How I Treat: A Man With Hypertension, Type 2 Diabetes, Obstructive Sleep Apnea, Paroxysmal Atrial Fibrillation
Matthew C. Tattersall, DO, MS | University of Wisconsin (Madison, WI)
A 50-year-old man with a past medical history of hypertension, type 2 diabetes, and treated, mild obstructive sleep apnea presents to the clinic with newly discovered paroxysmal atrial fibrillation (AF).
History. The patient visited the emergency department 2 weeks ago and reported 12 hours of palpitations, where his heart rate was 120 beats per minute (bpm) in AF, and his blood pressure (BP) was 165/110 mmHg. He received 10 mg of diltiazem, converted to normal sinus rhythm, and was discharged on apixaban 5 mg 2/d, along with chlortalidone 12.5 mg for elevated blood pressure.
The patient had been previously diagnosed with hypertension at 40 years of age, as well as type 2 diabetes (A1c 7.0%). He does not consume alcohol, and he does not smoke. There is no history of premature cardiovascular disease within his family. His current medications include: apixaban 5 mg 2/d, chlorthalidone 12.5 mg daily (started 2 weeks ago), hydralazine 50 mg 3/d, and diltiazem extended release 360 mg, daily.
During a physical examination at his current visit, the patient had a blood pressure (BP) of 170/110 mmHg. After a 5-minute recheck, his BP was 165/105 mmHg. The patient’s fundoscopic examination showed mild arterial venous (AV) nicking. His carotid upstrokes were +2, and his jugular venous distention was at the base of the neck at 45° of recumbence. His heart sounds were regular with an S1-S2 and an S4 gallop at the left lower sternal border. His lungs had normal vesicular breath sounds throughout, and his extremities were warm and well perfused with +2 pitting edema to the knees.
Diagnostic testing. The patient’s laboratory results were taken at the emergency room and during his current visit (Table 1). His urine protein to creatinine ratio showed that he did not have proteinuria. His electrocardiogram (EKG) taken at the ER showed an AF with a ventricular rate of 120 BPM, QRS and QTc intervals within normal range, and no ST-T abnormalities. There is left ventricular hypertrophy (LVH; Sokolow-Lyon criteria) with the S wave in lead AVL of 1.4 mV and S wave in V1 + R wave V5 = 40 mm.
Table 1: The patient’s laboratory results.
Test | ER | Current visit | Normal Range |
Sodium (Na) | 139 mmol/L | 140 mmol/L | 135 - 145 mmol/L |
Potassium (K) | 3.7 mmol/L | 3.3 mmol/L | 3.5 - 5.0 mmol/L |
Chloride (Cl) | 100 mmol/L | 99 mmol/L | 98 - 106 mmol/L |
Bicarbonate (HCO3-) | 25 mmol/L | 24 mmol/L | 22 - 28 mmol/L |
Blood Urea Nitrogen (BUN) | 21 mg/dL | 20 mg/dL | 7 - 20 mg/dL |
Creatinine | 1.2 mg/dL | 1.1 mg/dL | 0.6 - 1.3 mg/dL |
Glucose | 185 mg/dL | 130 mg/dL | 70 - 99 mg/dL |
Thyroid stimulating hormone | 1.2 mIU/L | N/A | 0.4-4.0 mIU/L |
Magnesium | 2.1 mg/dL | N/A | 1.7-2.2 mg/dL |
Calcium | 9.3 mg/dL | N/A | 8.5-10.5 mg/dL |
D-Dimer | < 500 ng/mL | N/A | < 500 ng/mL |
