|Year : 2014 | Volume
| Issue : 4 | Page : 115-116
A Case of Hypotension
Mary Grace, VK Shameer, Renjith Bharathan, Kripal T S
Department of Medicine, Government Medical College, Thrissur, Kerala, India
|Date of Web Publication||10-Dec-2014|
Dr. Mary Grace
Government Medical College, Thrissur, Thiruvananthapuram, Kerala
Source of Support: None, Conflict of Interest: None
Takayasu's arteritis is a large-vessel vasculitis which is characterized by both stenotic lesions as well as aneurymal lesions. 1 Aneurysmal lesions most commonly occur in the aortic root and arch leading to development of aortic regurgitation. AR is seen in about 24% of cases at the time of presentation. 2 The documentation of high blood pressure in Takayasu arteritis may be difficult because of subclavian and innominate artery stenoses. This case report highlights the importance of checking all the peripheral pulses and recording the blood pressure in both upper limbs and in the lower limbs in a case of "hypotension".
Keywords: Aortic regurgitation, assymetrical blood pressure and pulse, hypotension
|How to cite this article:|
Grace M, Shameer V K, Bharathan R, KripalT. A Case of Hypotension. Heart India 2014;2:115-6
| Introduction|| |
Takayasu's arteritis (TA) is a large vessel vasculitis, which affects the aorta and its major branches. It is more frequent in young women 10-20% occurs in people after the age of 40 years. TA usually presents with claudication, asymmetric pulse and blood pressure in the upper limbs and hypertension. Aortic regurgitation is the mode of presentation in <10% of patients. Aortic regurgitation commonly develops late in the course of the disease secondary to dilatation of the aortic root. Aortic regurgitation can lead to mitral regurgitation secondary to left ventricular dilatation.
| Case report|| |
A 44-year-old female patient presented to the casualty with chest discomfort of 4 h duration. She did not have any symptom other than chest discomfort, at the time of presentation. She had a history of fever with arthritis around 2 weeks prior to the current presentation and was treated as viral fever from another hospital and she had improved symptomatically. She was not a hypertensive or diabetic, nor did she have a history suggestive of rheumatic fever in childhood.
On examination, she had a pulse rate of 100/min. The pulse was regular in rhythm, low in volume in both the upper limbs, especially in the left upper limb and well felt in the lower limbs. Her blood pressure was 80 mm Hg systolic in the right upper limb, not recordable in the left upper limb; 210/100 mm Hg in the right lower limb and 190/96 mm Hg in the left lower limb. She had prominent neck pulsations. Cardiovascular system examination revealed a normal sized heart with an early diastolic murmur in the aortic area. There was no evidence of pulmonary artery hypertension. Other systems were within the normal limits. The clinical diagnosis of acute aortic regurgitation (AR) with an underlying large vessel vasculitis was considered.
Investigations showed an elevated erythrocyte sedimentation rate (70 mm/h) and C-reactive protein (36.8). There was Twave inversion in leads v4 to v6 with negative cardiac biomarkers. ECHO showed moderate AR with aortic root dilatation and trivial mitral regurgitation. Magnetic resonance angiography (MRA) [Figure 1] showed focal areas of narrowing at the origin of right common carotid; proximal right subclavian. Right upper-limb collaterals were present. Left common carotid and subclavian were not seen from the origin due to occlusion. With the above ECHO and MRA findings, the final diagnosis of TA type 1 with AR was made.
Takayasu's arteritis is a large-vessel vasculitis of unknown etiology that has a predilection for the aorta and its primary branches. It is characterized by both stenotic lesions as well as aneurymal lesions.  Aneurysmal lesions most commonly occur in the aortic root and arch leading to the development of AR. AR in TA was first described by Jervell in 1954. AR is seen in about 24% of cases at the time of presentation. 
Aortic regurgitation usually develops, as a result, of aortic root dilatation and pulling apart of the aortic cusps. Aortic regurgitant jet induces morphological change in the aortic valve leaflets, and this worsens the regurgitation.  It is also postulated that primary leaflet damage and not the aortic root dilatation, which is the main pathology. Aortic regurgitation is an important risk factor for mortality in TA, and it is also one of the indications for surgery.
The documentation of high-blood pressure in TA may be difficult because of subclavian and innominate artery stenoses. The asymmetry in the pulse and blood pressure of the upper and lower limbs in the presence of prominent neck pulsations were the clue to the underlying vasculitis. This highlights the importance of checking all the peripheral pulses and recording the blood pressure in both upper limbs and the lower limb in the case of "hypotension."
| References|| |
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Takayasu's arteritis: A study of 104 Italian patients. Arthritis Rheum 2005;53:100-7.
Maksimowicz-McKinnon K, Clark TM, Hoffman GS. Limitations of therapy and a guarded prognosis in an American cohort of Takayasu arteritis patients. Arthritis Rheum 2007;56:1000-9.
Matsuura K, Ogino H, Kobayashi J, Ishibashi-Ueda H, Matsuda H, Minatoya K, et al.
Surgical treatment of aortic regurgitation due to Takayasu arteritis: Long-term morbidity and mortality. Circulation 2005;112:3707-12.