THE HYPERTENSION PUZZLE: DIAGNOSING THE UNEXPECTED

Objective: Although coarctation of the aorta (CoA) is a curable cause of hypertension (HT), after surgical correc-tion, the risk of hypertension and left ventricular hypertrophy (LVH) persists. Design and method: We present you the case of a 59-year-old patient, with surgery for coarctation of the aorta at 20 years, smoker, hypertensive, dyslipidemic (allergic to statins), presenting for therapeutically uncontrolled hypertension. Clinical examination reveals bilateral carotid murmurs, a 20mmHg lower systolic blood pressure (BP) in the left upper limb and 50 mmHg lower in the lower limb. Electrocardiogram shows left ventricular hypertrophy with secondary changes of ventricular repolarization. Echocardiography reveals severe concentric LVH with ventricular wall thickness of 20 mm and dynamic medioventricular obstruction with a dynamic gradient of 64 mmHg, raising the hypothesis of the association of a hypertrophic cardiomyopathy. At the level of the descending aorta, below the emergence of the subclavian artery, a turbulent systolic-diastolic flow was recorded, suspecting a CoA restenosis. AngioCT examination confirms the diagnosis of CoA restenosis, identifies hypoplasia of the left subclavian artery and severe bilateral carotid atheromatosis. Results: In this context, the antihypertensive treatment was adjusted with optimal control of hypertension values. Antiplatelet drugs were added to the medication regimen and alternative lipid-lowering treatment with Ezetimibe and PCSK9 inhibitors was considered. The patient was referred to cardiovascular surgery clinic for correction of the CoA restenosis and subsequently of the other atherosclerotic lesions. Drug control of hypertension was difficult, because upon reaching target BP values, the patient developed intermittent claudication due to the occurrence of ischemia through hypoperfusion of the lower limbs, in the absence of CoA correction. Conclusions: Restenosis at the site of coarctation is common when the correction is performed in childhood and rare when it is performed in adults, the association of hypoplasia of the left subclavian artery, described very rarely in CoA, is a particularity of this case. Severe left ventricular hypertrophy and significant intraventricular dynamic gradient require the exclusion of concomitant hypertrophic cardiomyopathy.