A 17-year-old student and a football player is referred to your primary care office
for evaluation of high blood pressure.
During an annual checkup, he's noticed to have an arterial blood pressure of 155/90,
and have obviously no symptoms: he's active and vigorous, playing football.
On physical exam, the blood pressure seems even a little higher, 162/94,
heart rate is normal at 59, normal for an athlete which is quite slow,
and he has a systolic ejection murmur heard over the spine between the shoulder blades.
So, you don't hear the heart sounds but what you hear when you listen over the back is you hear --
and you can't find his femoral pulses. They're not well felt.
So, this is suggestive actually of a coarctation of the aorta because normally,
you'd expect an athlete to have vigorous peripheral pulses.
All of his blood tests are normal.
So the important factors here is there's history of hypertension, it's confirmed in the office,
his heart rate is slow but that's expected in an athlete and he has this systolic murmur heard
over the back that suggest the coarctation and you can't find his femoral pulses,
that's a particularly telling sign.
He gets his electrocardiogram.
Take a few moments to review this electrocardiogram and think about what it might show.
Indeed, what it shows is very tall R waves that lead 1 and AVL
as well as deep S wave in lead 3 and the diagnosis is left ventricular hypertrophy.
No surprise because he's been hypertensive for all of his life.
He gets a chest X-ray and we see rib notching which is indicative of coarctation.
So, what's rib notching?
On the undersides of the ribs, instead of the rib being smooth,
there's actual notching like circular notches on the rib. What is that?
Those are large collateral blood vessels that have developed
bringing blood to the lower extremities because of the coarctation.
The coarctation prevents normal flow down to the distal aorta,
to the femoral and iliac arteries and so consequently,
there's a huge network of collateral blood vessels that developed.
One of the collateral blood vessel systems is the costal arteries
which are on the lower edge of the rib and consequently,
they enlarge and they cause some bone erosion
and so you actually see rib notching on the lower margins of the chest X-ray.
Usually what happens actually is you don't see it on the chest X-ray
and you get a phone call from the radiologist,
"Hey, did you know you've got a patient with a coarctation?"
Because they've seen the rib notching.
In any case, this man has already got some effects from his hypertension.
He needs to have it treated. This is so-called secondary hypertension. There's a cause.
He gets stenting of his coarctation in the catheterization laboratory.
Usually these folks still have some high blood pressure afterwards
so he's put on an angiotensin receptor blocker and his blood pressure normalizes
and he needs yearly cardiology appointments to monitor his blood pressure in a long-term future.
These patients often have a bicuspid aortic valve
that also has to be watched for possible infection after dental work and so forth
and they may also have a small cerebral blood vessel aneurysms
that could rupture at later date although that's much less common.
With good medical care, these former coarctation patients should do very well.