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A case study: hypertensive emergencies caused by complications and non-compliance

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  • Save Public Health Research 2013, 3(5): 153-155 DOI: 10.5923/j.phr.20130305.08 A Case Study: Hypertensive Emergency Secondary to Complications and Non-Compliance Andee Dzulkarnaen Zakaria1,*, Wan Zainira1, Syed Hassan1, Siti Nur Salmah Alias2, Tanveer Azam2, Amer Hayat Khan2 1Department of Surgery, School of M edical Sciences, Universiti Sains M alaysia, Health Campus, Kelantan, M alaysia 2Department of Clinical Pharmacy, School of Pharmaceutical Sciences Universiti Sains M alaysia, Penang, 11800, M alaysia Abstract Introduction: Myocardial injury is one of the most notorious complications of a hypertensive emergency. Electrocardiogram signs are used to detect level of cardiac injury and related effect on other organ. Lack of early signs to predict end-organ damage might lead to a delay in the initiation of therapy and selection of the incorrect therapeutic strategy. Case presentation: A 50 year-old Malay lady presented with left -sided body weakness associated with numbness of her left upper limb . She was diagnosed for hypertensive emergency evidenced by elevated blood pressure measurement 215/109 mmHg. Electrocard iogram indicated T-wave inversion and echo revealed concentric left ventricu lar hypertrophy, trivial tricuspid regurgitation and diastolic dysfunction. Her brain co mputed tomography scans indicated right middle cerebral artery territory infarction related to the left hemiparesis. Conclusion: Hypertension crisis result in increased mortality. Frequent monitoring, timely recognition and treatment are essential in preventing organ damage. Intensive care unit is necessary to achieve appropriate therapeutic endpoints. Individualizing treatment protocol must be developed according to the presence of specific target organ damage and underly ing co morbid ities. Extensive counseling should be provided to avoid hypertensive emergency. Keywords Hypodense Lesion, Centru m Semiovale, Triv ial Tricuspid Regurgitation, Ventricu lar Hypertrophy, Sinus Rhythm 1. Introduction Hypertension emergency is used to describe a blood pressure elevation>180/120 with evidence of progressive target organ dysfunction. Hypertension urgency also associated with abrupt increase in blood pressure>180/120 without any sign of o rgan damage[1]. The treat ment goal in hypertension emergency and urgency is the reduction of blood pressure near to the normal to min imize the risk of organ injury[2]. Both clinical situations needed to be managed appropriate with individualizing the treatment protocol according to the organ involved. One out of three individuals has raised blood pressure, increasing the mortality rate fro m stroke and heart disease worldwide. African region has highest prevalence of blood pressure 36.8%, its prevalence is more in male than female[3]. Malaysia had an overall prevalence of raised blood pressure of 27.8% in 2008 that increased 32.7% in 2012. Most Risk ethnic population in Malay 34% followed with Chinese 32.3% and Indians 30.6[4]. * Corresponding author: (Andee Dzulkarnaen Zakari a) Published online at Copyright © 2013 Scientific & Academic Publishing. All Rights Reserved 2. Case Presentation A 50 year old lady presented to the Accident and Emergency (A&E) Depart ment, Hospital Universiti Sains Malaysia (HUSM), co mplaining of weakness involving left side of body associated with numbness of her left arm over past 12 hours. Patient denied any co mp laint regarding blur vision, headache, chest pain, nausea or palpitation. Patient has history of hypertension for past 14 years and was on combination antihypertensive therapy (Metoprolol 100mg tablet twice daily, Nifedipine 10mg tablet three times a day). On query patient told that she stopped taking medicines one week back as she ran out of medicines without consulting to her doctor. Patient’s blood pressure measured 215/ 109 in sitting position and 194/117 at standing position that was quit high than the normal value of 120/ 80, heart rate and body temperature was normal recording 70beets/min and 99o F. The neurological examination revealed that patient was conscious; her pupils were reactive with normal facial symmetry. Abnormality was observed with reflexes, detectable only after rein forcement at both the left and right side of the upper limb and the right side of the lower limb. Hypotonia was observed with marked ly reduced power of left side limbs, both leg and arm and her cranial nerves I-XII 154 Andee Dzulkarnaen Zakaria et al.: A Case Study: Hypertensive Emergency Secondary to Complications and Non-Compliance were intact. No murmu r o r carotid sound was heard beside S1 and S2 with stethoscope, her lungs were clear with 95% of oxygen saturation and abdomen was soft. Her Laboratory investigation such as complete blood count , Blood Urea Nitrogen, electrolyte and g lucose levels were normal but a high value of Lactate dehydrogenase i.e. 516 IU/ L (normal range: 56-194 IU/L) and CK 340 IU/ L (normal range: 38-174 IU/ L) was observed. Patient’s electrocardiogram revealed T-wave inversion with a normal sinus rhythm measuring heart rate 65beats/min. Echocardiogram indicated concentric left ventricular hypertrophy, trivial tricuspid regurgitation and diastolic dysfunction with a normal eject ion fraction of 72% (normal 50% to 70%). Patients computed to mography scan did not provide any sign of intracranial hemorrhage. A hypodense lesion at lateral aperture and internal capsule in farction at right side was noted. It also revealed mu ltip le well-defined small lesions of Cerebrospinal fluid density in both basal ganglia, head of left caudate nucleus, both parietal regions and right centrum semiovale in keep ing with mult ifocal o ld infarcts. Physiological calcifications were also present at the pineal gland, choroid p lexi and falx cerebri. Patient was provisionally diagnosed with right middle cerebral a rtery territory infa rction with le ft side hemiparesis. It was a hypertension emergency secondary to non-complia nce. Treat ment was started with Aspirin 300mg and Captopril 20mg orally. Blood pressure was monitored every half hour; aim was to obtain 20% reduction within 24 hours. She was followed by aspirin 150mg, Perindopril 2mg and Atorvastatin 20mg. Perindopril was rep laced with Perindopril/Indapamide (5mg/1.25mg) once a day. No progression of the limb weakness was noted. She complained of heaviness at the nape of her neck. She was started on low salt and low fat diet. Her systolic blood pressure spikes to >200, she was immediately ad ministrated I/ V infusion of Isosorbide dinitrate along with Captopril 12.5mg . Felodip ine 5mg was started immed iately after discontinuation of Isosorbide dinitrate. Perindopril / Indapamide was discontinued after 4 days and change back to Perindopril 8mg once a day. She was provided with limb physiotherapy. She was discharged after 6 days and was prescribed with Aspirin 150mg once a day, Atorvastatin 20mg every night, Perindopril 8mg once a day and Felodipine 10mg once a day. in b lood pressure, an abrupt lowering of BLOOD PRESSURE can precipitate co mplications such as atherosclerosis and peripheral vascular d isease[1,2]. Aspirin and Captopril as initial therapy was appropriate choice for this patient. Patient in this case has elevated Creatinine Kinase that indicates the muscle disorder and myocardial infarction; LDH level referred cell damage. Electrocardiogram and echo results did confirm some degree of card iac muscle abnormality. Electrocard iogram pointed out a rare condition of T-wave inversion with a normal sinus rhythm. Rochlin et al reported that T-wave inversion may due to high carbohydrate meal or low potassium level in such patients and can lead to misdiagnosis of coronary artery malfunction [6]. In this case patient has diastolic dysfunction may caused T-wave inversion. Patients denied any clinica l symptoms such as blur vision, headache, chest pain, nausea or palpitation except a numbness on left side extremit ies that is odd as per investigation there was a clear sign of involvement of brain, nerves and cardiac condition. On investigation the case was of hypertension emergency. Varon and Marik et al provided that a patient with a sustain high blood pressure>180/120 has compro mised system so in such individual it is difficu lt to assess elevated blood pressure[7]. In this case patient informed that she was on chronic hypertension medication and missed follo w-up for one week, sympto ms of weakness developed overtime, her facial examination was normal. Patient might has persistent elevated blood pressure level due non-compliance toward her med ication that resulted in a gradual development of muscle cell damage, cardiac and brain events, change was adopted by her body system and a result no sign develop of hypertension crisis. Physiological calcificat ion noted in this patient is a normal event that is related to the old age and is usually develops intracranial [8,9]. The elevation of blood pressure that was observed after initial successful control might be due to the Captopril related elevated potassium level. The use of Isosorbide dinitrate resulted in control of High blood pressure and lowers the potassium level. Potassium level monitoring is important with Captopril regimen. Felodipine also help in depletion of potassium level so counter the effect of Captopril. 3. Discussion Noncompliance is a major issue in hypertensive chronic med icine users resulting in hypertension crisis. In this case noncompliance resulted in target organ damage. Patient regarding old age and stress missed the follo w up that might resulted in hypertension emergency[5]. Hypertensive emergencies must be managed in intensive care unit because regular v ital sign mon itoring is necessary over the time. Management of hypertension crisis need a gradual decrease 4. Conclusions Hypertensive emergency is associated with increased mortality and require intensive med ical care with proper hypotensive agents. Prompt recognition and early treatment is crucial in preventing or halting progressive target organ damage. Sodiu m Nitroprusside is used for rap id action but patient underlying comorb idit ies must be considered before its admin istration as it may associate with certain toxicity. Other agents that can be used in management are Perindopril, Atorvastatin, Nicardipine, Labetolol and Fenolodipam. Public Health Research 2013, 3(5): 153-155 155 Patient must properly counsel about the importance of compliance in maintaining blood pressure. Pharmacist ro le is 15th NIH Scientific Conference, Corporating THE NHM S AND GATS 12-14 JUNE 2012. important in patient counseling regarding importance of [5] Baksaas I, Helgeland A et al Patient reaction to information regular mon itoring and controlling of blood pressure. and motivation factors in long-term treatment with antihypertensive drugs 1980;207(5):407-12. REFERENCES [6] Isidore Rochlin and Jack W. L. et al Edwards The misinterpretation of Electrocardiograms with Postprandial T-Wave Inversion Circulation, journal of the American Heart Association, 1954; Vol. 10: 843-849 [1] M ark A. Perazella, Chirag K. Vaidya, Jason R. Ouellette et al Hypertensive Urgency and Emergency Hospital Physician M arch 2007, [7] Joseph Varon and Paul E M arik Clinical review: The management of hypertensive crises Critical Care October 2003 Vol 7 No 5, 374-384 [2] Carl J Vaughan, Norman Delanty et al Hypertensive emergencies THE LANCET, Vol 356; 411-17, July 29, 2000. [8] Daghighi M H, Rezaei V, Zarrintan S, Pourfathi H. Intracranial physiological calcifications in adults on computed tomography in Tabriz, Iran US National Library of [3] WHO: 2012 World health statistics Report.http://www.who. int /gho/n cd/risk_fa ct ors/blood_p ressure_p revalence_t e xt /en/. M edicine, National Institutes of Health, 2007 M ay; 66(2):115-9 Accessed 21 April 2013. [9] Reinders TP, Rush DR, Baumgartner RP Jr, Graham AW. [4] Gurpreet K, Guat Hiong T, Feisul M ustapha, Jamaiyah Haniff, Selvarajah S, Wan Nazaimoon WM , Noran N Hairi The Epidemiology of Hypertension in Malaysia: Current Status Pharmacist's role in management of hypertensive patients in an ambulatory care clinic US National Library of M edicine, National Institutes of Health, 1975 Jun;32(6):590-4.

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