MSGM Case Presentation May 2025

Prepared by Dr Siti Khairizan binti Rahim

Supervised by Associate Prof Dr Khor Hui Min

Title: The Blood Pressure Paradox: Navigating Hypertension and Orthostatic Hypotension in One Patient.

2018

Mr A is a 66-years-old gentleman with underlying diabetes mellitus, hypertension,

dyslipidaemia, bilateral knee osteoarthritis, and obesity (BMI 30 kg/m 2 )

He is independent with all instrumental and basic activities of daily living and his Clinical Frailty Scale is 3.

His medication prescription and laboratory investigations are as shown:

Upon review during clinic appointment, his blood pressure (BP) was 180/90mmHg and heart rate was 68 bpm. His BP monitoring at home was around 160-180/90-100 mmHg over the last 2 weeks.

Questions:

1. How would you manage his hypertension?

2. What is the target BP for this patient?

2024

Mr A is now 72 years old and his latest BMI is 27 kg/m 2 .

He was recently diagnosed with benign prostatic hyperplasia as having hesitancy with terminal dribbling and started on Terazosin 1mg ON and finasteride 5mg ON for the past 1 week by a urologist.

He presented to the emergency department early in the morning due to right hip pain and difficulty walking. He claimed he had tripped and fell in his room while walking to the toilet at night due to the urinary frequency. His wife also noticed he has tremor over his right hand and was walking slower for the past 1 year.

Upon admission, his BP was 150/88 mmHg, HR was 70 bpm and pelvic X-ray showed right intertrochanteric fracture.

On examination he has reduced facial expression, pill-rolling resting tremor over the right hand, and cogwheel rigidity over the right upper limb.

His prescribed medications in the ward are as shown:

He underwent internal fixation of his right hip, and two days after the surgery, he complained of mild giddiness. His lying BP was 158/88 mmHg, HR was 64 bpm, and standing BP was 100/72 mmHg, HR was 72 bpm. His pain was well controlled, and he continued to take all his medications in the ward.

Questions:

1. What are the possible reversible causes of his orthostatic hypotension?

2. Can you rank his antihypertensive medications from the lowest to the highest risk of orthostatic hypotension?

3. How would you manage his hypertension?

4. What is the target blood pressure for this patient now?

Mr A progressed well with rehabilitation and was able to walk with a 2-wheeled walker under supervision. Upon reassessment, he was then diagnosed with Parkinson’s disease and started on Madopar 62.5mg three times/ day. Terazosin was withdrawn and replaced with tamsulosin 0.4mg ON. His BP medication was adjusted as shown:

6 months later

Mr A was reviewed at the falls clinic and was able to walk independently using a quadripod.

His Clinical Frailty Scale (CFS) is 5.

He complained of an episode of giddiness 2 weeks ago, associated with sudden darkening of his vision whilst in the kitchen. His wife noticed that he was about to fall and managed to sit him down on the sofa quickly. He was well before the incident with no history of vomiting, diarrhoea, or symptoms of infection. He denied any chest pain, shortness of breath, or palpitations.

According to his wife, Mr A was unresponsive for a few seconds and woke up after they laid him on the sofa. His blood pressure recorded was 58/38 mmHg and repeated after 5 minutes later was 98/57 mmHg. He resumed full consciousness after 5 minutes and was unable to recall what happened. His son had stopped all antihypertensive medications (Coversyl Plus and metoprolol) for a week but restarted metoprolol as his blood pressur shot up to 170-180/70-90mmHg.

His medication during review is as shown:

A tilt table test was performed, and the results are as shown:

ECG showed sinus bradycardia with HR 58 bpm, no AV block, normal QTc

Questions:

1. How would you interpret the result of his tilt table test, and what is the diagnosis?

2. How would you manage this patient?

3. What will be the target blood pressure for this patient?

References:

1. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. (2015). New England Journal of Medicine, 373(22), 2103–2116. https://doi.org/10.1056/ nejmoa1511939

2. Wiersinga J, Jansen S, Peters MJL, Rhodius-Meester HFM, Trappenburg MC, Claassen JAHR, Muller M. Hypertension and orthostatic hypotension in the elderly: a challenging balance. Lancet Reg Health Eur. 2024 Dec 3;48:101154. doi: 10.1016/j.lanepe.2024.101154. PMID: 39717228; PMCID: PMC11665365.

3. Juraschek SP, Cortez MM, Flack JM, Ghazi L, Kenny RA, Rahman M, Spikes T, Shibao CA, Biaggioni I; American Heart Association Council on Hypertension. Orthostatic Hypotension in Adults With Hypertension: A Scientific Statement From the American Heart Association. Hypertension. 2024 Mar;81(3):e16-e30

4. Chapple CR. A Comparison of Varying alpha-Blockers and Other Pharmacotherapy Options for Lower Urinary Tract Symptoms. Rev Urol. 2005;7 Suppl 4(Suppl 4):S22- 30. PMID: 16986051; PMCID: PMC1477612.

5. Chrysant SG. The tilt table test is useful for the diagnosis of vasovagal syncope and should not be abolished. J Clin Hypertens (Greenwich). 2020 Apr;22(4):686-689. doi: 10.1111/jch.13846. Epub 2020 Apr 5. PMID: 32248628; PMCID: PMC8030070.

6. Simova, I. (n.d.). Role of tilt-table testing in syncope diagnosis and management. https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-13/role-of-tilt-table-testing-in-syncope-diagnosis-and-management

7. Isaacson SH, Dashtipour K, Mehdirad AA, Peltier AC. Management Strategies for Comorbid Supine Hypertension in Patients with Neurogenic Orthostatic Hypotension. Curr Neurol Neurosci Rep. 2021 Mar 9;21(4):18. doi: 10.1007/s11910-021-01104-3. PMID: 33687577; PMCID: PMC7943503.

8. Elgebaly A, Abdelazeim B, Mattar O, Gadelkarim M, Salah R, Negida A. Meta analysis of the safety and efficacy of droxidopa for neurogenic orthostatic hypotension. Clin Auton Res. 2016 Jun;26(3):171-80. doi: 10.1007/s10286-0160349-7. Epub 2016 Mar 7. PMID: 26951135.