Chest Pain and Cardiovascular Symptoms in a Young Adult with Uncontrolled Hypertension

Case at a Glance

A 21-year-old male with a 5-year history of hypertension presents with acute onset chest pain, shortness of breath, and associated symptoms after being off antihypertensive medication for one year due to loss of insurance coverage.

Patient's Story

The patient is a 21-year-old male with a significant medical history of hypertension diagnosed at age 16. Despite extensive cardiac workup at the time of diagnosis, no underlying structural cause was identified, though there is a positive family history of hypertension. The patient had been managing his condition with lifestyle modifications including regular exercise, balanced nutrition, elimination of red meat, and reduced sugar intake. Due to family conflicts resulting in loss of health insurance coverage, he discontinued his antihypertensive medication (Hydrochlorothiazide 12.5mg daily) approximately one year ago and has not had medical follow-up since.

Initial Assessment

Five days prior to presentation, the patient experienced sudden onset sharp chest pain localized to the left precordial area, accompanied by an unusual sensation of chest uneasiness and tremor-like feelings. The pain exhibited a characteristic pattern of being absent during ambulation but consistently present during rest or recumbent positioning. Initial symptoms progressed over subsequent days, with the patient developing additional concerning features including intermittent left arm numbness during rest, left eyelid twitching, and episodes of dyspnea.

The Diagnostic Journey

The patient's presentation raised several diagnostic considerations given his young age and specific symptom pattern. The positional nature of his chest pain (worse when supine, improved when upright) suggested possible pericardial involvement. However, his history of uncontrolled hypertension for one year raised concerns for hypertensive cardiovascular complications. The combination of chest pain, dyspnea, and his significant cardiac risk factors warranted immediate cardiovascular evaluation despite his young age. His previous medication regimen included Hydrochlorothiazide for blood pressure control and had a history of ADHD treatment with Daytrana patch, which he had discontinued.

Final Diagnosis

Suspected hypertensive cardiovascular disease with possible early heart failure symptoms, complicated by medication non-compliance and lack of medical monitoring. Differential diagnosis included pericarditis, anxiety disorder exacerbation, or early hypertensive cardiomyopathy. The patient's description of symptoms lasting multiple days, unlike his typical brief panic episodes, supported an organic etiology.

Treatment Plan

Immediate medical evaluation was recommended given the constellation of cardiac symptoms in a patient with uncontrolled hypertension. Emergency department assessment was advised for comprehensive cardiac workup including ECG, chest X-ray, echocardiogram, and laboratory studies including cardiac biomarkers. Urgent reinitiation of antihypertensive therapy under medical supervision was indicated. Patient counseling regarding the importance of medication compliance and regular medical follow-up was essential.

Outcome and Follow-up

The patient was counseled on the serious nature of his symptoms and the potential cardiovascular risks associated with uncontrolled hypertension at his age. Despite financial concerns regarding emergency care, the severity and progression of his symptoms warranted immediate medical attention. Plans were made for insurance enrollment during the next available period and establishment of regular cardiovascular care. The case highlighted the critical importance of medication adherence and continuous medical monitoring in young adults with hypertension.