Patient with high blood pressure
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To the Center for hypertension was sent a patient A.D. (33 years) with a resistant hypertension. Elevated blood pressure was first diagnosed 4 years ago. Mr. A.D. use three antihypertensives (medications for high blood pressure) currently, and yet fail to achieve physiological values, current BP – 160 / 95.
The Doctor ordered an all-day monitoring of blood pressure (BP Holter) and laboratory tests.
BP Holter results:
Mean BP in 24 hrs: 154/74 mmHg (normal values < 125/80)
Mean BP day: 152/74 mmHg (normal values < 135/85)
Mean BP night: 156/74 mmHg (normal values < 120/70)
BP Holter description: in all intervals are high values of mean systolic pressure, mean diastolic pressure was increased only slightly at night. Completely missing physiological nocturnal decrease.
BP Holter conclusion: mainly systolic hypertension with systolic pressure peaks in the evening and no nocturnal decrease in pressure.
Laboratory results: (only selected findings)
Biochemistry-serum:
Na 145 mmol/l, K 3.1 mmol/l, Cl 104 mmol/l, Mg 1.0 mmol/l, P 0.83 mmol/l, Urea 8.6 mmol/l, Creatinine 67.0 umol/l, Total cholesterol 5.3 mmol/l, TAG 1.49 mmol/l, HDL 1.46 mmol/l, LDL 3.22 mmol/l, Glycemia: 4.5 mmol/l
Biochemistry-urine:
Total protein in 24 hours: 0.04 g / day
Questions:
Evaluate the results of laboratory tests. Could some of them explain the high blood pressure ? Would it be interesting for you to know a Ca2+ level, which is not listed here ?
Do some lab results threaten Mr. A.D. on life ? If so, how would you intervene ?
A very common cause of poorly correctable hypertension in young people is an endocrine disorder of blood pressure regulation. Therefore doctors focused their search in this area. They took blood for an endocrinological investigation.
Questions:
What endocrine systems are physiologically involved in the regulation of blood pressure? Describe their effect.
Describe the role of the endothelium in the regulation of blood pressure.
Results of an endocrinological investigation: (only selected findings)
TSH 1.704 mU/l (normal level)
Plasma metanephrines (metanephrine and normetanephrine) – normal levels
Cortisol in serum (at 7.00) 50 nmol/l (decreased)
Free cortisol in urine / 24 hours 28 nmol/day (decreased)
Aldosterone 27.9 ng/dl (increased)
Plasma renin activity 0.48 ng/ml/h (normal level 0.2 – 2.8)
The ration aldosterone/plasma renin activity 58 (increased – normal level below 30) – indicative of primary aldosteronism
Questions:
Describe the results of endocrinological examination.
What are metanephrines? How are they produced in the human body ?
Do the results of serum/urine – biochemistry correspond with the results of endocrinological examination ?
Given these findings, CT examination was performed. It found tumour of the left adrenal gland (21x21x19 mm), which was indicated for a surgery. After surgery, there was a significant decrease in blood pressure and Mr. A.D. could stop taking antihypertensives.