A 74-year-old man comes to the office to establish care. The patient has been in good health and has no symptoms. He has not been to a primary care physician for several years. Medical history includes right knee osteoarthritis, for which he occasionally takes ibuprofen. The patient does not use tobacco or alcohol. Blood pressure is 165/75 mm Hg and pulse is 70/min. A 2/6 systolic ejection murmur is heard at the right sternal border without radiation. Peripheral pulses are full without delay. ECG reveals left ventricular hypertrophy with secondary ST-segment and T-wave changes. Echocardiogram reveals moderate left ventricular hypertrophy without significant flow abnormalities. Ejection fraction is 60%. Which of the following is the most likely cause of hypertension in this patient?

Question

A 74-year-old man comes to the office to establish care.  The patient has been in good health and has no symptoms.  He has not been to a primary care physician for several years.  Medical history includes right knee osteoarthritis, for which he occasionally takes ibuprofen.  The patient does not use tobacco or alcohol.  Blood pressure is 165/75 mm Hg and pulse is 70/min.  A 2/6 systolic ejection murmur is heard at the right sternal border without radiation.  Peripheral pulses are full without delay.  ECG reveals left ventricular hypertrophy with secondary ST-segment and T-wave changes.  Echocardiogram reveals moderate left ventricular hypertrophy without significant flow abnormalities.  Ejection fraction is 60%.  Which of the following is the most likely cause of hypertension in this patient?

Quizplus · Accepted Answer

This patient has isolated systolic hypertension (ISH), generally defined as a systolic blood pressure (BP) ≥140 mm Hg with a diastolic BP <90 mm Hg (specific BP parameters differ among various guidelines). ISH is associated with increased cardiovascular morbidity and mortality and warrants lifestyle modifications and pharmacologic therapy, just as for other forms of primary hypertension. ISH is most common in elderly patients and is likely due to increased stiffness or decreased compliance of the aortic and arterial walls. This change reduces the ability of the arteries to dampen systolic pressure and leads to increased pulse wave velocity and pulse wave reflection in systole. This manifests as increased systolic and pulse pressures (ie, difference between systolic and diastolic BPs). (Choice A) Aortic insufficiency can cause ISH due to increased stroke volume, but it typically is associated with a diastolic (not systolic) murmur and diagnostic findings on echocardiography. This patient has a benign systolic murmur in the aortic area (no radiation, full peripheral pulses with no delay, no associated hemodynamic effects) consistent with aortic sclerosis, which is common in older patients and generally has minimal effects on blood pressures. (Choice B) An increase in plasma renin activity is seen in patients with renovascular hypertension (renal artery stenosis), an important cause of secondary hypertension. However, there usually is an increase in both systolic and diastolic BPs. Renin activity is low to normal in patients with ISH. (Choice C) Increased cardiac output can cause ISH in hyperdynamic states (eg, anemia, hyperthyroidism, arteriovenous fistula). This patient's history is not consistent with a hyperdynamic state, and there is no evidence of hyperdynamic circulation on physical examination (eg, ventricular heave, hyperdynamic precordium). (Choice D) Increased intravascular volume usually causes both systolic and diastolic hypertension. This can occur in renal disorders in which the kidney's ability to excrete solutes or water is reduced. Educational objective: Isolated systolic hypertension, an important cause of hypertension in elderly patients, is caused by increased stiffness or decreased compliance of the arterial wall. It is associated with an increase in cardiovascular morbidity and mortality, and management should be similar to that of primary hypertension, with lifestyle modifications and pharmacologic therapy. References: Aortic diameter, aortic stiffness, and wave reflection increase with age and isolated systolic hypertension. (http://www.ncbi.nlm.nih.gov/pubmed/15699456)

A 74-Year-Old Man Comes to the Office to Establish Care