Case Scenario: Hypertensive Crisis, Percutaneous Transluminal Angioplasty, and Intra-Aortic Balloon
Pump in the ICU
Patient Profile
Name: Deys
Age: 63 years
Sex: Male
Medical History: Long-standing hypertension, coronary artery disease (CAD), type 2 diabetes mellitus,
smoking history (30 pack-years), hyperlipidemia.
Presenting Complaint
Deys was admitted to the ICU following a hypertensive crisis and acute coronary syndrome (ACS). He
arrived with severe chest pain, shortness of breath, and altered mental status.
Assessment:
Signs and Symptoms
1. Severe chest pain (10/10) radiating to the left arm and jaw.
2. Shortness of breath, tachypnea.
3. Confusion and restlessness, indicating possible end-organ damage (hypertensive encephalopathy).
4. Nausea and diaphoresis.
5. Dizziness, blurred vision, and a severe headache (suggestive of hypertensive crisis).
Vital Signs
- Blood Pressure: 220/130 mmHg
- Heart Rate: 115 bpm (sinus tachycardia)
- Respiratory Rate: 30 breaths per minute
- Oxygen Saturation: 89% on room air
- Temperature: 37.4°C
Laboratory Results
- Troponin I: 8.5 ng/mL (elevated, indicating myocardial injury)
- CK-MB: 100 U/L (elevated)
- BNP: 1500 pg/mL (elevated, consistent with heart failure)
- BUN/Creatinine: 50/2.3 mg/dL (acute kidney injury due to hypertensive crisis)
- Electrolytes: Na+ 135 mEq/L, K+ 4.0 mEq/L, Cl- 100 mEq/L
- ABG: pH 7.30, pCO2 35 mmHg, pO2 60 mmHg, HCO3 18 mEq/L (respiratory alkalosis with mild
metabolic acidosis)
- Blood glucose: 300 mg/dL (elevated, consistent with diabetes)
Diagnostic Imaging:
- ECG: ST-elevation in leads II, III, and aVF: consistent with an acute inferior wall myocardial infarction
(MI).
- Coronary angiography: Revealed 90% stenosis of the right coronary artery (RCA), indicating the need
for immediate intervention.
ICU Course of Treatment:
Medical Management:
1. Cardiac Management
- Intravenous nitroglycerin drip: To manage the hypertensive crisis and reduce preload/afterload.
- Beta-blocker (IV metoprolol): to control heart rate and reduce myocardial oxygen demand.
2. Electrolyte Management
- Diuretics (IV furosemide): for fluid overload.
[Link] therapy:
- via nasal cannula; maintain SpO2 > 95%.
[Link] and Support
- Daily echocardiograms to assess ventricular function.
- Close monitoring of renal function and urine output.
Surgical Management:
1. Percutaneous Transluminal Coronary Angioplasty (PTCA)
The patient was immediately transferred to the catheterization lab, where a percutaneous transluminal
coronary angioplasty (PTCA) with stent placement was performed to relieve the coronary artery
obstruction.
Post-PTCA Course
Despite successful PTCA, the patient continued to show signs of cardiogenic shock due to left ventricular
dysfunction (EF 25%). To stabilize the patient and support cardiac function, an intra-aortic balloon pump
(IABP) was placed.
2. IABP Insertion:
The IABP was inserted via the femoral artery and positioned in the descending aorta.
Purpose: To reduce afterload, improve coronary perfusion, and support cardiac output.
Repeat Lab Values (6 hours post-IABP placement):
- Troponin I: 7.0 ng/mL (downtrending)
- BNP: 1300 pg/mL
- ABG: pH 7.38, pCO2 40 mmHg, pO2 85 mmHg, HCO3 24 mEq/L (normalized)
- Renal function: BUN/Creatinine 40/1.8 mg/dL (improving)
Clinical Outcome
After 48 hours, the patient's hemodynamics stabilized. The IABP was weaned off and removed after his
cardiac function showed improvement (EF 40%). Blood pressure was maintained at 130/80 mmHg with
oral antihypertensive medications. The patient was extubated, and he showed significant clinical
improvement.
He remained in the ICU for further observation and was later transferred to the step-down unit for
continued recovery and rehabilitation.
