Hypertensive Crisis with Congenital Aortic Stenosis in Resource-Limited Setting

Case at a Glance

A 28-year-old female with congenital aortic stenosis and uncontrolled hypertension presents with hypertensive crisis symptoms while facing significant barriers to healthcare access due to socioeconomic constraints and systemic healthcare inequities.

Patient's Story

The patient is a 28-year-old woman with a known history of congenital aortic stenosis and hypertension who presented to our emergency department after experiencing worsening symptoms over several weeks. She had been previously managed on atenolol 50mg daily but had been unable to continue treatment due to financial constraints. The patient reported being homeless and staying in temporary shelter accommodations, with limited access to healthcare resources. She described experiencing severe headaches, chest tightness, fatigue, and a sensation of 'impending doom.' Her medical history was significant for the loss of her primary caregivers, after which her health management deteriorated significantly. She also reported having autism spectrum disorder, which complicated her ability to navigate complex healthcare systems independently.

Initial Assessment

Upon presentation, the patient appeared distressed and reported symptoms consistent with hypertensive crisis including severe headache, chest pain, and dyspnea. Vital signs revealed significantly elevated blood pressure. Physical examination was notable for findings consistent with aortic stenosis. The patient expressed significant anxiety about her prognosis and ability to access ongoing care. Social assessment revealed complex barriers to healthcare access including homelessness, lack of insurance coverage, transportation difficulties, and systemic barriers related to socioeconomic status.

The Diagnostic Journey

Initial workup included comprehensive metabolic panel, cardiac enzymes, ECG, and echocardiogram to assess current cardiac function and degree of aortic stenosis. Blood pressure monitoring revealed persistently elevated readings requiring immediate intervention. The diagnostic process was complicated by the patient's inability to provide complete medical records due to her housing instability. Cardiology consultation was obtained to evaluate the severity of her aortic stenosis and its contribution to her current presentation.

Final Diagnosis

1. Hypertensive crisis, likely secondary to medication discontinuation
2. Congenital aortic stenosis, moderate to severe
3. Heart failure with preserved ejection fraction
4. Social determinants of health significantly impacting medical management
5. Autism spectrum disorder affecting healthcare navigation

Treatment Plan

Immediate management focused on controlled reduction of blood pressure using IV antihypertensive agents. The patient was restarted on oral antihypertensive therapy with close monitoring. Social work consultation was initiated to address housing instability and healthcare access barriers. Care coordination was established with local community health resources and patient assistance programs for medication access. The treatment team worked to identify sustainable long-term management strategies given the patient's social circumstances. Cardiothoracic surgery consultation was deferred pending stabilization of acute issues and establishment of reliable follow-up care.

Outcome and Follow-up

The patient's blood pressure was successfully reduced to target range over 48 hours. She was discharged with a 30-day supply of medications obtained through hospital assistance programs and connected with community health resources for ongoing care. Social services arranged temporary housing assistance and transportation vouchers for medical appointments. Follow-up was scheduled within one week at a federally qualified health center. The case highlighted the complex interplay between medical conditions and social determinants of health, emphasizing the need for comprehensive care approaches that address both clinical and social needs. Long-term prognosis depends significantly on establishing sustainable access to care and addressing underlying social barriers.