An overweight (BMI 35) 45-year old man has been referred for investigation of his high blood pressure (160/95 mmHg). He has no significant past medical or family history, but socially he consumes at least 15 pints of beer per week and smokes five cigarettes per day. A 24-hour urinary cortisol is raised and low-dose dexamethasone test is normal.
What is the appropriate management?
This man has pseudo-Cushing’s syndrome; a raised level of cortisol that can be found in obesity and during depression. High cortisol is confirmed most accurately by a 24-hour urine collection. A low-dose dexamethasone suppression test is used to determine whether the hypercortisolaemia is endogenous. If it is positive, a high-dose test is required to determine whether the source is adrenal or pituitary. A normal low-dose test makes pseudo-Cushing’s syndrome a likely diagnosis, and this requires lifestyle intervention in the first instance.
A 16-year-old patient has been referred to you for investigation of a murmur. Auscultation reveals a mid-systolic murmur on the anterior chest. There does not appear to be a radiofemoral delay, but the recorded brachial blood pressure is 143/90 mmHg. There is a family history of premature stroke but no family history of kidney problems.
What would the best investigation be?
Whilst an echocardiogram is not unreasonable, the clinical suspicion of aortic coarctation requires additional aortic imaging as most coarctations are post-ductal and thus difficult to visualize on echocardiography. CT aortography provides excellent images of the aorta, but it involves radiation. In a young individual who is likely to require repeated scans at follow-up a cardiac MRI which includes aortic imaging provides excellent image quality and diagnostic yield, and does not involve ionizing radiation. A renal ultrasound and cerebral MRA are more appropriate for individuals with adult polycystic kidney disease, which is an autosomal dominant condition that can also present as hypertension in this age group.
A patient is followed up at a 6-week appointment following a primary percutaneous intervention for an anterior STEMI. An echocardiogram pre-discharge estimated overall LVEF as 40%. He is asymptomatic, compliant with all medications, and has no problems from side effects. His blood pressure is 95/70 mmHg, with no evidence of a postural drop, and his heart rate is 55 bpm. His GP has recently increased his medication to 5 mg bisoprolol and 7.5 mg ramipril.
What are your recommendations?
There is no evidence of a J-shaped curve in the treatment of hypertension in individuals with established coronary artery disease. The up-titration of medication was desirable and should be maintained in the absence of side effects.
A 65-year-old hypertensive non-diabetic has an eGFR <40. Screening tests showed microalbuminuria and a normal renal ultrasound.
Which class of antihypertensive medication should you instigate?
The control of blood pressure and blocking of the renin–angiotensin system are essential to preserve renal function. The African American Study of Kidney Disease (AASK) showed that ACE inhibitors were better at slowing eGFR decline than beta-blockers or calcium-channel blockers. This is true of diabetic and non-diabetic patients, especially if there is evidence of proteinuria. Optimal BP control is <130/80 mmHg or <125/75 mmHg in the instance of proteinuria. It is likely that the benefits of renin– angiotensin blockage are additional to the benefits derived from absolute blood pressure reduction.
The side effects of the broad spectrum of calcium-channel blockers (CCBs) include the following, except:
Peripheral oedema is caused by pre-capillary dilatation and, as with gum hypertrophy, occurs mostly in dihydropyridines. CCBs are negatively ionotropic and should be avoided in left ventricular dysfunction. Beta blockers rather than CCBs cause dyslipidaemia, reducing HDL and increasing triglycerides.