A 63-year-old woman is admitted to the hospital for sudden-onset shortness of breath and chest heaviness that began 2 hours ago. She had a similar episode of shortness of breath with hypertensive urgency 8 months ago. An echocardiogram at that time showed left ventricular hypertrophy, modest diastolic dysfunction, and an ejection fraction of 60%. Stress testing showed no evidence of ischemia. The patient's medical problems include a 5-year history of intermittent claudication, hypertension, hyperlipidemia, and type 2 diabetes mellitus. She is a former smoker with a 35-pack-year history. She works as an accountant and admits to feeling stressed at work. Blood pressure is 210/100 mm Hg, pulse is 110/min, and respirations are 20/min. BMI is 34 kg/m². Pulses are equal in all 4 extremities. She appears dyspneic. Jugular venous pressure is normal. There are bibasilar lung crackles and a prolonged expiratory phase of respiration. ECG shows sinus tachycardia, left ventricular hypertrophy, and nonspecific T-wave abnormalities. Chest x-ray reveals pulmonary edema. The patient is treated with intravenous furosemide, antihypertensive agents, and noninvasive positive-pressure ventilation. Four hours later, her symptoms resolve and she appears comfortable. Blood pressure is 144/89 mm Hg and pulse is 75/min. Laboratory results are as follows: Urinalysis shows 1+ protein. This patient should be evaluated for which of the following conditions?

Question

Quizplus · Accepted Answer

11ec193a_9738_c40f_853d_7328fe7bb456_MD0002_00 This patient is experiencing her second episode of flash pulmonary edema associated with severe hypertension. She has peripheral arterial disease (intermittent claudication) and multiple risk factors (smoking, diabetes, hyperlipidemia) for diffuse atherosclerosis. Recurrent flash pulmonary edema in patients with atherosclerotic disease should raise suspicion for renovascular hypertension due to bilateral renal artery stenosis. Patients with bilateral renal artery stenosis can experience flash pulmonary edema (Pickering syndrome) despite normal left ventricular ejection fraction. Other clues for renovascular hypertension include an acute rise in serum creatinine (>30%) after initiation of an ACE inhibitor or unexplained renal asymmetry on imaging studies. Patients who have a high likelihood of renovascular disease should be evaluated with renal Doppler ultrasound or CT or MR angiography to detect renal artery stenosis. (Choice A) Adrenal cortisol-producing tumors can cause Cushing syndrome. Patients may develop secondary hypertension along with Cushingoid features - central obesity, facial plethora, proximal muscle weakness, abdominal striae, and ecchymosis. This patient has no clinical features to suggest Cushing syndrome. (Choice C) Coarctation of the aorta is a congenital abnormality with narrowing of the descending thoracic aorta, usually just distal to the left subclavian artery. Patients typically present with higher blood pressure in the upper extremities than in the lower, as well as with headaches, epistaxis or blurred vision, and diminished or delayed femoral pulses (brachial-femoral pulse delay). (Choice D) Chronic lymphocytic (Hashimoto) thyroiditis is characterized by a gradual loss of thyroid function leading to hypothyroidism. It may occasionally cause an early transient thyrotoxicosis, but this is less common, and recurrent flash pulmonary edema is more suggestive of renal artery stenosis. (Choice E) Depending on the severity of the stenosis, intracranial carotid artery stenosis can remain asymptomatic or cause transient ischemic/cerebrovascular attacks. Educational objective: Renovascular hypertension due to renal artery stenosis should be suspected in patients with recurrent flash pulmonary edema, severe hypertension, and atherosclerotic risk factors. These patients should be evaluated with renal Doppler ultrasound or CT or MR angiography. __________ References: Secondary arterial hypertension: when, who, and how to screen? (http://www.ncbi.nlm.nih.gov/pubmed/24366917) Flash pulmonary oedema and bilateral renal artery stenosis: the Pickering syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/21406441)

A 63-Year-Old Woman Is Admitted to the Hospital for Sudden-Onset