Strange HTN case

[Anonymous666]

39 year old male

6 ft 200 lbs

No significant hx

BP in right arm 180/120. BP in left arm 144/98. HR 80. Radial pulses, pedal pulses 2+ Bilat. No bruits heard. Pt is basically asymptotic

Been taking amlodipine 5mg daily x2 days, increased to 10 mg daily x4 days.

BP is still unchanged

Labs done. No issues. Total cholesterol 261. Pt states he is sedentary

Renal artery US ordered and scheduled

Chest CTA w/wo, and abdominal aorta CTA w/wo ordered and scheduled

All imaging to be done over the next two weeks then f/u physical in PCP office.

Thoughts?

I’m kinda worried about the Norvasc not “kicking in” yet? Maybe it needs an extra antihypertensive med in the meantime... I don’t like the idea of someone running around with a SBP in the 170’s,180’s and DBP 120’s,130’s

[Anonymous666]

11 hours ago, adventure_rn said:

Woah, calm down.

...

We are a community of professionals who are here to support one another; if you want to throw a tantrum, please take it to Reddit.

Sorry if I hurt anyone’s feelings. My “rant” was more of a general statement than a direct and personal stab at any one individual. I do appreciate the responses; I just simply as that folks read what has already been said before chiming in.

[Anonymous666]

10 hours ago, MunoRN said:

Sorry we're so stupid. But since your comprehension is so superior to the rest of us I'm sure you're already aware that the most likely cause of L vs. R arm blood pressure differences is due to subclavian stenosis, which can't actually be evaluated by CT scan, even though you claimed that stenosis had been ruled out by CT.

I did not claim that stenosis had been ruled out by CT. I stated the symptoms, my suspicions of SC stenosis, and the results of the CTA w & w/o.

You, however, have made the claim that subclavian artery stenosis cannot be evaluated by CT. I’m interested in hearing more about why you say this, as the doctor who ordered it specifically stated (as I mentioned before in an earlier post) that we should skip the US to r/o SC artery stenosis and go straight to a CTA given the huge difference in BP readings per arm.

It is my understanding that CTA would be, and is, used to diagnose SC artery stenosis, as well as r/o any other malformations, etc.

If you could elaborate, I’d appreciate it...

[MunoRN, RN]

48 minutes ago, Anonymous666 said:

I did not claim that stenosis had been ruled out by CT. I stated the symptoms, my suspicions of SC stenosis, and the results of the CTA w & w/o.

You, however, have made the claim that subclavian artery stenosis cannot be evaluated by CT. I’m interested in hearing more about why you say this, as the doctor who ordered it specifically stated (as I mentioned before in an earlier post) that we should skip the US to r/o SC artery stenosis and go straight to a CTA given the huge difference in BP readings per arm.

It is my understanding that CTA would be, and is, used to diagnose SC artery stenosis, as well as r/o any other malformations, etc.

If you could elaborate, I’d appreciate it...

Diagnosing subclavian stenosis requires some way of evaluating flow and velocities, an ultrasound is the standard method.

While subclavian stenosis is the more common explanation for a significant left vs right difference in BP, a dissection is the more concerning cause, which can be evaluated by CT.

[Anonymous666]

1 hour ago, MunoRN said:

Diagnosing subclavian stenosis requires some way of evaluating flow and velocities, an ultrasound is the standard method.

While subclavian stenosis is the more common explanation for a significant left vs right difference in BP, a dissection is the more concerning cause, which can be evaluated by CT.

Putting aside the fact that, as I stated earlier, the doctor who ordered the CTA for this pt rationalized his decision to skip the less invasive and more preliminary diagnostic procedure of ultrasound for the more invasive and comprehensive diagnostic procedure of CTA as being due to the immense difference in BP between the left and right arms (SBP of 180 versus 140) indicating there is definitely something not right and that instead of taking the usual diagnostic path of more preliminary and non-invasive tests first we’ll just skip to getting a good look at what’s going on with all the blood vessels in this pt’s body with a CTA, you’re saying that subclavian artery stenosis is cannot be evaluated by CT because “ultrasound is the standard method”?

To simplify:

Doctor: “Wow! This pt’s BP is so different when comparing each arm that I’m pretty confident something is pathologically and/or structurally wrong with his blood vessels that following the usual route of first doing an ultrasound of the subclavian arteries would be unnecessary, as I’m pretty sure we’ll be following up with a CTA, anyway. So, I’m just gonna skip that step and go straight to the CTA.

You: Subclavian Artery Stenosis cannot be evaluated by CT scan.

Me: Really? Can you elaborate on that claim?

You: Subclavian Artery Stenosis cannot be evaluated by CT scan because an ultrasound is the standard method.

Just curious as to what your understanding of CTA (Computed Tomography Angiogram) is and why you think this particular doctor ordered one for this patient... also maybe what your understanding of IV contrast is...?

[MunoRN, RN]

3 hours ago, Anonymous666 said:

Putting aside the fact that, as I stated earlier, the doctor who ordered the CTA for this pt rationalized his decision to skip the less invasive and more preliminary diagnostic procedure of ultrasound for the more invasive and comprehensive diagnostic procedure of CTA as being due to the immense difference in BP between the left and right arms (SBP of 180 versus 140) indicating there is definitely something not right and that instead of taking the usual diagnostic path of more preliminary and non-invasive tests first we’ll just skip to getting a good look at what’s going on with all the blood vessels in this pt’s body with a CTA, you’re saying that subclavian artery stenosis is cannot be evaluated by CT because “ultrasound is the standard method”?

To simplify:

Doctor: “Wow! This pt’s BP is so different when comparing each arm that I’m pretty confident something is pathologically and/or structurally wrong with his blood vessels that following the usual route of first doing an ultrasound of the subclavian arteries would be unnecessary, as I’m pretty sure we’ll be following up with a CTA, anyway. So, I’m just gonna skip that step and go straight to the CTA.

You: Subclavian Artery Stenosis cannot be evaluated by CT scan.

Me: Really? Can you elaborate on that claim?

You: Subclavian Artery Stenosis cannot be evaluated by CT scan because an ultrasound is the standard method.

Just curious as to what your understanding of CTA (Computed Tomography Angiogram) is and why you think this particular doctor ordered one for this patient... also maybe what your understanding of IV contrast is...?

A CT is used to assess for a dissection, since that is more concerning reason for a large L vs R difference in BP readings. Typically such a large difference should be evaluated by CT first to rule out a life threatening dissection.

To evaluate for stenosis an ultrasound isn't just a preferable method compared to CT since stenosis can't be assessed by CT. Think of it like trying to assess how fast someone runs, this can be done using video but using a still photo. Evaluation of stenosis requires flow, turbulence, and vascular response to the systole and diastole phases. These are not data obtained by a CT.

[KatieMI, BSN, MSN, RN]

1). When you see someone with BP of 200/120 in the office out of the blue air, please stop and think:

- this human being was walking just like that for the last X years without anybody knowing about it. He is asymptomatic. He did not have a srtoke/AMI/etc. so far. We have nothing to 100% prevent any of it. He can, or can't, have sny of it within the next 5 min, and neither doctor, nor you cannot do anything about the fact. He also can walk just like that for the next X years with no evil effects, anc you can do nothing with that.

Got it? Treat the patient, not the number. If patient is asymptomatic, frantic efforts to "control" BP can be harmful, and your level of "comfort" is irrelevant to that. Within 1 week of starting therapy for previously untreated and just diagnosed HTN decrease of systolic of 10-15% (with several measurements done correctly) , diastolic 10% is the goal. If that gives you 180/110 but the patient remains asymptomatic and without side effects, so be it.

In this case, patient (beinb experienced ICU nurse, used to quick movements and decisions one in a split second) was SYMPTOMATIC (dizziness, panic) after "controlling" her BP. Which with all possibilities means that it was way too well controlled. The treatment should be decelerated.

2). We do not know what causes elevated BP in each and single case. We just have no ways to know exact mechanism for every patient. So, yeah, in one guy CCBs may work less than ACEI. Or ACEI worse than ARB. Or nothing of above works but alpha-blocker does the job. It is always a trial and error, and jumping on and off meds and doses every 3 days in outpatient is not a good thing. It shouldn't happen.

3). Totally asymptomatic subclavian stenosis, and especially asymptomatic dissection are very much "zebras". The former one is evaluated by arterial doppler and the latter one by contrast imaging (CTA, MRA, etc). Subclavian steal should have more than just BP difference, including pulses difference, in order for workup to make clinical sense:

https://emedicine.medscape.com/article/462036-clinical#b3

CTA cannot show hemodynamic values. The % of occlusion (which is the $1.000.000 question here) can only be evaluated by Doppler method. That's from a funny thing named "physics".

Chronic type A aortic dissection seems to be very rare by itself and even rarer to ve entirely asymptomatic all along if ever (in the following article and literature all patients had symptoms although they varied in intensity and were misinterpreted). The widened aorta can be seen on usual A/P chest Xray.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5068495/#s1title

In addition to this, one should be cautious ordering CTA aorta (which uses a lot of IV contrast) on someone with chronically uncontrolled HTN. You never know when someone's kidneys might go belly up.

Overall, lessons to take home from the case:

- treat the patient, not a number. Whatever the number can be;

- 90+% of diagnosis are in history and assessment, if they are done correctly;

- see a huff print? Go hunt a horse, not a zebra.

- for chronic conditions, drive like your aunt Sally on a highway. Start low, go slow, get safely to goal.

Ol' good school of clinical medicine, 101.

[Anonymous666]

51 minutes ago, MunoRN said:

...stenosis can't be assessed by CT...

Although I’m sure pursuing this claim of yours will only lead to a semantical debate, I beg to differ.

CTA is an effective method to evaluate for upper extremity artery stenosis. It has even been proven to be more reliable than US when measuring and classifying carotid stenosis.

Just to clarify, however, according to you, this patient should go back to his PCP and request an ultrasound of his subclavian arteries to r/o subclavian stenosis as he believes the CTA not only might have missed it but is actually a test that is not capable of assessing for stenosis because an RN on the internet told him so?

[KatieMI, BSN, MSN, RN]

3 minutes ago, Anonymous666 said:

Although I’m sure pursuing this claim of yours will only lead to a semantical debate, I beg to differ.

CTA is an effective method to evaluate for upper extremity artery stenosis. It has even been proven to be more reliable than US when measuring and classifying carotid stenosis.

Just to clarify, however, according to you, this patient should go back to his PCP and request an ultrasound of his subclavian arteries to r/o subclavian stenosis as he believes the CTA not only might have missed it but is actually a test that is not capable of assessing for stenosis because an RN on the internet told him so?

Please read the "workup" section in the article link in my previous message. Ultrasond is #1 and most important step, if it shows flow disruption, then CTA goes as #2.

[Anonymous666]

3 minutes ago, KatieMI said:

Please read the "workup" section in the article link in my previous message. Ultrasond is #1 and most important step, if it shows flow disruption, then CTA goes as #2.

I’m unable to read the “work up” section, as it requires medscape membership. Maybe you could just paraphrase?

Why would a CTA be the follow up test after an US shows flow disruption, only to r/o dissection, or could there possibly be other reasons?

[Anonymous666]

14 minutes ago, KatieMI said:

Please read the "workup" section in the article link in my previous message. Ultrasond is #1 and most important step, if it shows flow disruption, then CTA goes as #2.

Don’t worry. I remembered my medscape password.

The work up section actually states that CTA has replaced the current gold standard, conventional angiography, as the first line modality for the diagnosis of subclavian occlusive disease in most centers.

Still confused why this patient after having a negative CTA needs to follow up with an US...?

[KatieMI, BSN, MSN, RN]

10 minutes ago, Anonymous666 said:

Don’t worry. I remembered my medscape password.

The work up section actually states that CTA has replaced the current gold standard, conventional angiography, as the first line modality for the diagnosis of subclavian occlusive disease in most centers.

Still confused why this patient after having a negative CTA needs to follow up with an US...?

Read the whole section. U/s is #1. Only if it shows anomalous flow, the more invasive CTA makes sense.

Imagine you are state road surveyor. You have several reports about "traffic disruption" between Titusville and Bitusville, both busy suburbs with several highway exits between them. You have no other details. You need to figure out what is going on there. You can:

- send a drone which will fly over all potentially affected area, analyze the pics and live video it will do and then go from there;

- send several teams of workers on every intersection they can cover and make them reporting to you what they observe

What will be an easier and quicker way to begin from?

First way is u/s, second is CTA.

[LovingLife123]

But what promoted this icu nurse with no history to check their BP in both arms?

My immediate thought was dissection. I was also wanting to see what other symptoms the pt was having to prompt them to come in. I’m an icu nurse and I don’t just up an decide to take my own blood pressures at home. Something had to trigger them to think to take it. Especially with no history.

I had a recent experience with the floor bouncing a pt back to us numerous times because the didn’t grasp that after the dissection repair the BP would read differently in the arms.

I feel like there is some background info missing.