[Walrus]

Well, I am just a MBBS and saying as much as my knowledge serves and it is poor in case of hypertension with so many associated conditions. But, here I can attempt to defend my claim

The case is not as simple as I saw it the first time and every reply after me has pointed my mistakes.

HydatidCyst correctly pointed that I should be careful prescribing ACE-I here.

JNUS showed all the points I over looked and RajuPangeni has also right points.

I am just defending my claim here. Please show where I say wrong.

This case of HTN might be long standing and the physical findings does point to Left Vent Outflow Obstruction but to me it seems more like Subvalvular than a valvular cause. I have weak knowledge in cardiology but still, the murmur does not support AS and in AS valsalva decreases the intensity of the murmur in AS. I was thinking the murmur and the findings were more in support of Hypertensive heart disease or may be correctly said 'Hypertrophic Cardiomyopathy with HTN or Hypertensive Cardiomyopathy'. The findings of the mumur - LSB and increasing with Valsalva exactly fits in.

Soul asked me why I said the patient is in failure. There is no much clinical finding to support my diagnosis. But, this patient is already having a hypertensive heart disease so I should have CCF in mind too. CCF is missed lot of time. A patient with HTN and LVH will have diastolic dysfunction and in the course LVH will also fail to compensate cardiac output so it is not wrong to think of CCF in this case.

With LVH, almost all antihypertensive are OK but ACE-I may be slightly better. With renin angiotensin system activation, there will be fluid retention and peripheral vasoconstriction. So, ACE-I (and/or ARB) is justified to delay systolic failing also.

In this case, low dose Hydrochlorthiazide is not just for diuretic effect but it has much more beneficial effects.

Enalapril (or Losartan) and Hydrocholrthiazide both have some evidence showing beneficial effect in HTN and DM and LVH in reducing cardiovascular morbidity and mortality as for example stroke. They also have reno-protective effect which I will definetly want to think for this diabetic patient.

So, I would still stick to ACE-I and low dose Hydrochlorthiazide.

Please comment on my choice. Else, I will be doing this always.