Dounia Jama, Kamal Haless, Marouane Selmaoui, Meryem Haboub, Rachida Habbal, Abdenasser Drighil, Leila Azzouzi
Service of Cardiology, CHUN Ibn Rochd: Centre Hospitalier Universitaire Ibn Rochd, Casablanca, Morocco.
J Med Case Rep. 2024 Feb 20;18(1):102. doi: 10.1186/s13256-024-04346-0.
Cardiac autonomic neuropathy is a highly prevalent pathology in the diabetic population, and is the leading cause of death in this population. Orthostatic hypotension is the main clinical manifestation of the disease. In some patients, this orthostatic hypotension is associated with supine hypertension, posing a therapeutic challenge since treatment of one entity may aggravate the other. The challenge is to manage each of these two hemodynamic opposites without exposing the patient to a life-threatening risk of severe hypotension or hypertension.
We report a case of a 62-year-old ethnic Moroccan woman who has cardiovascular risk factors such as type 2 diabetes, arterial hypertension, and dyslipidemia. The patient's symptoms included dizziness, tremors, morning sickness, palpitations, and intolerance to exertion. Given her symptomatology, the patient benefited from an exploration of the autonomic nervous system through cardiovascular reactivity tests (Ewing tests), which confirmed the diagnosis of cardiac autonomic neuropathy. In addition to orthostatic hypotension, our patient had supine arterial hypertension, complicating management. To treat orthostatic hypotension, we advised the patient to avoid the supine position during the day, to raise the head of the bed during the night, and to have a sufficient fluid intake, with a gradual transition from decubitus to orthostatism and venous restraint of the lower limbs. Supine hypertension was treated with transdermal nitrates placed at bedtime and removed 1 hour before getting up. One week after the introduction of treatment, the patient reported a clear regression of functional symptoms, with an improvement in her quality of life. Improvement in symptomatology was maintained during quarterly follow-up consultations.
Cardiac autonomic neuropathy is a very common pathology in diabetic patients. It is a serious condition with a life-threatening prognosis. Its management must be individualized according to the symptomatology and profile of each patient. The treatment of patients with orthostatic hypotension and supine hypertension requires special attention to ensure that each entity is treated without aggravating the other.
心脏自主神经病变在糖尿病患者中是一种高度普遍的病理状况，并且是该人群死亡的主要原因。直立性低血压是该疾病的主要临床表现。在一些患者中，这种直立性低血压与卧位高血压相关，这构成了一个治疗挑战，因为对一种情况的治疗可能会加重另一种情况。挑战在于管理这两种血流动力学相反的情况，同时又不使患者面临严重低血压或高血压的危及生命的风险。
我们报告一例62岁的摩洛哥裔女性病例，她患有心血管危险因素，如2型糖尿病、动脉高血压和血脂异常。患者的症状包括头晕、震颤、晨吐、心悸和运动不耐受。鉴于其症状，患者通过心血管反应性测试（尤因测试）受益于自主神经系统检查，这证实了心脏自主神经病变的诊断。除了直立性低血压外，我们的患者还患有卧位动脉高血压，使管理变得复杂。为了治疗直立性低血压，我们建议患者白天避免仰卧位，夜间将床头抬高，并摄入足够的液体，从卧位逐渐过渡到直立位，并对下肢进行静脉约束。卧位高血压采用睡前经皮应用硝酸酯类药物治疗，起床前1小时去除。治疗开始一周后，患者报告功能症状明显减轻，生活质量有所改善。在每季度的随访咨询中，症状改善情况得以维持。
心脏自主神经病变在糖尿病患者中是一种非常常见的病理状况。它是一种严重的疾病，预后危及生命。其管理必须根据每个患者的症状和情况进行个体化。对直立性低血压和卧位高血压患者的治疗需要特别关注，以确保在不加重另一种情况的前提下对每种情况进行治疗。
