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]

2 minutes ago, KatieMI said:

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.

I hate to be pedantic, but in your traffic analogy the drone is the US and the several teams of workers are the CTA?

[Anonymous666]

1 minute ago, LovingLife123 said:

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.

The patient had been experiencing a very stressful life situation— moving to a new state and dealing with a neighbor that involved the police on a number of occasions. I imagine he checked it out of interest because he was stressed...

His mother has HTN. Besides that, there’s really not much else.

[KatieMI, BSN, MSN, RN]

47 minutes ago, Anonymous666 said:

I hate to be pedantic, but in your traffic analogy the drone is the US and the several teams of workers are the CTA?

Yes.

Drone will not see an exact cause of congestion (stenosis). It flies too high for it. It will show if it is truly there, where approximately it starts or ends and how much it affects the whole. If the problem really exists, you can then send workers exactly there or do something else. But it might not be there at all as well, you do not know at this point.

Workers will sit there and report that where they are traffic flows smoothly or not. They can spot that broken car which holds it. They won't be able to say where congestion starts. Depending on how much of them you use and other factors they may or not be able to say how much the whole place is affected.

There are in fact several things which can lead to subclavian steal syndrome (SSS) and not all of them can be seen on CTA or MRA unless radiology knows what to look for. In fact, accidental finding of SSS in a female is an indication for mammogram, in a smoker for chest Xray and in anyone after age of 45 for fecal occult blood and/or fecal cytology or colonoscopy because mets of cancers of lung, colon and breast into regional lymph nodes can cause it, and that happens not that infrequently. But the first thing is to make sure that the steal is really there. U/s is cheaper, risk-free and answers this first question, that's why it should be used first.

[KatieMI, BSN, MSN, RN]

Dissection should be a really back-burner Dx for a totally asymptomatic patient with no murmur and no pulse differences. Considering risk factors (male, overweight, stressed) the workup should be started from routine labs incl renal profile and anti-stess as much as possible for a couple of weeks with bi-weekly BP measurements done correctly, same cuff, right size. Everything else could be done after, providing the patient is asymptomatic and continues to have no other symptoms.

BTW, measuring BP on the wrist can produce different results under normal conditions otherwise, especially on well-built males who gave clear right or left dominance. The "better" hand will show higher number.

Again, BTW, taking BP in any other place except for brachial artery should not be done under normal circumstances.

[Anonymous666]

3 minutes ago, KatieMI said:

Yes.

Drone will not see an exact cause of congestion (stenosis). It flies too high for it. It will show if it is truly there, where approximately it starts or ends and how much it affects the whole. If the problem really exists, you can then send workers exactly there or do something else. But it might not be there at all as well, you do not know at this point.

Workers will sit there and report that where they are traffic flows smoothly or not. They can spot that broken car which holds it. They won't be able to say where congestion starts. Depending on how much of them you use and other factors they may or not be able to say how much the whole place is affected.

There are in fact several things which can lead to subclavian steal syndrome (SSS) and not all of them can be seen on CTA or MRA unless radiology knows what to look for. In fact, accidental finding of SSS in a female is an indication for mammogram, in a smoker for chest Xray and in anyone after age of 45 for fecal occult blood and/or fecal cytology or colonoscopy because mets of cancers of lung, colon and breast into regional lymph nodes can cause it, and that happens not that infrequently. But the first thing is to make sure that the steal is really there. U/s is cheaper, risk-free and answers this first question, that's why it should be used first.

Absolutely. In this particular case, however, the doctor decided that the reports of traffic congestion were so extreme he figured he’d skip sending the drone up and employ teams of workers on to each intersection to get a better idea of what’s going on. The reports back from the workers show no congestion.

MunoRN appears to be claiming that sending in teams of workers will not result in reports of congestion and that sending in the drone is the only way to see if there actually is a traffic issue at all, because teams of workers on each intersection are unable to see the traffic.

So now what does our road surveyor do, given that he has reports of traffic congestion but negative reports back from the teams of workers on all the intersections sent to report on the congestion?

[Anonymous666]

12 minutes ago, KatieMI said:

Dissection should be a really back-burner Dx for a totally asymptomatic patient with no murmur and no pulse differences. Considering risk factors (male, overweight, stressed) the workup should be started from routine labs incl renal profile and anti-stess as much as possible for a couple of weeks with bi-weekly BP measurements done correctly, same cuff, right size. Everything else could be done after, providing the patient is asymptomatic and continues to have no other symptoms.

BTW, measuring BP on the wrist can produce different results under normal conditions otherwise, especially on well-built males who gave clear right or left dominance. The "better" hand will show higher number.

Again, BTW, taking BP in any other place except for brachial artery should not be done under normal circumstances.

As stated before, the patient is now taking Norvasc 10 mg and Lisinopril 10 mg daily. He has been on a daily exercise regime and eating healthy for the last 2 weeks. He’s lost 7 lbs since his last office visit and checks his BP regularly throughout the day.

He’s averaged out at low 140’s / 90’s on the right arm and 120’s / 80’s on the left. His HR now averages 70’s-90’s at rest, whereas his norm before was low 60’s. He is less stressed and remains asymptomatic.

Surprised no one suggested he go see a cardiologist...

[KatieMI, BSN, MSN, RN]

1 minute ago, Anonymous666 said:

Absolutely. In this particular case, however, the doctor decided that the reports of traffic congestion were so extreme he figured he’d skip sending the drone up and employ teams of workers on to each intersection to get a better idea of what’s going on. The reports back from the workers show no congestion.

MunoRN appears to be claiming that sending in teams of workers will not result in reports of congestion and that sending in the drone is the only way to see if there actually is a traffic issue at all, because teams of workers on each intersection are unable to see the traffic.

So now what does our road surveyor do, given that he has reports of traffic congestion but negative reports back from the teams of workers on all the intersections sent to report on the congestion?

Then it means the workers happened to be in a place where there was no congestion. It was at the next exit but they were not there, so they missed it.

You got false negative study result. Send more and more workers. Or stop going crazy and treating reports as if they were real events. Make sure the problem is here first. Send the drone.

And doc just had a knee jerk and wanted "to do something" however wrong or useless it might be instead of analyzing the situation and explaining the patient the appropriate management and workup protocol.

Or the patient, being experienced ICU nurse, was holding the typical nursing point of view of "doing something for something!!!" without ever thinking what that something could be and if that something is even real. He is used to work with STAT imaging, asked or prompted doc to order it and got it done. It showed nothing. We still do not know if the problem is there.

[KatieMI, BSN, MSN, RN]

https://onlinelibrary.wiley.com/doi/full/10.1111/jch.12125

11% of young healthy adults had systolic BP difference > 10 mm between hands, reproducible

Large difference is linked to increased CV risk:

https://www.hindawi.com/journals/ijhy/2018/9370417/

and many others

Also please see the case discussion:

https://www.medscape.com/viewarticle/436713 Some researchers cited there found up to 40% incidence over population (the case itself is irrelevant due to patient belonging to entirely different subset)

Evaluate for CV risk factors. Correct what is correctable (cholesterol, A1C). No need in ASA as of right now (no clear indications if patient had no s/s of heart disease, chest pain or any other symptoms, and in asymptomatic population NNT of ASA for primary CV prevention is in high hundreds and higher than number of those who got GI bleed). Cardiologist might be needed in perspective; as patient is asymptomatic and ECG is normal, as you wrote above, there is no need for immediate consult. Do the u/s and stop freaking out about numbers. If u/s positive, consult vascular surgeon.

That's it. It is a simple outpatient case for any NP (not M.D.) with nerve and experience.

[Anonymous666]

9 minutes ago, KatieMI said:

Then it means the workers happened to be in a place where there was no congestion. It was at the next exit but they were not there, so they missed it.

You got false negative study result. Send more and more workers. Or stop going crazy and treating reports as if they were real events. Make sure the problem is here first. Send the drone.

And doc just had a knee jerk and wanted "to do something" however wrong or useless it might be instead of analyzing the situation and explaining the patient the appropriate management and workup protocol.

Or the patient, being experienced ICU nurse, was holding the typical nursing point of view of "doing something for something!!!" without ever thinking what that something could be and if that something is even real. He is used to work with STAT imaging, asked or prompted doc to order it and got it done. It showed nothing. We still do not know if the problem is there.

What if the doc sent the workers to look for a dissection? Do you think they probably missed that, too? I wonder what else they missed...

If that’s the case—these workers miss traffic congestion and dissections—even though these workers, per the literature you cited, are replacing the current gold standard for diagnosing subclavian occlusive disease in most centers, maybe they should be fired?

As previously mentioned in this thread (I think maybe more than once) this particular doctor, rather than skipping protocol per the request of his patient (?), stated that given the data (the BP difference mentioned a few times before) that he would skip the usual protocol of less invasive tests first with more comprehensive follow up studies to be ordered after receiving the results of said more preliminary tests, as he was sure he would be ordering the more comprehensive tests anyway, and just went ahead and ordered the CTA.

To any mods paying attention, I really am doing my best to restrain my sarcasm when responding by simply repeating myself over and over.

[Anonymous666]

6 minutes ago, KatieMI said:

...Do the u/s ... If u/s positive, consult vascular surgeon. ...

I thought if US positive, you’re supposed to do a CTA (according to you and the medscape piece you cited)...

Also, the vascular surgeon would indeed order a CTA before going anywhere near a scalpel or to help size a stent...