Case Study 2:A 44-year old male
Cardiovascular risk factors identified:
- Known hypertension – blood pressure fluctuating around 140/100 mmHg
- Smoker until two years ago (approximately 40 pack years)
- Moderate alcohol consumption, occasionally moderate physical exercise (jogging, swimming)
- Regular snoring
- No significant family history of cardiovascular disease
TREATMENT APPROACH:
The patient was already being treated for hypertension sporadically using beta-blockers, which have now been stopped following abnormal fatigue and orthostatism.
DIAGNOSIS FOLLOWING INTIAL TESTS (SEE TABLE 8 - MARCH):
- Essential arterial hypertension grade I, impaired fasting glucose, suspected non alcoholic fatty liver disease (NAFLD), mild hyperuricemia, vitamin D defiency, metabolic syndrome
- Risk for a fatal cardiovascular event according to SCORE (www.heartscore .org): 1 percent in 10 years. The risk for fatal cardiovascular disease is low in absolute terms due to the young age of the patient, but it is still four times higher than it could be in this age group
- Treatment targets according to ESC, ESH and EAS: blood pressure less than 140/90 mmHg; LDL cholesterol less than 115 mg/dl (2.98 mmol/l)
The patient was recommended to increase the level of physical activity and to modify diet.
- increase the proportion of vegetables and fibre at the expense of saturated fat from butter and cheese
- avoid excessive salt intake
In addition:
- Ramipril was started at 10 mg daily for hypertension
- Vitamin D was substituted at 1000 IE daily
According to the EAS and ESC guidelines for the management of dyslipidemia, the target value for LDL-cholesterol is 115 mg/dl (2.98 mmol/l). The patient was, however, reluctant to accept a lipid-lowering drug and wished to await the effects of life style changes. After 2 months follow-up the patient’s weight was unchanged at 98 kg, and both blood pressure and LDL- cholesterol were lowered.
- Blood pressure 130/85 mmHg
- LDL-cholesterol 142 mg/dl (3.68 mmol/l) HDL cholesterol 34 mg/dl (0.88 mmol/l)
The patient reported that he had failed to intensify physical activity.
The patient was again motivated to intinsify life style changes. Specifically, he was strongly recommended to increase physical activty (two to three times per week 45 to 60 minutes endurance training). For lowering cholesterol, it was suggested that butter should be replaced by plant sterol or plant stanol containing margarine to achieve and intake 2 g of plant sterols or stanols per day.
- Blood pressure 120/85 mmHg
- LDL-cholesterol 101 mg/dl (2.62 mmol/l); HDL cholesterol 48 mg/dl (1.24 mmol/l)
The patient was reviewed again 3 months later. Through the combination of dietary changes including daily consumption of plant sterol or plant stanol and increased physical activity this patient successfully lost weight and improved his cardiovascular risk profile. The abnormal relaxation pattern of the left ventricle disappeared and the physical performance capacity of the patient significantly improved. Blood pressure was well controlled on treatment with Ramipril 10 mg daily. Vitamin D remains subnormal. LDL cholesterol decreased by 39 percent and is within the recommended target range, HDL cholesterol increased by 21 percent, triglycerides slightly improved. Drugs for lowering cholesterol have not been required.
| 2011 | Weight | BMI | Waist circ | Blood pressure | Other laboratory controls | LDL- C | HDL- C |
|---|---|---|---|---|---|---|---|
| Mar | 98 kg | 28,6 kg/m2 | 101 cm | 140/110 mmHg 24 hours blood pres- sure recording: daytime mean 143/94 mmHg; nighttime mean 116/74 mmHg; average 133/87 mmHg |
|
165 mg/dl (4.27 mmol/l) | 38 mg/dl (0.98 mmol/l) |
| May | 98 kg | 26,3 kg/m2 | 130/85 mmHg |
|
142 mg/dl (3.68 mmol) | 34 mg/dl (.88 mmol/l) | |
| Aug | 90 kg | 96 cm | 120/85 mmHg 24 hours blood pres- sure recording: daytime mean 123/86 mmHg; nighttime mean 104/70 mmHg; average 119/83 mmHg |
|
101 mg/dl (2.62 mmol/l) | 48 mg/dl (1.24 mmol/l) |