Archives of the Balkan Medical UnionCopyright © 2017 Balkan Medical Union

vol. 52, no. 2, pp. 215-220June 2017

RÉSUMÉ

L’hypertension chez un patient jeune: le stress chro-nique en tant que déclencheur unique

Introduction: L’hypertension chez les jeunes est se-condaire, mais le stress pourrait constituer un facteur de risque important pour l’hypertension et les compli-cations cardiaques dans le temps.Rapport de cas: Un patient de 21 ans s’est présenté pour des valeurs élevées de la tension artérielle pendant les deux derniers mois. Il n’était pas fumeur et n’avait pas d’antécédents médicaux. L’examen physique: poids normal, la tension artérielle 160/90 mmHg. Les tests de laboratoire: hypercholestérolémie légère. L’échographie abdominale: le rein gauche hypotrophique. La sur-veillance ambulatoire de la tension artérielle a confir-mé l›hypertension quotidienne avec plus de 47% des valeurs diurnes supérieures à 140 mmHg. La scan et l’angiographie ont montré deux veines rénales gauches, l’une d’entre elles sur l’artère, mais avec un calibre nor-mal de l’artère rénale gauche.Discussion: Beaucoup d’études ont révélé que le tra-vail stressant a augmenté la tension artérielle systolique,

ABSTRACT

Introduction: Hypertension in young people is se-condary, but stress could be an important risk factor for hypertension and heart disease complications over time.Case report: A 21 year-old patient presented for high blood pressure values in the last two months. He was non-smoker and he had no medical history. Physical exam: normal weight, blood pressure (BP) 160/90 mmHg. Laboratory tests: mild hypercholesterolemia. Abdominal ultrasound: hypotrophic left kidney. Ambulatory BP monitoring confirmed diurnal high BP, with more than 47% of diurnal values greater than 140 mmHg. Contrast enhanced CT scan and angiogra-phy showed two left renal veins, one of them over the artery, but with normal caliber of the left renal artery.Discussion: A lot of studies revealed that stressful work increased systolic blood pressure and heart rate reactivity and decreased vagal tone. The high BP values occurred in conditions of a job with a lot of stress to a young patient with a left kidney malformation, but with normal renal function. The slight increase in se-rum cholesterol and cortisol confirms this hypothesis.

CASE REPORT

HYPERTENSION IN A YOUNG MALE PATIENT: CHRONIC STRESS AS THE ONLY TRIGGER

Alice Balaceanu1,2, Diana Olteanu1,2, Adriana Diaconu1,3, Gheorghita Aron1,2, Ion Dina1,2, Camelia Diaconu1,4

1 University of Medicine and Pharmacy “Carol Davila“, Bucharest, Romania2 Department of Internal Medicine, Clinical Emergency Hospital “Sf. Ioan“, Bucharest, Romania3 Department of Pediatry, Clinical Hospital Fundeni, Bucharest, Romania4 Department of Internal Medicine, Clinical Emergency Hospital of Bucharest, Romania

Corresponding author: Alice Balaceanu, MD, PhD

Department of Internal Medicine, Clinical Emergency Hospital “Sf. Ioan“,

Bucharest, Romania

e-mail: alicebalaceanu@yahoo.com

Hypertension in a young male patient: chronic stress as the only trigger – BALACEANU et al

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INTRODUCTION

Hypertension in young people is secondary, but stress could be an important risk factor for hyperten-sion and heart disease complications over the time.

CASE REPORT

A 21 year-old patient presented for high blood pressure values in the last two months. He was non-smoker and he had no medical history. Physical exam: normal weight, blood pressure (BP) 160/90

mmHg at both arms, 75 bpm. Laboratory tests: mild hypercholesterolemia. Abdominal ultrasound: right kidney 124/55mm, normal parenchyma, normal flow speeds in the renal artery. Left kidney 66/48mm without hydronephrosis, 12 mm thin parenchyma. Transthoracic echocardiography and thyroid echog-raphy were within normal limits. Ambulatory blood pressure monitoring (ABPM) was done with a device (Mobil-O-GraphNG) at 20-minute intervals diurnal and 30-minute interval nocturnal on the nondomi-nant arm. ABPM showed maximum daytime BP 190/112 mmHg (Fig.1), more than 47% of diurnal

We could not find any other cause of secondary hy-pertension.Conclusion: Nowadays, stress is responsible for many physiological changes, including constant increase in blood pressure. The scale of cardiovascular risk should be reevaluated in young people through proper trials.

Keywords: arterial hypertension, stress, kidney mal-formation.

la réactivité de la fréquence cardiaque et a diminué le ton vagal. Les valeurs de la haute tension sanguine se sont produites dans des conditions de travail avec beaucoup de stress chez un jeune malade avec une mal-formation rénale gauche mais une fonction rénale nor-male. La légère augmentation du cholestérol sérique et du cortisol confirme cette hypothèse. Nous n’avons pas trouvé d’autre cause d’hypertension secondaire.Conclusion: De nos jours, le stress est responsable de beaucoup de changements physiologiques, y compris une augmentation constante de la tension artérielle. L’ampleur du risque cardiovasculaire devrait être ré-évaluée chez les jeunes grâce à des essais appropriés.

Mots-clés: hypertension artérielle, stress, malforma-tion rénale.

Figure 1. Ambulatory blood pressure monitoring report showed maximum daytime BP 190/112 mmHg.

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Figure 2. Ambulatory blood pressure monitoring report showed more than 47% of diurnal values greater than 140 mmHg and diurnal average blood pressure 137/85 mmHg.

Figure 3. Ambulatory blood pressure monitoring report showed nocturnal average blood pressure 115/72 mmHg.

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values greater than 140 mmHg (Fig.2), with diurnal average blood pressure 137/85 mmHg and nocturnal average blood pressure 115/72 mmHg (Fig.3). Pulse pressure was 42.7 mmHg (Fig.4). Serum TSH, free T4, aldosterone, renin, urinary metanephrines, norme-tanephrines, 3-methoxy- tyramine, vanillylmandelic acid were in normal limits. Plasma cortisol was 589 nmol/L. Contrast enhanced chest CT in normal lim-its. Abdominal CT: left kidney 70 mm, 5 mm cortical thickness, normal shape and position, normal secre-tion and excretion, homogeneous opacified ureters, normal size (Fig.5). Contrast enhanced CT (Fig.6) and angiography (Fig.7,8) showed two left renal veins, one of them over the artery, but with normal calibre of the left renal artery.

DISCUSSION

3.3 % of the people between 25 and 34 years old reported hypertensive diseases in the EU-281. European guidelines for hypertension in young peo-ple recommend lower BP to <140/90 mmHg2.

A lot of studies revealed that stressful work in-creased systolic blood pressure and heart rate reac-tivity and decreased vagal tone3,4,5. Another study

revealed that increased blood pressure in a lot of young people was significantly related to anxiety and university identification6.

High blood pressure in adults over 25 years, from youth to middle age, leads to left ventricle sys-tolic and diastolic dysfunction in middle-aged adults7. A large study on young adult men with high blood pressure showed increased mortality due to cardio-vascular disease and coronary heart disease 25-year later8. Systolic blood pressure above 120 mmHg in-creases long-term cardiovascular risk and could be more useful in assessment the risk in young people than high diastolic blood pressure8.

The underlying mechanisms imply activation of the sympathetic nervous system with high levels of catecholamine, with subsequently high cardiac output by increasing heart rate and finally hyperten-sion9,10. High cardiovascular reactivity in individuals with genetic vulnerability, as well as decreased BP recovery after stress, are important mechanisms10,11.

The heart rate variability is reduced and sympa-thetic tachycardia accompanies hypertension, leading to brain, hormonal and immunologic dysfunctions11. Sympathetic and renin-angiotensin system stimula-tion leads to high levels of homocysteine and finally to

Figure 4. Ambulatory blood pressure monitoring report showed the pulse pressure of 42.7 mmHg.

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endothelial damage, atherosclerosis and impaired vas-cular reactivity11. The stress-induced norepinephrine increases serum iron via transferrin mechanism, favors bacteria dispersion on the surface of atherosclerosis plaques and finally leads to thromboembolic events11. Stress increases corticotropin-releasing hormone, acti-vates hypothalamus-pituitary-adrenal axis, with subse-quently high levels of glucocorticoids, as cortisol11.

Cortisol has multiple effects on vascular patho-physiological cascade: decreases cAMP levels and

NO synthesis, promotes hyperglycemia, lipid dys-regulation, oxidative imbalance, inflammation11,12,13. Hyper-reactivity to stress contributes to glomerular hy-perfiltration and predicts hypertensive nephropathy14.

Our patient was non-smoker, with normal body mass index, non-sedentary young man. He had high blood pressure values in the last two months and cli ni cal exam revealed mild hypertension. ABPM showed that the patient was dipper. These high blood pressure values occurred in conditions of a job with a

Figure 5. Abdominal CT scan (sagittal view) showed normal right kidney and 70 mm left kidney, with normal

shape and position, normal secretion and excretion.

Figure 7. Angiography showed normal right kidney artery.

Figure 6. Contrast enhanced CT scan (axial view) showed two left renal veins, one of them over the artery.

Figure 8. Angiography showed normal ramification of the left kidney artery.

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lot of stress to a young patient with a left kidney mal-formation, but with normal renal function. The mild increase in serum cholesterol and cortisol confirms this hypothesis. We could not find any other cause of secondary hypertension15,16,17,18.

CONCLUSIONS

Nowadays, stress is responsible for a lot of physi-ological changes, including constant increase in blood pressure. The scale of cardiovascular risk should be reevaluated in young people through proper trials.

Acknowledgement: Eureka CT, Clinical Emergency Hospital “Sf. Ioan“, Bucharest, Romania

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