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A 46 years old man was on appointment in the cardiology clinic for medical evaluation of exertional shortness of breath. He has always been zealous in maintaining aerobic fitness, but about six (6) month before his cardiology clinic, he began to note severe breathlessness as he approached the completion of his daily run which conclude with a long but gentle uphill climb. During the intervening 6 months, the patient reports a progression in his symptoms to the point that, now, he rarely completes the first half of his daily run without resting. He denies chest discomfort at rest or with exercise. His family history is notable for hypertension and premature atherosclerosis. He has never used tobacco product before.
On clinical examination, the patient is hypertensive (BP = 160/102 mmHg), and a prominent presystolic S4 is heard at the left ventricular apex. The examination is otherwise unremarkable. The chest X-ray is reported as normal. The electrocardiogram (ECG) reveals normal sinus rhythm with voltage criteria for left ventricular hypertrophy. He is referred gpt a noninvasive cardiac evaluation, including the treadmill exercise test (ETT) and a transthoracic echocardiogram. On the ETT, he reaches a peak heart rate of 70 beat/min during the exercise and has to terminate the test because of severe dyspnea at a workload of 7 METS (METS are metabolic equivalents, a measure of energy consumption, a value of 7 METS is below normal for the patient’s age). His blood pressure at peak exercise is 240/120 mmHg. There is no evidence of myocardial ischemia by ECG criteria. The two-dimensional echocardiogram reveals concentric pattern left ventricular hypertrophy. An enlarged left atrium, and a normal aortic and mitral valve. Global and regional left ventricular systolic function are normal. Left ventricular diastolic filing is abnormal, with a reduced rate of early rapid filling and a significant increase in the extent of filling during atrial systole.
What are the current recommendations for initiation of antihypertensive drug therapy, and what are the therapeutic goals?
Thiazide diuretics have been used for many years as first line therapy in patients with hypertension. What specific clinical circumstances might favor use of another agent, such as an angiotensin converting enzyme inhibitor?
Given the severity of the hypertension in this case, the patient will likely require at least two drugs to achieve adequate control of the blood pressure. When is multidrug therapy required?