CPC 2018 | Case 2: Diagnosis and Management of Resistant Hypertension: a Case Report

CPC 2018 | Case 2: Diagnosis and Management of Resistant Hypertension: a Case Report


– Good afternoon
colleagues and professors, and thank chairman for your introduction. My name is Wen-Yi Yang, and my colleague’s name is Doctor Zhang. So, we are going to … first of all, I would like to congratulate to the first two presenters, I think they presented
very nice, two real cases, but we are going to
present the cases which is relatively common, and
we’re confronting almost every daily practice. So, I will just first
introduce to you, summarized, the very simple, medical history. This is a male, 29 years
old, admitted to our hospital due to infection of upper
respiratory tract in 2012, with extremely high office
blood pressure of 230/150. And he also claimed fatigue,
but not really severe dyspnea. No previous history of hypertension, no history of sleep apnea, and he reported his
father had hypertension. And he don’t smoke, don’t drink too much, and don’t have the drug addiction problem. And he didn’t received any treatment before visit emergency room. And we did, of course,
the physical examination at the beginning. So, first of all, we can
have a look that actually this patient is obese, and with a BMI of 33.7 kilogram per square meter, and the bilateral jugular vein signs is, negative. And we also checked the lung signs, and they had rough breath
sounds, no dry or wet rales. And we also detected enlargement
of left ventricular heart, with a heart rate of 100. The heart rhythm is regular, no murmur. And the hepatojugular refluxion
sign is also negative. No edema of low limbs. So what could you, we would ask expert here
what you are going to do for the next day. What kind of examination you would suggest for this patient. – [Ji-Guang Wang] Comment? The microphone, please. – I guess this patient is young, he’s having a very high blood pressure. These two are indications
to go and look for seriously about secondary cause for
his high blood pressure. After that, I go for the
number two screening. So will go for ultrasound
if echo has been done. As well to evaluate better the fundi. If all these, led me to any direction, feeling good. Otherwise I go deep in the history, and the family history as well, to look for any leading track, for further investigation
before going further. – [Ji-Guang Wang] Another comment? Please, that microphone, sorry. – I think in this young obese gentleman I need to look for history
of also the sleep apnea because it also could be part of the causes. – [Ji-Guang Wang] They reported no sleep apnea history, but– – Yeah. Yeah. Another thing
is this amphetamine usage. Even though he deny, but
we still have to check with the urine for the substance abuse. – [Ji-Guang Wang] Very good. Back there. – [Woman] Hi I was think that– – [Ji-Guang Wang] Please, over there. Microphone. – [Woman] I would give this patient some blood-pressure-lowering drugs first. (Ji-Guang Wang and audience laugh) – [Ji-Guang Wang] Very good idea, because
– [Zhen-Yu Zhang] Very good – [Ji-Guang Wang] (laughs)
Okay, so it means, Please. – [Man] Well the patient are very fat. – [Wen-Yi Yang] Yes, that’s what we– – [Zhen-Yu Zhang] BMI a certain– – Did he had a history… Sorry, sorry. – [Audience Member] Diabetes. – Yeah, yeah, diabetes. – [Zhen-Yu Zhang] We will
answer this question– – [Wen-Yi Yang] We’ll
answer this question– – [Zhen-Yu Zhang] On the next slide. – [Wen-Yi Yang] Yeah. (Ji-Guang Wang laughs) – Sorry, I’m a vascular surgeon so if the patient comes to see me, I would first check the renal artery. – [Ji-Guang Wang] Renal artery. – Yeah – [Ji-Guang Wang] Renal artery. Okay. So we have some suggestions, so we need to first the diagnosis, then clinical evaluations. – Probably we work further and with more information – [Man] Could you tell us what you– – [Ji-Guang Wang] And
tell us what you did. – [Man] Yes. – So all very good suggestions. I think this is what we did
for the chemical examination. So first I checked
blood glucose in detail. This patient has a very high levels for random blood glucose. And also the fasting glucose is high. And HbA1c is also high. And then we checked the
potassium and sodium. So the levels are normal,
within the normal range. By the serum creatinine,
it’s within the upper limit. So the serum, of course you can see here, so the serum homocystein is above normal. Also the urinary acid. – [Audience Member] Uric. – Uric acid, sorry. And the HDLC is slightly
above the threshold. We also tested the troponin I, but we tested for two times. And the both of them are
normal, within the normal range. However, this patient has
a very high levels of BNP. And also the urinary albumin
levels is above normal. For the additional examination, so you can see the ECG is sinus rhythm, and also the heart rate
is a little bit high, so more than 100 beat per minute. And you have a depression of ST segment. But it’s not specific. With echocardiography, we
could see the enlargement of a left atrium. And also left ventricle internal diameter during the end diastole is enlarged. And also the left ventricle posterior wall and the septum wall are hypertrophic. But this patient has only
a ejection fraction of 33% and we can see this is
a global disfunction. We cannot see the segment
disfunction in this patient. And also, of course, diastolic disfunction because it’s very common in
the heart failure patients. About 50% of them has
diastolic dysfunction also. For the chest x-ray, the
findings are confirmative with the echocardiography, so we can see the enlargement
of left ventricle. And we also do, as what you suggested, we also monitored this
pulse overnight, oximetry. So it’s normal. We didn’t see any evidence, for the sleep apnea. Then we monitored 24-hour
ambulatory blood pressure, as you can see. So 24-hour blood pressure is high. And also daytime and
nighttime blood pressure. So what would be the next step? What’s your proposal? – [Ji-Guang Wang] Yeah,
we have a lot of data now. Please, over there. Yeah, here. Yes. – [Woman] I think this case
is emergency hypertension in view of the blood pressure
is more than 220 and 120, with the evidence of second organ damage. where there is a reduced ejection fraction and the ST depression. So I think the main thing here, we have to control their
blood pressure slowly within 12 hours, I mean,
cut down the blood pressure reduction by 25% within 12 hours by using the infusion of the beta blocker– – [Ji-Guang Wang] Normal level? – Huh? – [Ji-Guang Wang] Within
12 hours to normal level? – No, no, reduction of 25% of
the systolic blood pressure within twelve hours. Because this is emergency hypertension with second organ damage. Which is different from the urgency where they can reduce 25% within 24 hours. – [Ji-Guang Wang] Okay.
Any other suggestions? Comments, yeah. Please. Ah, yes. – I think this is a case
of metabolic syndrome, apart from the hypertensive crisis. And we can see all the
increased blood-sugar levels, and also creatinine hyperhomocysteinemia and I think we should
go with the ultrasound, and then probably check for CT. – [Ji-Guang Wang] Ultrasound for what? – Ultrasound for brain, sorry for the adrenals– – [Ji-Guang Wang] And later those. – And later we’ll go for a CT. – [Ji-Guang Wang] Okay. Another comment? Okay, over there. Please. – I propose to examine
aldosterone and renin ratio, and maybe cortisol also for excluding the endocrine hypertension, because he is young, he has
the low potassium level, and he has a very high
level of blood pressure. – [Ji-Guang Wang] Okay. Please. – I do emphasize the first
message that ultrasonograph imaging has to be done
for the adrenal and renals and the Cushing’s with
dexamethasone suppression test to be done as far he is already obese and he having this very
high blood pressure. Whether to control or
not the blood pressure is something else, I think it not within the scope of this discussion, I guess. – [Ji-Guang Wang] Yeah. Okay. Any other suggestions? Otherwise, please, Wen,
tell us what you did and the priority for post-diagnosis
and treatment, please. – I think quite a lot of
the audience already said that we should study the treatment, but of course we studied, but we would like to put
that part little bit later on so we talk about the diagnosis first. But actually I also would
like to highlight here, actually if you look at the report of 24-hours’ blood-pressure
monitoring here like that, you have 24-hours’ average blood pressure. You have daytime and nighttime. But you can observe obviously here, you have relatively low daytime, but relatively high nighttime. So do you have any… – [Woman] If I may, lack of nocturnal dips suggests secondary hypertension. – Yeah. – [Woman] Especially in 29-year-old man. – [Ji-Guang Wang] Yes? Any comments from the audience? – [Audience Member] We agree. – [Ji-Guang Wang] They agree. And so please? Please move on. – So I will provide the detail, individual monitoring readings here. So you can see here from this patient, we have the daytime readings and we also have the nighttime readings. I’m sorry, why the nighttime
reading is not showing here? So you can see that the daytime
almost equals to nighttime. But one of, quite interesting
thing here, actually, we observed is night period. So conventionally, actually,
I’m not sure how ’bout in your clinics, we just
generally used a short-time fixed period to define
the daytime and nighttime. But sometimes you need to be careful, because I think the guidelines
recommend all of us to when you are going to do the ABPM, you should record the diary parallel. It’s very important, especially
for Asian people, I think. – [Ji-Guang Wang] Siesta dipping. Siesta tipping that’s very
typical in China and South Europe and Italy. (laughs) Please. – [Wen-Yi Yang] So, but anyway, if you exclude the nap time, and if you just take
the real sleeping period to ask the information from the patient, and you still can see that, actually. This patient still have
similar daytime, nighttime, and is certainly a non-dipping patient. And as Professor said
that, actually, you might suggest some, the secondary hypertension. – [Ji-Guang Wang] Please. – [Female Audience Member] Microphone. – [Male Audience Member]
Microphone, microphone, please. – [Female Audience Member] Microphone. – [Ji-Guang Wang] Just a minute. – I think it is difficult to say that this is a non-dipping patient because you can see that
during the afternoon nap, there is a typical dip, so the alternative way to look at it is that something is
going on during the night. And– (audience and hosts laugh) – [Zhen-Yu Zhang] Possible. – And if you look at
the curves, you can see, I think why vividly there are some peaks during the night, suggesting to me that perhaps this patient was, up during the night, perhaps to pass urine. Someone with severe hypertension might have pressure not to
avoid this during the night. So I am not, because he was certainly dipping in the afternoon, where
the sleep is shorter, I am not sure that he can be
categorized as a non-dipper and perhaps there is
some sort of behavior, because of which he gets up at night, and therefore the nocturnal
blood pressure is elevated. – Yeah, he emphasized
the importance of diary, so we always need a diary for 24-hour blood-pressure monitoring, and, yes– – A little comment, it is
not only the late at night, is the whole night is more
than the whole daytime. So it may gives that there
is some behavioral issue, or something else. We have to look for it. – [Ji-Guang Wang] Yeah,
just one more comment here. – Can I comment on the
blood-pressure variability on this patient? Because I can see the
minimum and the maximum level is a very, a very big range, so I feel that this blood
pressure variability on this patient is very high. So it could be contribute to this– – [Ji-Guang Wang] To the risk? – Yeah. Yes. – [Ji-Guang Wang] Yeah. Yeah. – Okay. Please. – Actually, I would like to
make one more, I’m sorry. Actually, this ambulatory
blood-pressure monitoring, we’re taking in the hospital. So I’m not sure whether
you’re going to do that for these patients because generally, for the clinical practicing,
we would like the patient to have their generally daily life. – [Audience Member] Yeah. – But I think staying in the hospital, they don’t have any physical activity during the daytime. Maybe that’s one of the explanation for these so-called
non-dipping or phenomena, let’s call it. So. – I think the other reason
is because this patient is taking this ambulatory
blood pressure in the hospital, and during the nighttime,
the nurse will check the, well, check the unit from time to time. This is also, I mean, the
patient cannot sleep very well in the hospital. That’s very common. – So here, actually, is the
suspicion of the diagnosis. Well, almost at least all
of this diagnosis here. But actually, of course,
for the general things, it doesn’t matter too much. I think it’s very clear from
all of these examinations. But how do you think about what is the hypertension diagnosis? Primary or secondary? Is heart failure, and
then what is the cause of the heart failure? – [Ji-Guang Wang] Yeah. Please. – The microphone there. – [Michael Burszytyn] I
think it must be assumed that it is secondary. – [Woman] Wait a second, yeah. – I think it must be assumed
that it is secondary. At the age of 29, he has
left ventricular hypertrophy. He has, nephropathy. So he must have had this
very high blood pressure for a long time, and, at such an age, I think we must assume, it is secondary until
we don’t find a cause. The presence of uncontrolled
diabetes certainly contributes both to the renal, to the nephropathy, and, probably to the cardiomyopathy, unless he has focal oncocytoma, which can also be a cause of hypertension at a young age and cardiomyopathy. – [Ji-Guang Wang] Okay. Another comment. – I do agree, he has underlying, secondary cause of hypertension, but I think the pseudoepinephrine
could be cause him to have a high, his blood pressure high because he has admitted for the
upper respiratory infection, he could be on pseudoepinephrine, which cause the blood
pressure to be higher. – [Ji-Guang Wang] Yeah. – I think first we need to be sure that this patient had hypertension. Because we already have seen that there is a very large
blood pressure variability during the ambulatory
blood-pressure monitoring. So I think we need to repeat ABPM. – [Ji-Guang Wang] Yeah, Any other comment? – At this time, no cortisols
and no thyroid done? – [Ji-Guang Wang] Yeah. Yeah. – Up to this level? – [Audience Member] Good point. – [Ji-Guang Wang] Yeah, very good point. So all the diagnosis for
now are based on the data we had in the previous several slides. Please. Probably we’ll move on. – So about the question that
professor Li just raised, we repeat the measurement for 24-hour ambulatory blood pressure. And of course, the high
blood pressure, hypertension, is confirmed at this stage. And secondly, to exclude
the secondary hypertension, this is all the examinations that we did. So in matter of the ACTH, cortisone, aldesterone, and also renin activity. And all the examinations
are within the normal range. And we measured it
according to the guidelines, and this patient was
in the supine position. And also for the other
reasons for hypertension, for instance, the parasitic dysfunction, we also check it, and it’s
within the normal range. We did the adrenal gland CT and CTA. The result is normal. And then, we do this, pituitary body MRI and
the result is also normal. So what would be the next step? Do you think we exclude
the secondary hypertension? – [Ji-Guang Wang] Any other suggestions? Microphone, please. Over there. – I still am emphasizing cortisol with suppression done or not. This is just the cortisol
readings without suppression. Okay. – We have it took day and night. It’s measured at 8:00 a.m. and 4:00 p.m. So it’s – two times.
– And repeated after suppression with
dexamethasone or not? [Ji-Guang Wang] Suppression? [Zhen-Yu Zhang] Suppression, we didn’t–
[Wen-Yi Yang] Yeah, we didn’t. [Zhen-Yu Zhang] Check
it because the result of the cortisone is normal, so we didn’t do the suppression test. [Ji-Guang Wang] Okay, please. – I must be– [Audience Member] There
is a comment at the back. [Ji-Guang Wang] Yes, right, back, back. – I would like to emphasize
on the hyperhomocysteinemia, which could be probably causing
increased vascular stiffness and increasing the hypertension. So I think we can go with
the secondary hypertension as it is a metabolic cause. – [Woman] Okay, that’s all very good. But we want to know more about the kidney. Because we’ve excluded
the endocrine causes, but I haven’t seen enough of
kidney detailed investigation. – [Ji-Guang Wang] Both the
renal artery and the kidneys. Please. – Yeah, certainly we did
the renal arteries CTA for this stage. So, as you can see. As you can see here, is
the CTA reconstruction. The aorta and two sides
of the renal artery. And if you look at this image, and what’s your interpretation? And do you, are you going to
link the renal artery stenosis to these cases, or some interesting part. Thank you. – [Ji-Guang Wang] Any
comment from the audience? Yeah. Please. Microphone, microphone. – From the outset, the
low plasma renin activity does not necessitate the
renal artery imaging. – [Ji-Guang Wang] Okay. Please. – So we have another question. What do you think the
cause of heart failure? – [Ji-Guang Wang] Yeah,
that’s something I think you must have a lot of comments. – Several reasons. The first one is the person
that is young, and the obesity, and I think maybe it’s something associated with the insulin resistance. You know, insulin resistance is associated with hypertension. And this the first one. And the second one, we have
found some abnormal orthostatic. So, the blood sugar is narrow. We just found that. So I think this the reason, and from my recent research, we also found some… The results may be associated with the peripheral vascular resistance. Yeah. – [Ji-Guang Wang] Carry through. Please. – So for the causes of heart failure, do you think we can exclude
acute myocardial infarction? (audience members respond both yes and no) – No? Who said no? Give me some reasons. (crowd laughs) – That’s good. To hear a different voice. – Yeah. – I think this patient is too young to assume that they are diabetic, cardiomyopathy had
occurred to such an extent, and in diabetic patients, premature myocardial infarction is likely. The presence of renal atherosclerosis, although minimal in such young subjects, supports, to some extent, the possibility of
coronary atherosclerosis and I think that, acute myocardial, past myocardial infarction, is the leading diagnosis
of this heart failure. Again, unless he has focal oncocytoma which could
(Ji-Guang Wang laughs) cause hypertension,
cardiomyophathy, and everything. – [Ji-Guang Wang] But
they reported normal, normal recordings and also– – [Wen-Yi Yang] Troponin. (man in audience speaking
foreign language) – [Zhen-Yu Zhang] Normal troponin. – [Ji-Guang Wang] Oh, normal- – [Wen-Yi Yang] Normal troponin – [Ji-Guang Wang] Yes, please. – [Zhen-Yu Zhang] So we
measured normal troponin two times, and both times– – [Wen-Yi Yang] Troponin i – [Zhen-Yu Zhang] Yeah, troponin I – [Wen-Yi Yang] At the beginning
of the emergency, yeah. – [Zhen-Yu Zhang] So both
times they are negative. – And also you didn’t see
the segmental disfunction. It’s a global disfunction. And also for the EKG, it’s only the depression of ST. For such a young patient,
normally we would expect it, that he has elevated ST, elevated ST in myocardial infarction, not normal ST. Elevated in myocardial infarction. Of course, you can see
that he has diabetes, and maybe you have a
very severe, actually, for instance, the three big
arteries all have impairment, then, I mean, this is a possibility. But then the troponin i,
we repeated for two times. So I think this one we can exclude. And this patient don’t have
any symptoms of chest pain. This is also another evidence that we can exclude acute
myocardial infarction. – [Ji-Guang Wang] Yeah. Please. – We also did– – Of course, just the
reason that you mention, this patient is obese and has diabetic. We think it is rational to
measure the coronary CTA, but the result is normal. So it’s confirmatory that this patient don’t have
any coronary heart disease. Do you think we can exclude myocarditis? – Myocarditis. – Myocarditis. – [Ji-Guang Wang] Myocarditis. Any comment from the audience? Whether we can exclude? Yeah, please. – What about very a very simple diagnosis. This is a patient with
essential hypertension, and he got heart decompensation because of his high blood pressure. This is how I would approach the patient. And then my next question is how would you treat the patient? So what would you do? – [Ji-Guang Wang] Again, treatment? – Treatment. I think treatment is most important. – [Ji-Guang Wang] Okay, but we should first exclude myocarditis (laughs) Okay. Any other comments on this? Otherwise we will move on. Please. – Okay so, I think we can exclude this. Of course, this patient has a history of upper respiratory tract infection, but then you can see the troponin i. We repeated for two times. If this is the case for the myocarditis, then the troponin i should elevated. So this is the reason that
we excluded this myocarditis. And just as Professor Staessen said, this is, we think,
hypertension is the reason for this heart failure. This is the cause of heart failure. – But you still have to look at the influence of, lung infection. That can exacerbate heart failure, even though heart failure
was caused by hypertension, and this patient was hospitalized because of upper
respiratory tract infection. This infection can also
exacerbate heart failure in many cases. Please. – So I think, yes of course
I agree with Professor Wang for this cases. But we can also thinking about, let’s treat the patient afterwards to see how about the
heart failure recovery and the prognosis of the heart failure. I think maybe you can answer
some part of the question. And first, our final diagnosis, we made thinking the primary hypertension, with very high level of his blood pressure and extremely high-risk group. And we were thinking about
the heart failure were caused by the hypertensive cardiomyopathy and with severe left
ventricular enlargement with chronic heart
failure and with symptom New York Heart Failure
Association classes grade II. So of course for diabetes, I think it’s quite easy to confirm. But also for the micro-albuminuria, but do you think it’s a
chronic kidney disease or it’s, it’s like acute kidney disease? – [Ji-Guang Wang] May I
comment on this question? If not, yes? Somebody here? – I’ve got several questions. First, for this patient, if you think the heart failure
is due to hypertension, probably that means the patient have got chronic hypertension. Is that the case? And I may have missed the fundus exam. Did you see any diabetic retinopathy or hypertensive changes? Because if you think this is CKD due to not taking medicine, diabetes, most diabetics there
would be some changes say, at the retina. And this is the first question. Second question is that you mention about 30% renal artery stenosis. Do you think this is a possible cause of the hypertension or that’s
just an incidental finding? Also with renal artery stenosis, do you try to examine
for radiofemoral delay because there could be
a possibility of say, Takayasu’s disease. So these are all my question, thank you. – [Ji-Guang Wang] Yeah, please. – First of all, I would like
to start with the easy one. I actually I think very few
of ours would agree that actually the Rhinostenosis
with such a certain percent would be the causes of hypertension. Actually there is, I don’t
it will be some kind of hemodynamic problem, but for the, Micro-albuminuria actually I
think in this case for this moment it’s very difficult
for us to determine what will be the causes, but we will continue, we will tell you more. – Was the fundus
examination highly normal? – [Wen-Yi Yang] Fundi. – I will express some changes. – [Ji-Guang Wang]
Whether the patient had– – [Zhen-Yu Zhang] This one,
we also check it and it’s not normal, I mean this is just
the sign of the duration of diabetes so this patient
already has some organ damage. So this is, we can justify
that the diabetes has already lasted for some years but
we don’t know how long it has been lasted because
this patient don’t have any symptom before the admission of this, to hospital this time. – The rapid changes, where was it? Any diabetic retinopathy? – [Zhen-Yu Zhang] Excuse– – [Ji-Guang Wang] Retinopathy? – Retinopathy, do you see any changes? In relation to the diabetes because I hear Scott’s suggestion of leukopathy. Yeah, eye changes. – I think that’s very good suggestion. Unfortunately we didn’t do that. But actually yeah that’s– – [Ji-Guang Wang] (laughs) Yeah actually that’s very
important to look at. – [Wen-Yi Yang] Yeah, yeah. – [Ji-Guang Wang] It is very
important for diabetes it is important for such severe hypertension. – [Wen-Yi Yang] Yeah. – [Ji-Guang Wang] So that’s
something we should consider. Any other comment please,
to the back side, Dr. Cheng. – Have you ever measured
the size of kidney? And have you ever did, I
think you must have did, the regular blood tests. Did the patient has anemia? Which is most common in
coronary kidney diseases. – [Zhen-Yu Zhang] We did, I
go back to just normal in– – [Ji-Guang Wang] Blood routine test. – [Zhen-Yu Zhang] Exactly. – [Ji-Guang Wang] Whether
the patient has anemia. (laughs) – [Zhen-Yu Zhang] I just
want to comment once. So the micro-albuminuria,
if you want to diagnose a chronic kidney disease,
one test is not enough. So you have to repeat it
at least after one day. And then you have to see
whether this has still lasted. – [Ji-Guang Wang] Microphone please. Where is the microphone? – [Zhen-Yu Zhang] Yeah. Because this patient has
this acute respiratory, because this patient has acute
respiratory check infection, and also this is a reason
for the micro-albuminuria. For some patient we see this. And another reason might be the diabetes. As what you suggested because the, sorry, diabetic, yeah has
already lasted for some years. So this is also one of the reasons. Another reason maybe because
the high blood pressure. It’s also we have a lot of
blood loading in the kidney. So this also may cost a kidney injure. We think that’s the reason. But whether it’s chronic or not we cannot, conclude this at this moment,
we need a repeat measurement. – [Ji-Guang Wang] Okay– – [Wen-Yi Yang] And I’ll also
come back to the question of the anemia, actually we do check, we did check it of course. There is not in this case. The patient don’t complain
anything about that, and also the routine
blood tests were normal. And so that maybe as what you
suggested might be indicate is not the case of the
coronary kidney disease. But actually we highlight this question, we raised this question
actually so we need to there in the clinic practice, a vote actually. I neglect that actually. For the very high, extremely
high blood pressure actually can cause quite acute kidney injury and you will
with this micro-albuminuria. – [Anna F. Dominiczak]
Can I add something? – Yeah. – So it’s very good that you
honestly told us that you didn’t look into the fundus. But for me that creates an
additional diagnostic problem. Because with the presentation
of blood pressure, 230 of 150, this could be malignant hypertension. And if it is a malignant hypertension, then this is a presentation
that includes kidney disease, acute on chronic perhaps on
the top of diabetic neuropathy. So my problem is that I
will never now know whether that was a presentation of malignant accelerated hypertension or not. Because without fundi I will never know, and I have a chest pain when I hear this. – So I think that’s the reason why we didn’t check it because
this patient didn’t have any symptoms with their eyesight. He can clearly see it and
he didn’t have any headache. Of course it is not the, not the absolute evidence
but I think that’s the reason why we didn’t change it
or we didn’t check it. And another reason is because
we lower the blood pressure immediately with the
intravenous medicine and the symptoms is resist, very fast. – [Ji-Guang Wang] Yeah, please. – So for the treatment
of this hypertension… Sorry. – [Ji-Guang Wang] Yeah. – Yeah. – [Ji-Guang Wang] Yes, please. – For the treatment of hypertension, what kind of drug would you use? – [Ji-Guang Wang] Yeah any
suggestions from the audience? Which drug would you choose? – [Audience Member] Microphone there. – I will use labetalol infusion. – [Ji-Guang Wang] Okay. Please. – So, according to the deadlines
for this young patient, with the age of less than 55 and this is a non-black individual. We could start from ACI
or ARB or a beta blocker. And if the blood pressure
is not very well controlled, we could consider to combine it. Either calcium-channel
blocker or diuretics. If the blood pressure is still
not very well controlled, we would use calcium-channel
blocker, diuretics, plus ACI or a beta blocker. And at the in-stage if
we think that this is our resistant hypertension
we should use aldosterone. We should use aldosterone
antagonist, for instance the spironoLactone, sorry. – [Ji-Guang Wang] Spironolactone. – Yeah, spironolactone, yeah. – [Ji-Guang Wang] Yeah, please. – And for the selection of the medicine, I think that forgiveness
is very important. We need to select the medicine
with a long half-life. So this is to make the blood pressure low, in fact very stable. For instance another thing,
of course you can see here, if you only take 50
percent of the dose that doctors prescribed, you still
can have a very stable level of the blood pressure and
the green line indicates minus 15 millimeter mercury. So this is why we choose
this long half-life medicine. And in this case, would you mind? – Yeah, okay. So because we repeated again and again, for such a high blood
pressure what we should do emergency because we didn’t
mention this part because certainly we will do it because
I think it’s kind of better, so we will just use intravenous drug to temporarily control the
drug and also related to left ventricular load
to release the symptom. And of course we also initiate
the antidiabetic treatment, and also we combine the
several drugs including the urine diuretics and then
after I think two weeks, and more than two weeks,
I think the patient will discharged with an office
blood pressure 168 over 112, millimeter of mercury. – [Ji-Guang Wang] That’s still
in stage three hypertension. (laughs) Okay he’s a… No, no, no, no. No. Yeah, one more. No, no, no, no. – So the next question would be, is this a resistant hypertension patient? Is it or not? – [Ji-Guang Wang] All agree, please. – All agree. – [Ji-Guang Wang] Easy, nobody. – Okay, so. Of course we do the 24
hour blood pressure. And we see is this
patient has hypertension. But we forget, that could be the reason, that
could be another possibility. That this patient had a
pseudo-resistance hypertension. – [Ji-Guang Wang] No because
you did already many times of 24 hour blood pressure, okay. Any suggestion? Because we don’t have much
time, we’re running out of time. If there is– – [Anna F. Dominiczak] We
now need to hear this all the way to the end because
we are near at the end. – Yeah, just one more
because we didn’t check the adherence of this patient. Of course we checked the
24 hour blood pressure but we didn’t check the
adherence of the patient. So how can you exclude the possibility of pseudo-resistant hypertension? Okay. So for this patient we use
the Morisky questionnaire. Of course this is not the best
way to assess the adherence. Because the more, the golden
standards that propose the idea guideline is the measurement
of the urine of blood of the metabolites of the drug. But of course we didn’t
do it in this case. So for this patient we think,
we checked this questionnaire and this patient has very good adherence. That’s why we proceeded
to the Renal denervation. – Yeah so actually you know
the patient was admitted to our hospital in 2012. Actually that time is actually
is a hot-point for that just because of the
relief of simplicity too. And we were motivated to
do the Renal denervation. Actually that was the first
case we did in our hospital. And according to the CTA and also the Renal arterial angiography
actually you can see that the anatomy is very suitable
for this Renal denervation because we can start several
sites so that’s what we did following the procedure what
reporting is simplicity too. And then we did the operation
by using the simplicity, the first degeneration
one tip, the device. And after the Renal denervation
there is no complication. And urine analysis is normal,
and no any other complication. And the in-hospital monitor
and blood pressure was. And then we followed this
patient for until now, it’s almost six years and
in this first months you already observed that actually the office blood pressure
decreased and we also already because of the micro-albumin problem, we also already started the diuretics and then we continued to follow this patient and
decreased the dosage of the anti-hypertensive treatment drugs. And actually the office blood
pressure were controlled, as well as 24 hours of
blood pressure until now. And also ECG tend to be normal, and Urine Albumin actually
now I see that it’s normal. And left ventricular function
recovered at six months to left ventricular ejection frequency 66. And it remained to now, the normal left ventricular function. And then actually our
conclusion is at last. Style changes maybe is
also help in this case to optimize medical treatment
remained the first-line therapy. And the most recent trials
such as SPYRAL-MED-OFF and MED-ON are reviving the
Renal denervation recently as a treatment modality hypertension. But for the treatment-resistant
hypertension should not be excluded from the
new clinical trials because they are now focused on,
likely the treatment naive or not very high, treatment
resistant hypertensions. They are trying to
exclude these people from continuing the trials, thank you. – [Ji-Guang Wang] Okay,
thank you very much for (audience claps)
the extra patience. And also of course for the
discussions from the audience. You still have a question? We don’t have time, sorry. Last question, very short
question and very short answers. (audience member speaking faintly) – So I have a question. If we want to treat
out-patients with heart failure, how to make his, Ecvelo stable. Because, I just see you, use three to a fog has it for anti, hypertensive treatment. Yes? – [Ji-Guang Wang] Yes.
Yes. But no one is social with the small vascular resistance. What I mean is that the
small vascular resistance, the small vascular contract and then the blood sugar increased, right? But then during this I didn’t
see any drug to show this. And I was just– – [Ji-Guang Wang] Use this inhibitor. They use this inhibitor. – [Audience Member] Perindo. – [Ji-Guang Wang]
Perindopril, perindopril. – And– – [Ji-Guang Wang] It’s very strong in dilating the small arteries. Yeah, okay. Do you have any comment, very short? – [Audience Member] Just to
thank the chairperson for giving us the opportunity– – [Ji-Guang Wang] Okay. – [Audience Member] For all this. – [Ji-Guang Wang] Okay,
thank you very much. (audience claps) – [Woman] Thank you, thank you.

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