Skill Checkup: A Woman With Long‐standing Hypertension and Worsening Dyspnea on Exertion

Yasmine S. Ali, MD

Disclosures

December 23, 2021

The Skill Checkup series provides a quick, case-style interactive quiz highlighting key guidelines- and evidence-based information to inform clinical practice.

A 68-year-old woman with long-standing hypertension, obesity, and type 2 diabetes presents with shortness of breath on exertion that began 6 months ago and has since gradually worsened. She is not experiencing exertional chest pain. She can shop in the local supermarket, but carrying her packages home has become increasingly difficult. She wants to return to her previously active life.

Current medications include amlodipine 10 mg/d, metformin 1000 mg/d, lisinopril 20 mg/d, and atorvastatin 20 mg/d. On exam, her blood pressure (BP) is 140/80 mm Hg, heart rate is 78 beats/min, height is 5' 5", and weight is 190 lb (body mass index, 31.6 kg/m2). She also has peripheral edema and increased jugular venous distention elevated 10 cm above the right atrium. Electrocardiography does not demonstrate ischemic changes. Her baseline resting echocardiogram showed mild left ventricular (LV) hypertrophy with an ejection fraction (EF) of 55% and a right ventricular systolic pressure of 50 mm Hg. During stress echocardiography, she exercised for only 3 minutes on a modified Bruce protocol, stopping because of extreme shortness of breath. At peak exercise, her BP was 196/90 mm Hg, with a peak heart rate of 105 beats/min. Echocardiographic images at end exercise demonstrated augmentation of contractility of all walls, without significant mitral regurgitation.

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