Skill Checkup: A 79‐Year‐Old Man With Long-Standing Hypertension and Obesity Presents With Shortness of Breath on Exertion

Yasmine S. Ali, MD

Disclosures

July 08, 2022

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

A 79-year-old man in Europe with long-standing hypertension, dyslipidaemia, and obesity presents with shortness of breath on exertion that began 6 months earlier; it has since gradually worsened to the point where it now interferes with daily activities, including short walks. He was hospitalised for heart failure (HF) 2 months ago. He has not noticed any exertional chest pain.

Current medications include hydrochlorothiazide 200 mg daily, amlodipine 10 mg daily, lisinopril 20 mg daily, and atorvastatin 20 mg daily; he admits to less than perfect adherence. On examination, his blood pressure (BP) is 160/80 mm Hg, heart rate (HR) 78 beats per minute and body mass index (BMI) 36 kg/m2. He has peripheral oedema and increased jugular venous distension, elevated 10 cm above the right atrium. An electrocardiogram does not demonstrate ischemic changes. His baseline echocardiogram shows mild left ventricular hypertrophy with an ejection fraction (EF) of 55% and a right ventricular systolic pressure of 50 mm Hg.

During stress echocardiography, he exercised for only 3 minutes on a modified Bruce protocol, stopping for extreme shortness of breath. His BP at rest was 160/70 mm Hg, and HR was 76 beats per minute. At peak exercise, his BP was 196/90 mm Hg, with a peak HR of 105 beats per minute. Echocardiographic images at the end of the exercise demonstrated augmentation of contractility of all walls, without significant mitral regurgitation.

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