A rare cardiac finding in a morbidly obese patient with severe hypertension

Abstract

Dr. Fiore, Dr. Marinoni: A 46-year-old morbidly obese man was admitted to our emergency department (ED) with the acute onset of epigastric pain, nausea, and vomiting. He reported having a 10-year history of hypertension treated with doxazosin, atenolol, ramipril, and potassium canrenoate; in addition, during the last 2 years, he was treated with overnight continuous positive airway pressure (C-PAP) device for obstructive sleep apnea syndrome. He had never smoked or used illicit drugs. On examination, he appeared anxious. The height was 190 cm, the weight 155 kg, and the body-mass index (BMI, the weight in kilograms divided by the square of the height in meters) 42.9. The abdomen was soft and obese, with mild-to-moderate tenderness in the epigastrium, with no rebound tenderness or guarding. The bowel sounds were normal. The lungs were clear to auscultation, and the first and second heart sounds were faint but normal; a diastolic murmur (grade 1/6) was heard at the right sternal border. The temperature was 36.1 C, heart rate 97 beats per minute, blood pressure was 210/115 mmHg, respiratory rate 20 breaths per minute and oxygen saturation 98% while he was breathing ambient air. The sclerae were anicteric. Routine blood measurements revealed a hypochromic microcytic anemia (hemoglobin: 9.6 g/dl; hematocrit: 30%; mean corpuscular volume: 75 fl) and increased values of the classical markers of inflammation (erythrocyte sedimentation rate: 99 mm/h; C-reactive protein: 13.1 mg/l). A complete blood count, serum levels of glucose, creatinine, total protein, albumin, globulin, troponin I, creatine kinase and creatine kinase isoenzymes, lactate dehydrogenase, amylase, lipase and results of liver-function tests, and serum protein electrophoresis were normal. An electrocardiogram was normal. The patient was treated with intravenous labetalol and proton-pump inhibitors. Although symptoms, physical examination, and anemia were consistent with peptic ulcer or erosive gastritis, an esophagogastroduodenoscopy was unremarkable. The initial symptoms improved gradually during the following 24 h, although mild epigastric discomfort persisted. However, several hypertensive crises (systolic and diastolic values in a range of 180–220 and 110–140 mmHg, respectively) occurred that required labetalol infusion for 3 days. Upon labetalol withdrawal, therapy with doxazosin (16 mg daily), transdermal clonidine (10 mg weekly), atenolol (200 mg daily), spironolactone (50 mg daily), furosemide (50 mg daily), amlodipine (10 mg daily), ramipril (10 mg daily) was gradually set, still with poor blood pressure control.