A patient with syncope

[Soul]

42 yr old male with episode of syncope while at work came to see u. BP high, but not taking drugs properly. H/O DM 2 controlled by diet. O/E Dyspnea n dizziness on exertion. BP 163/95, HR 75 bpm. Cardio exam: sustained max impulse and grade 4 systolic ejection murmur at LSB, which increases with Valsalva manouver. ECG shows LVH. What should be the most appropriate mgmt for his HTN?

(1) ACE-I
(2) BB
(3) CCB
(4) Diuretic

[Walrus]

Treatment of HTN is so confusing for me. I hope someone will share their experience here.

In such patients what I do is -

ACE -I with Hydrochorthiazide.

I cannot give reference at the moment but I think that will be the best treatment for this case - HTN w LVH w CCF w DM.

[Soul]

Superb thinking Walrus, I am looking for some more views in this case.

[hydatidcyst]

I think BB would not be safe here as the patient is in failure. The best is to start with ACE - I and Diuretic and follow up the patient with Echocardiography and other necessary investigations. Since the patient has come to you with syncope, consider observation as ACE - I may cause hypotension also.

[Walrus]

I completely missed that point. First-dose hypotension can be severe with ACE-I.

[JNUS]

Most likely its a case of Aortic Stenosis, symptomatic one. Syncope suggesting low cardiac output... LVH due to AS ---> HTN . Patient is having exertional dyspea, not in failure. But patient is in risk of developing Failure and development of arrythmias ---> may lead to sudden death of the patient.

Mx of HTN will be best by ACE-I .( 1st dose hypotension -- advise patient to take 1st does in night just before sleeping). Diuretics may deplete intravascular volume, aggravating syncope.

Immediate ECHO and doppler (to measure pressure gradient) is suggested and should be Planned for Surgery ( valve replacement ) if i am correct from the begining.

[Soul]

Walrus and hydatidcyst, what made you to think that this pt is in heart failure?
JNUS you are very close..great thinking.

[rajupangeni]

i agree with jnus to some extent.. i think the question itself creates some confusion.. it seems that the patient is having aortic stenosis, though the murmur of AS is audible mostly in right upper sternal border rather than LSB and significant AS will cause either fixed or low cardiac output and hence normal (or in severe AS, decreased) blood pressure.. (hypertension and AS in elderly is not uncommon though!) the pulse pressure is also narrow unlike in this case where it is quite wide (70 mmHg)..
the simplest rule to follow in AS is either do nothing if asymptomatic, or go for surgery if symptomatic.. ACE inhibitors are not recommended in AS while they are cornerstone of therapy for other cardiac failures.. and diuretics also should be used with extreme caution as they cause significant hypotension..
i would go for echocardiography and look for the left ventricular function and pressure gradient which wud guide to decide the severity of the disease.. and till then, manage hypertension (which i think is quite unlikely) with diuretics.. otherwise, in a diabetic patient with hypertension or if associated with nephropathy, ACE inhibitors would be preferable.

[JNUS]

Originally Posted by rajupangeni

ACE inhibitors are not recommended in AS while they are cornerstone of therapy for other cardiac failures.. .

Could u please explain this statement clearly.
And what will be ur prescribtion for HTN in this particular case ?

I am excited for the final answer to be released.

[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.