The Vulnerable Patient:

Case Examples:

Patient 1: SPRINT

A 68 year old nondiabetic male with stage 3 CKD, who had a coronary stent placed in his LAD 1 year ago for stable angina presents to his primary care provider to establish care after moving into the area. His office blood pressure is 138/84 mm Hg. His nephrologist had placed him on HCTZ years ago for his CKD and his cardiologist placed him on low dose metoprolol succinate following his stent.  

What makes this patient vulnerable?

This patient fits the inclusion criteria and in some ways represents the typical SPRINT trial participant: Over age 50 (mean age 68) with established CAD or CKD (has both) on ~ 2 drugs for hypertension.

Patient 2: White Coat Hypertension

A 36 year old female marathon runner with BMI of 20 presents to her PCP office for evaluation of bunions. She has no other chronic medical problems except for mild anxiety - mostly in social situations. She takes occasional propranolol prior to public speaking but otherwise no other medications. 

She ran 10 miles earlier that day but cut it short because it was hot outside and her foot was acting up. She apologizes for being 5 minutes late to the appointment. 

Her blood pressure in the office is 147/92 mm Hg with a HR of 87 bpm. Her last office visit 6 months ago for plantar fasciitis showed a BP of 142/91 mm Hg and HR of 78 bpm. She states her BP is always high in the office but she doesn’t check it at home. She is surprised by her HR since her Apple Watch typically shows it in the mid 50s when resting at home. 

Her PCP informs her that she has Stage 2 Hypertension and by the latest guidelines she should be treated aggressively with 2 different agents. She places her on hydrochlorothiazide because it is a first line agent and a low dose beta blocker since her HR has gone up so much and it might help with her anxiety.

What makes this patient vulnerable?

First of all, it’s highly unlikely this patient actually has hypertension. Again, hypertension is a disease. It usually keeps close company with many other cardiometabolic diseases such as obesity, sedentary lifestyle, diabetes or prediabetes, CKD, cardiovascular diseases and aging. She has none of those.

This patient is a young, athletic and otherwise healthy individual, with an optimal BMI. As a marathon runner, she no doubt has a high vagal tone (parasympathetic nervous system) but also a robust sympathetic response to stress (doctor’s office, pain, dehydration, anxiety). The relatively high HR and BP are more likely a reflection of her adrenergic state, than a true representation of the disease of hypertension. Furthermore, (this should come as no surprise) the doctor’s office rarely has the time to check BP’s in accordance with guideline recommendations. 

In this setting the biomarker is not being employed and interpreted correctly. 

Treating this particular patient - an endurance athlete - with a diuretic (yikes) and a beta blocker is a recipe for disaster. Yet it happens. At best she will feel miserable trying to get her HR up when she runs. But more likely she will have worsening dehydration, electrolyte abnormalities (low sodium, high/low potassium, low magnesium), kidney impairment (from thiazide diuretic) and risk for syncope (passing out) with the combination of both. 

Patient 3: Masked hypertension

A 58 year-old male smoker is seen in the primary clinic for his annual follow up visit. His blood pressure is 132/83 mmHg. Similar to last year and the year before that. He typically fasts and doesn’t drink any water prior to his office visits in the event he has to do lab work. 

He has a high stress job selling cars at the local dealer. He hates drinking water and prefers coffee during the day and then several alcoholic beverages nightly to help him relax after work. He doesn’t feel he has time to exercise but his wife, who accompanies him to the visit, occasionally forces him to go for evening walks with her but at a casual pace. She also checks his blood pressure at home and reports that more often than not it is in the 140-150’s/80-90s mmHg. 

What makes this patient vulnerable?

The precise cause of masked hypertension is not entirely known but is typically seen in those with untreated risk factors of smoking, alcohol abuse, sedentary lifestyle and job stress. There may be many reasons why the office based blood pressures tend to be normal, while the out of office measures are elevated. Chronic dehydration, alcohol consumption, poor eating behaviors, disrupted sleep patterns and lack of exercise/activity all have unpredictable influences on blood pressure as an accurate biomarker for hypertension recognition and for gauging its severity. 

Hypertension, in many ways, is a “gateway” disease to other cardiometabolic disease states. When hypertension fails to be diagnosed and treated, so too do the other cardiometabolic diseases which accompany it.

Vital signs are just that - they are “vital.” When the most important “vital” sign, blood pressure, is “normal” in the office, the patient may be overlooked despite demonstrating numerous warning signs of uncontrolled metabolic syndrome. This represents a high risk patient at greater risk for stroke, heart attack and heart failure when left untreated year after year.