Nice hypertension case studies

Luerding, MD Presentation R.

Nice hypertension case studies

Case Study Presentation An 85 year old patient presents to the ER with worsening shortness of breath and a history of known pulmonary hypertension. Her chest x-ray reveals massive cardiomegaly.

An echo is ordered to assess the status of her pulmonary hypertension. We will present this echo to illustrate the correct techniques when performing an echocardiogram with the indication of pulmonary hypertension. Right Ventricle Pathophysiology During pulmonary hypertension, there is chronic progressive pressure loading of the right ventricle causing hypertrophy and eventual dilation.

The enlargement then causes contractile impairment, low cardiac output and eventual right heart failure. Below is the echo in the parasternal long axis, short axis and apical four chamber views. This echo demonstrated the findings of a ratio greater than one when comparing the right and left basal dimensions.

Right Ventricle Hypertrophy Right ventricular hypertrophy is defined by a free wall thickness of greater than 5 mm. The new ASE guidelines recommend measuring the RV wall thickness in the subcostal window below the tricuspid annulus on a zoomed image with the focus on the RV mid-wall.

The subcostal view can also be useful in estimating the degree of RV dysfunction and RV wall thickness in patients whose other views are difficult to image. This patient presented with a RV free wall dimension of 5. Moderator Band The moderator band is one of the first structures to become hypertrophied.

In normal patients, the moderator band is thin and difficult to see on an echo. However, this patient presented with a moderator band that was clearly visible, as is often the case in pulmonary hypertension. Flattening of IVS In a normal heart, the left ventricle maintains a circular shape.

In pulmonary hypertension, the increased RV pressure moves the interventricular septum to the left. This makes the left ventricle appear with the characteristic D-Shape.

What is covered

This case study had the classic presentation of septal D flattening. Pressure Overload Remember that a right ventricle that is overloaded purely by a volume overload will only deviate the septum in diastole.

This is because a volume overload will raise the end diastolic pressure.

Nice hypertension case studies

On the other hand, when the right ventricle is overloaded with a pressure overload the septum will deviate in systole. With severe pressure overload the septum will deviate into the LV cavity.


What is the LV Eccentricity Index and how is it measured? As you can see in the case study images below, the pressure overload creates systolic flattening of the septum which results in an increased eccentricity index. The LV eccentricity index in pulmonary hypertension is greater than 1.

What is it?

Hemodynamics Severe Tricuspid Regurgitation The dilation of the right ventricle results in tricuspid annular dilation. This is the cause of the severe tricuspid regurgitation associated with pulmonary hypertension. Tricuspid regurgitation can be evaluated by the structure of the valve, jet area and density or measurement by continuous-wave Doppler.

This patient presented with moderate to severe tricuspid regurgitation.

Nice hypertension case studies

Systolic Pulmonary Pressure One of the many useful findings with echocardiography in the RVSP evaluation of pulmonary hypertension is the ability to calculate the pulmonary systolic pressure.

In the absence of pulmonary stenosis, the pulmonary systolic pressure is assumed equal to the right ventricular systolic pressure RVSP. This patient presented with severe pulmonary hypertension with a calculated RVSP of mmHg We are all familiar with calculating the RVSP through the measurement of the tricuspid regurgitant jet velocity.

The latest update in the ASE Guidelines now simplifies the process of determining the RAP by replacing ranges with specific values.

The easiest way to remember the specific RAP values is to understand the opposite ends of the RAP spectrum — the normal versus high pressure. Everything else will just fall into the middle category. For example in a patient that has a dilated IVC but demonstrates normal collapsibility or vice versa, normal IVC size but abnormal collapsibility.Medical Nutrition Therapy Hypertension Case Study Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising.

If you continue browsing the site, you agree to the use of cookies on this website. Improving health and social care through evidence-based guidance Find NICE guidance. Browse guidance by area: Conditions and diseases. Evidence-based recommendations on the diagnosis and management of hypertension (high blood pressure) in adults.

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Hypertension in adults: diagnosis and management | Guidance and guidelines | NICE