 mmHg
- Home BP monitoring diary (2 weeks): Average 146/92 mmHg
- Basic metabolic panel: Normal (Creatinine 1.0, K+ 4.2)
- Fasting lipid panel: Total cholesterol 228, LDL 148, HDL 42, Triglycerides 190
- Fasting glucose: 108 mg/dL
- Urinalysis: No protein
- ECG: Normal sinus rhythm, no LVH

### Assessment and Diagnosis
1. **Stage 2 hypertension** - BP consistently ≥140/90 mmHg on home monitoring
2. **Hyperlipidemia** - Elevated LDL, low HDL
3. **Prediabetes** - Fasting glucose 100-125 mg/dL
4. **Overweight** - BMI 29
5. **High cardiovascular risk** - 10-year ASCVD risk 8.2%

### Management Plan

**Blood Pressure Confirmation:**
- Home BP monitoring confirmed elevated readings
- Stage 2 hypertension warrants pharmacotherapy plus lifestyle modifications

**Pharmacotherapy:**
- Start lisinopril 10mg daily
  - ACE inhibitor chosen given prediabetes (renal protection potential)
  - Alternative: ARB if ACE-I cough develops
- Recheck BP and potassium/creatinine in 2-4 weeks
- Goal BP: <130/80 mmHg

**Lifestyle Modifications:**
- DASH diet counseling (rich in fruits, vegetables, whole grains, low-fat dairy)
- Sodium restriction <2300 mg/day (ideally <1500 mg)
- Reduce caffeine intake
- Regular aerobic exercise: 30 minutes most days, 150 minutes/week
- Weight loss: Target 5-10% body weight
- Limit alcohol to ≤2 drinks/day
- Stress management techniques

**For Hyperlipidemia:**
- Calculate 10-year ASCVD risk: 8.2% (intermediate risk)
- Discuss moderate-intensity statin therapy (atorvastatin 20mg)
- Focus on lifestyle first with reassessment in 3 months

**For Prediabetes:**
- Lifestyle intervention primary approach
- Consider Diabetes Prevention Program referral

### Follow-Up
- Return in 4 weeks to reassess BP and medication tolerance
- If not at goal, increase lisinopril or add second agent (thiazide diuretic)
- Repeat labs in 3 months (lipids, glucose, renal function)
- Annual cardiovascular risk reassessment

### Teaching Points
1. **Proper BP measurement:** Use correct cuff size, patient seated quietly for 5 minutes, arm supported at heart level, average of 2-3 readings. Out-of-office measurements (home or ambulatory) are recommended to confirm diagnosis.

2. **BP classification (2017 ACC/AHA):**
   - Normal: <120/80 mmHg
   - Elevated: 120-129/<80 mmHg
   - Stage 1: 130-139/80-89 mmHg
   - Stage 2: ≥140/90 mmHg

3. **Treatment thresholds:** Stage 2 hypertension warrants immediate pharmacotherapy plus lifestyle. Stage 1 hypertension may trial lifestyle first if ASCVD risk <10%.

4. **First-line medications:** ACE inhibitors, ARBs, thiazide diuretics, and calcium channel blockers are all appropriate first-line agents. Choice may be guided by comorbidities.

---

## Case 2: Resistant Hypertension

### Patient Demographics
- **Age:** 58 years old
- **Sex:** Female
- **Occupation:** Restaurant manager

### Chief Complaint
"My blood pressure is still high even though I'm taking three medications."

### History of Present Illness
Mrs. Angela Thompson is a 58-year-old woman with a 12-year history of hypertension who presents for follow-up. Despite being on three antihypertensive medications, her BP remains elevated. Home BP readings average 158/95 mmHg. She reports taking her medications regularly but admits she sometimes forgets the evening dose. She consumes a high-sodium diet due to working in a restaurant and tasting food frequently. She reports bilateral leg swelling and occasional headaches.

She denies chest pain, shortness of breath, or visual changes. She has gained 15 pounds over the past year.

### Past Medical History
- Hypertension (12 years)
- Obesity
- Sleep apnea, diagnosed 3 years ago, not using CPAP ("too uncomfortable")
- Depression

### Current Medications
- Amlodipine 10mg daily
- Lisinopril 40mg daily
- Hydrochlorothiazide 25mg daily
- Sertraline 100mg daily
- Ibuprofen 400mg 2-3 times daily for knee pain

### Family History
- Father: Hypertension, died of heart attack age 65
- Mother: Hypertension, stroke

### Social History
- Never smoker
- Alcohol: 1 glass of wine nightly
- Works long hours, high stress
- Lives with husband

### Physical Examination
- **Vital Signs:** BP 162/98 mmHg (right), 160/96 (left), HR 72, BMI 36
- **General:** Obese woman, appears fatigued
- **Neck:** Obese neck, difficult to assess thyroid
- **Cardiovascular:** Regular rhythm, S4 gallop, no murmurs
- **Lungs:** Clear
- **Abdomen:** Obese, no bruits auscultated
- **Extremities:** 2+ bilateral pitting edema

### Assessment and Diagnosis
1. **Resistant hypertension** - Uncontrolled on 3 medications including a diuretic
2. **Contributing factors identified:**
   - Medication non-adherence (missed evening doses)
   - High sodium intake
   - NSAID use (ibuprofen)
   - Untreated sleep apnea
   - Obesity
3. **Possible secondary hypertension** - Consider workup
4. **Target organ damage** - S4 gallop suggests LVH

### Outpatient Workup
- Basic metabolic panel: K+ 3.2 mEq/L (low), Creatinine 1.1
- Aldosterone: 18 ng/dL, Plasma renin activity: 0.3 ng/mL/hr
- Aldosterone-to-renin ratio: 60 (elevated, concerning for primary aldosteronism)
- TSH: Normal
- Urinalysis: No proteinuria
- ECG: LVH by voltage criteria
- 24-hour urine sodium: 5200 mg (very high intake)
- Renal ultrasound with Doppler: Normal kidney size, no renal artery stenosis

### Management Plan

**Address Modifiable Factors:**
1. **NSAID discontinuation** - Stop ibuprofen, causes sodium retention and reduces antihypertensive efficacy
   - Alternative: Acetaminophen for knee pain
2. **Sleep apnea treatment** - Strongly encourage CPAP use, discuss mask options
3. **Sodium restriction** - Reduce intake to <2000 mg/day, work with nutritionist
4. **Medication adherence** - Simplify regimen, consider combination pill
5. **Weight loss counseling** - Target 10% weight loss

**Medication Adjustment:**
- Given low potassium and elevated aldosterone-to-renin ratio:
- Add spironolactone 25mg daily (effective in resistant hypertension, addresses possible aldosteronism)
- Continue current medications
- Recheck potassium in 1 week

**Further Workup:**
- Refer to hypertension specialist/endocrinology for confirmatory testing for primary aldosteronism
- Consider CT adrenals if aldosteronism confirmed
- Echocardiogram to assess LVH and cardiac function

### Follow-Up
- Return in 2 weeks to assess BP and potassium
- Phone check in 1 week for potassium level
- Specialist referral for aldosteronism workup

### Teaching Points
1. **Definition of resistant hypertension:** BP above goal despite 3 medications at optimal doses, including a diuretic. Prevalence is 10-15% of treated hypertensives.

2. **Pseudo-resistance causes:**
   - White coat effect
   - Medication non-adherence
   - Improper BP technique
   - Suboptimal medication dosing

3. **Contributing factors:**
   - High sodium intake
   - NSAIDs (very common culprit)
   - Untreated sleep apnea
   - Obesity
   - Excess alcohol

4. **Secondary hypertension workup:** Consider in resistant hypertension. Primary aldosteronism is the most common secondary cause (5-10% of hypertensives). Screening with aldosterone-to-renin ratio; if elevated (>30), confirmatory testing indicated.

5. **Spironolactone:** Effective fourth-line agent for resistant hypertension, particularly if aldosteronism suspected. Monitor potassium closely.