Blood Pressure: Analysis of Laboratory Studies

This case follows a forty-five-year-old woman who is living with chronic obstructive pulmonary disorder (COPD), heart failure, diabetes mellitus and hypertension. During patient intake it was recorded that she eats a poor diet and smoked for twenty-two years. She is having symptoms of chronic cough with sputum, light headedness, distended neck veins, excessive peripheral edema and increased urination at night. Throughout this paper the symptoms will be connected to the disorders they contribute to, beginning with COPD, then heart failure, followed by hypertension and ending with diabetes. This paper will also analyze the lab results that M.K. had done to see where they fit in the puzzle.

What clinical findings correlate with M.K.’s chronic bronchitis?

Our patient has chronic bronchitis which is a form of chronic obstructive pulmonary disorder, also known as COPD. This disorder occurs when irritants are inhaled for a prolonged period of time. The case study tells us that our patient was a smoker for twenty-two years. The irritants in the cigarette can cause inflammation of the tracheobronchial tree which then causes an increased production of mucous and narrows the airway. Chronic bronchitis can lead to airway obstruction, hypoxemia and hypoventilation. Hypoventilation can trigger pulmonary vascular resistance (PVR) , with PVR increasing so does the afterload of the right ventricle.

Some clinical manifestations that M.K. presents with is a chronic cough, edema, and distended neck veins. The patient has distended neck veins from the right sided heart failure from the increased PVR. This happens because inflammation and compensatory vasoconstriction occurs during hypoventilation, which narrows the pulmonary arteries.

What type of treatment and recommendation would be appropriate for M.K.’s chronic bronchitis?

A modifiable treatment option for chronic bronchitis would be to stop smoking and avoid second hand smoke or other air pollutants. Other treatment course includes antibiotics to treat recurring infections, bronchodilators to clear out the mucus and sputum, diuretic to decrease the edema and corticosteroids for the inflammation of the tracheobronchial tree. The patient should also be advised to cover their mouth and nose going into a cold place because a blast of cold air can trigger a bronchospasm.

Which type of heart failure would you suspect with M.K?

Pathogenesis

Right-sided heart failure is suspected due to the presence of chronic bronchitis. In this type of bronchitis, the pulmonary arteries become in inflamed and vasoconstricted from hypoxemia and hypercapnia due to the hypoventilation. Hypoventilation occurs when airways become obstructed and begin to close. This closure traps the expired air inside the lungs which makes the body begins hypoventilation. As previously mentioned, hypoventilation can cause the PVR to increase and in turn the right ventricle after load increases. Because the patient has COPD which narrows the arteries, oxygen is not able to reach all the organs needed, like the lungs. The afterload increases to pump extra blood to reach the lungs, which makes it work harder, leading to increased pulmonary blood pressure.

Overview

Right sided heart failure occurs when something else is malfunctioning such as left sided heart failure, or in the patient's case, a pulmonary disorder has happened. Right sided heart failure has forward and backward effects. The forward effects of right sided heart failure are as follows: decreased output to the left ventricle, decreased left ventricular cardiac output - which can lead to decreased tissue perfusion and activation of the renin-angiotensin-aldosterone-system (RAAS)). The backward effect of right sided heart failure includes decreased ejection fraction, increased right ventricular preload, increased right atrial pressure, which can lead to systemic congestion.

The CDC tells that 5.7 million adults have heart failure in the United States. It also provides information that relays that heart failure deaths from 2013-2015 were higher in the south east area of the United States and Texas with an average annual death rate of 2329- 684.3 out of 100,000 deaths related to heart failure.

According to the Blood Pressure Value, what stage of hypertension is M.K. experiencing?

According to Banasik and Copstead there are four categories of blood pressure classification for adults. Normal blood pressure is less than 120 mm Hg systolic and less that 80 mm Hg diastolic, Prehypertension is a systolic of 120- 139 mm Hg with a diastolic of 80 – 89 mm Hg. Stage 1 Hypertension has a systolic of 140- 159 mm Hg with a diastolic of 90 –99 mm Hg. Finally, Stage 2 Hypertension has a systolic of greater than or equal to 160 mm Hg with a greater than or equal to diastolic of 100 mm Hg. M.K.’s blood pressure that was taken for vital signs was recorded at a systolic of 158 mm Hg with a diastolic of 98 mm Hg, this would classify her as having Stage 1 Hypertension.

Rationale of M.K.’s Hypertension Medication

The patient is on Lotensin to manage her hypertension with is an angiotensin-converting-enzyme (ACE). This medication lowers her blood pressure by preventing or inhibiting the angiotensin 1 to convert to angiotensin 2. Angiotensin 2 is a hormone that narrows blood vessels in order to increase blood pressure. The ACE medication stops that process so that M.K.’s blood pressure does not increase.

In addition to the ACE inhibitor, M.K. is also on Lasix which is a diuretic. This diuretic is useful for the edema she has in addition to the hypertension. As a hypertension medication the diuretic flushes out the high levels of sodium or salt that are in the body, this happens by increasing urination. When there is a buildup of sodium in the vessels this can make it harder for blood to flow through, when the diuretics flush away the buildup blood pressure will begin to decrease.

Hypertension in America

The CDC once again gives statistics on hypertension in America saying that 1 in every 3 adults in the United States have high blood pressure. However, of those 1 in 3 adults, only about 54% have the condition under control which can contribute to the 1,100 deaths that occurred in 2014 because of high blood pressure.

According to the lipid panel, what other condition is M.K. at risk for?

A normal lipid panel for an adult female over 20 years of age shows cholesterol levels below 200 mg/dL, HDL levels below 50 mg/dL, LDL levels above 100 mg/dL and triglyceride levels higher than 184 mg/dL. By these standards the patient has high cholesterol. Having high cholesterol makes M.K. at risk for coronary heart disease. Risk factors for this disease that the patient is already presenting with are diabetes, smoking and high blood pressure. According to the National Heart, Lung, and Blood Institute having a blood pressure over a systolic of 120 mm Hg with a diastolic over 80 mm Hg increases the risk of developing coronary heart disease. As previously mention in the paper, M.K. had a blood pressure of 158 mm Hg systolic and 98 mm Hg diastolic.

According to this case study, what other medications should be given and why?

The patient is already on ACE inhibitors and diuretics to manage her hypertension. In addition, she is taking Glucophage for her diabetes which works by increasing the sensitivity of the muscle cells to insulin so that sugar is easier to come out of the blood, which will lower glucose levels. For the right sided heart failure M.K. can be put on Nesiritde which will help decrease the afterload in the right ventricle as a short-term management medication. Her chronic bronchitis should be treated with corticosteroids for inflammation, diuretics to reduce edema and oxygen for the hypoxia.

What additional findings correlate for both hypertension and type 2 diabetes mellitus?

Some shared risk factors between hypertension and type 2 diabetes are smoking and a poor diet. Smoking can result in the body becoming more resistant to insulin, which makes the disease harder to manage as controlling glucose levels is already a struggle in diabetes. Smoking also causes plaque to build up inside the arteries which makes the heart work harder to get proper blood flow through which elevates blood pressure.

A poor diet, along with being overweight, is also a risk factor for diabetes and hypertension. A diet full of fats and sugars can lead to unstable glucose levels. A fatty diet can also lead to cholesterol build up on the arteries making it harder for blood to flow, like smoking does. Lastly, a salty diet can trigger the RAAS system or ACE inhibitors to become activated.

Interpret lab value for HbA1c

HbA1c is dependent on blood glucose concentration, “The HbA1c levels reflect the mean glucose concentration over the previous period of eight to twelve weeks” (Test ID: HBA1C, n.d.). Diabetic patients have higher HbA1c levels that normal patients because they have a higher level of concentrated glucose in their blood. If a patient has a HbA1c level that is greater than or equal to 6.5%, that patient is diagnosed with diabetes (Test ID: HBA1C, n.d.). The test should be repeated three to four times a year to monitor the patient's progression of the diabetes disorder.

Conclusion

M.K. has four conditions that all relate to one another however, they are manageable and preventable. The patient should modify her lifestyle habits to reduce the risk factors of developing more relatable disease. COPD, diabetes, hypertension and heart failure are serious diseases that require individual attention and treatment to manage them.