Case Report
An 88-year-old man was admitted to hospital on the acute medical ward with gradually worsening breathlessness and peripheral oedema. His comorbidities included myocardial infarction and coronary stenting 9 years ago, essential hypertension, hypercholesterolaemia and stage III chronic kidney disease. On initial assessment his BP was noted to be 232/92 with a heart rate (HR) of 52 bpm. There was clinical evidence of congestive cardiac failure with bilateral basal lung crepitations and pitting lower limb oedema. An ECG revealed CHB with a narrow complex escape rhythm at 46 bpm (figure 1). A chest x-ray showed mild pulmonary oedema. Admission blood tests were satisfactory including normal thyroid function and electrolytes. His regular medication included lacidipine 6 mg, candesartan 28 mg, bisoprolol 10 mg, furosemide 20 mg, aspirin 75 mg and atorvastatin 40 mg all taken once daily.
Bisoprolol was immediately stopped in view of CHB and he was referred to the cardiology team to consider permanent pacemaker implantation. An intravenous frusemide infusion of 240 mg over 24 hours was commenced. Despite a good diuresis in the first 24 hours his BP remained 202/69, therefore an intravenous glyceryl trinitrate (GTN) (50mg/50mls at 1-10mls/hr) infusion was started. BP remained 190/90 with 8 mls/hr of GTN.
Secondary causes of hypertension were investigated with normal 24-hour urinary catecholamine and serum angiotensin converting enzyme levels, and normal sized kidneys on renal ultrasound. There was heavy proteinuria with 24-hour urinary collection measuring 6.1 g. An echocardiogram showed normal left ventricular (LV) size and function, moderate concentric LV hypertrophy and mild aortic stenosis.
He achieved a 5.3 kg diuresis over 5 days. Attempts were made to wean off GTN however this only led to BP rising again to 215/89. Indapamide 2.5 mg once daily had a limited effect. Doxazosin was started and gradually increased to 4 mg twice daily. Methyldopa was initiated and uptitrated to 250 mg twice daily.
On day 7 pacemaker implantation was due to go ahead. On arrival to the cardiac catheter lab BP was 180/70 with GTN running at 10 mls/hr. GTN was discontinued shortly before the procedure anticipating that sedation and analgesia might conversely lead to acute hypotension. A dual chamber pacemaker was implanted successfully with no immediate complications. The right ventricular (RV) pacing lead was positioned at the RV apex. BP during the procedure was 169/51. With the device set for atrial sensing and ventricular pacing, HR was maintained around 90 bpm. BP immediately after pacing was 160/80 and remained controlled at this level without GTN. The post-implant ECG showed an atrial-tracked, ventricular-paced rhythm at 90 bpm (figure 2), and post-implant chest x-ray showed satisfactory lead positioning with no acute complications. Bisoprolol was restarted at 10 mg. The final documented BP prior to discharge was 100/52 with a HR of 82.