34 VOLUME 14, ISSUE 1, JANUARY 2002

RESEARCH

Secondary Hypertension In A Migrant Farm Worker:A Case Report Of Coarctation Of The Aorta

Scott Fleming, CRNP, MSN

Yves Lefranc, MD

George Rodway, CRNP, MSN

Beth Ann Wilson, RN, BSN

CASE PRESENTATION

A 33-year-old Hispanic male presented to a rural migrant farm worker’sclinic with abdominal pain. He was found to have severe uncontrolled hyper-tension and left flank tenderness. Secondary hypertension was suspected andhe was referred for emergency department evaluation and hospital admission.He had been scheduled for an initial visit concerning a recent urinary tractinfection (UTI) and uncontrolled hypertension.

He had been experiencing intermittent left flank pain and left lower quad-rant abdominal pain for several weeks. The pain was sharp and fleeting, oftenlasting only a few minutes. The discomfort was not associated with any nau-sea or vomiting, fever, change in bowel pattern, or appetite. Food intake mayhave helped the pain somewhat. He denied any weight loss, hematuria,melana, or hematochezia. The abdominal pain was not altered with move-ment or lifting. He stated he has had some mild urinary frequency anddysuria, which was improving after antibiotic therapy.

His past medical history was significant for hypertension for the past sixyears. Over the past two years he had intermittently taken antihypertensiveswith minimal effect on his blood pressure. There was no history of any pre-vious hospitalizations. He did not recall having any past diagnostic testingexcept for blood and urine testing. His current medications includedciprofloxacin 500 mg twice a day and hydrochlorothiazide 25 mg daily. Hedenied taking any other over-the-counter medications and he related he hadbeen compliant with his daily medications.

The patient’s social and family history revealed familial risk factors forhypertension, coronary artery disease, and diabetes mellitus. He spoke mini-mal English but related that he was born and raised in Mexico and has beenresiding in the United States for the past 4-5 years working as a migrant farmlaborer. There was no history of tobacco or illegal drug use. He rarely usedalcohol. Currently, he was married and lived with his wife in a migrant camp.The patient and his wife did not have any healthcare insurance. His review ofsystems was significant for occasional blurred vision, headaches, and dizzi-ness.

The patient’s physical examination revealed a well-developed and thinHispanic male in no acute distress. His vital signs revealed persistent hyper-tension: B/P 206/110 left arm, 198/110 right arm, 140/90 left leg, 138/92right leg. Temperature 98.6, pulse 64, respirations 18, weight 64 Kg, height167.6. His eye examination was remarkable for Grade II vessels withoutpapilledema. No exophthalmia was noted. The patient’s neck was supple. Nojugular venous distention or thyromegaly was noted. His carotids were 2+/2+without bruits. Cardiac examination revealed a normal PMI, S1, and S2. Agrade II/VI systolic murmur could be heard at the left lower sternal border.The murmur radiated to the thoracic region of the back at the T4 level.

PurposeTo report a case of undetected aortic coarcta-tion in an adult Hispanic migrant farm work-er that presented with uncontrolled hyperten-sion and transient left flank pain. A primarycare overview of the disorder, clinical diagno-sis, testing, and treatment are discussed.

Data SourcesCase report, scientific literature, diagnosticevidence.

ConclusionsCoarctation of the aorta is a significant con-genital cardiovascular anomaly and cause ofsecondary hypertension. The majority ofpatients with coarctation of the aorta are diag-nosed during infancy. Older children andadults may have a subtle presentation, but canbe identified as being at risk by having a thor-ough history and physical, as well as noninva-sive diagnostic testing.

Implications for PracticePrimary care providers must have a highdegree of suspicion in patients with risk factorsor in individuals that may have not benefitedfrom adequate health screening. Early diagno-sis and correction of the coarctation is impor-tant to reduce persistent postoperative hyper-tension and improve long-term survival.

Key WordsCoarctation of aorta; secondary hypertension.

AuthorsScott Fleming, CRNP, MSN, Yves Lefranc,MD, and George Rodway, CRNP, MSN, areclinical faculty for the Kent State Adult NursePractitoner Program, Kent, Ohio, and Hartville

JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS 35

The patient’s lungs were clear. His chest was symmetricwithout any precordial movement or thrills. The abdominalexam was significant for mild tenderness on deep palpation ofthe left lower quadrant. No peritoneal signs, masses, orhepatosplenomegaly were found. Abdominal aortic pulsationwas 2-3 cm in width. The rectal examination was normal.Peripheral vascular findings were as follows: Radial 3+/3+;Femoral 1+/1+; Dorsalis pedis 1+/1+; Posterior tibial 1+/1+.No peripheral edema was noted. A carotid femoral delay waspresent. Neurological examination was unremarkable. CranialNerves II-XII were intact. Deep tendon reflexes were brisk andsymmetric. Motor and sensory exam were nonfocal. Gait,speech, and memory were within normal limits.

An electrocardiogram (ECG) was obtained and revealed anormal sinus rhythm with a rate of 61. Diffuse T wave abnor-malities, left axis deviation and left ventricular and left atrialhypertrophy were present (Figure 1).

Laboratory testing included a normal complete blood countand chemistry profile. The BUN:creatinine ratio was within nor-mal limits. Urinalysis revealed a trace of ketones and hemoglo-bin. Urine sediment was normal.

The PA and lateral chest radiograph was significant for theclassic “3” sign of aortic coarctation, left ventricular enlarge-ment, and posterior rib notching (Figure 2). A computedtomography (CT) scan of the abdomen and pelvis was withinnormal limits. A 2D echocardiogram was performed andrevealed mild left atrial dilation and left ventricular hypertrophy.Mild mitral regurgitation and trivial aortic insufficiency werealso noted.

A transaxillary thoracic aortogram (TTA) was ordered. Theaortic valve was tricuspid. A high-grade stenosis of the proximaldescending thoracic aorta was identified just beyond the originof the left subclavian artery. There was marked dilation and col-lateralization of the mammary and subclavian arteries (Figure 3).

CLINICAL COURSE

A cardiovascular surgeon was consulted and the patientunderwent repair of the aortic coarctation with a 14 mm inter-position graft. On the second post-operative day, a revision ofthe graft was done because of residual proximal stenosis. Hispostoperative course was uncomplicated and his abdominal painresolved. The patient was discharged on a clonidine 0.1 mgpatch applied weekly, enalapril 20mg twice a day, and metopro-lol 50mg twice a day to control his persistent hypertension.Follow up appointments were scheduled for primary care andcardiac surgery. Interestingly, the exact etiology of the abdominalpain was never identified; however, a case of a 21-year-old femalewith coarctation of the aorta (status post balloon angioplasty)

Migrant Clinics, Hartville, Ohio. Beth Ann Wilson, RN,BSN, was a nurse practioner student at Kent StateUniversity, College of Nursing, and the Hartville MigrantClinic and is now an NP in private practice. Contact Mr.Fleming by E-mail at sflemin1@kent.edu

Figure 1. ECG

36 VOLUME 14, ISSUE 1, JANUARY 2002

with transient left flank pain related to aortopathy has beenreported in the literature (Wooley, Sparks, & Boudoulas, 1998).

PREVALENCE OF COARCTATION OF THE AORTA

Coarctation of the aorta is a common congenital cardiovas-cular defect that consists of a narrowing and infolding of the aor-tic wall. There are a wide range of anatomical features and asso-ciated defects. Aortic coarctation comprises over 5% of congen-ital cardiovascular defects and is considered an important causeof secondary hypertension (Leandro, Balfe, Smallhorn, &Benson, 1992; Rothman, 1998). Aortic coarctation has beenfound on necropsy in up to 1:1,550 patients (Jenkins, & Ward,1999). It is often diagnosed during infancy and is more commonin males and Caucasians (McCrindle, 1999; Roa, 1995;Rothman, 1998). Patients with Turner’s syndrome are particu-larly high risk with a reported prevalence of 15%-35%(Bordeleau, Cwinn, Turek, Barron-Klauninger, & Victor, 1997;Rothman, 1998). Unfortunately, untreated patients rarely sur-vive past the third decade of life (Jenkins, & Ward, 1999).

ASSOCIATED DEFECTS

Approximately half of all patients with coarctation of theaorta also have other cardiac and vascular defects (Rothman,1998). Commonly associated cardiac abnormalities include (a)bicuspid aortic valve, (b) hypoplastic left heart defects, (c) ven-tricular septal defect, and (d) valvular aortic stenosis. Vascularanomalies, such as aberrant subclavian arteries, which can evenoriginate distal to the coarctation, are well described in the liter-ature. In uncorrected aortic coarctation, abnormally large collat-eral vessels of the subclavian, mammary, intercostal, and spinalarteries develop. Hemangiomas are also found with increasedincidence in these patients (Rothman, 1998); cerebral aneurysmscan be found in 3%-5% of these patients (Hodes, Steinfeld, &Blumenthal, 1959; Roa, 1995).

CLINICAL PRESENTATION AND FEATURES

The clinical presentation of this condition is highly variable.Patient age, severity of stenosis, and associated defects may alterthe patient’s symptoms and physical findings. Infants may pre-sent with failure to thrive, with or without overt congestive heartfailure. Clinical decompensation or cardiogenic shock may betriggered by closure of the ductus arteriosus. Children and adultsoften have a more subtle presentation, such as headaches, legcramps, epistaxis, cold feet, and muscle weakness. Older childrenand adults are often discovered to have coarctation of the aortabecause of abnormal blood pressure readings, a heart murmur, orboth (Rothman 1998).

Physical findings are often apparent with a thorough physicalexamination. The hallmark of aortic coarctation is arm-leg bloodpressure discrepancy or a carotid-femoral delay. Most patients

with aortic coarctation have upper extremity hypertension anddiminished leg pulses. In normal older children and adults, uni-lateral as well as concurrent palpation of the carotid and femoralpulse should reveal a simultaneous impulse. Older patients withcoarctation will have a noticeable delay between the carotid orbrachial and femoral pulses. In the normal infant the blood pres-sure in the arms is equal to that in the legs or slightly higher inthe arms than in the legs. Older children and adults have slight-ly higher systolic leg pressures than pressures found in the arms(5-20 mmHg). It is important to recognize that aortic coarcta-tion can involve the left subclavian artery origin or the left sub-clavian artery may be proximal to the stenosis, in which case, theleft arm pressure will be normal. Rarely, the coarctation is prox-imal to both subclavian origins causing diminished blood pres-sures in all four extremities. Blood pressure should be measuredin both arms and one leg; any elevation over 20 mmHg in thearms compared to the legs should be considered suspicious foraortic coarctation (Roa, 1995; Rothman, 1998).

Heart murmurs and/or systolic clicks are often found inpatients with coarctation of the aorta. The systolic murmur willusually be loudest in the back and medial to the left scapula butmay also be present at the sternal borders, apex, or even the axil-la. In older children and adults, continuous murmurs from largecollateral vessels may be found on both sides of the chest. A thrillcan sometimes be palpated in the suprasternal notch.Appreciating an early systolic click can be an indication of acoexistent bicuspid aortic valve (Roa, 1995; Rothman, 1998).

DIAGNOSTIC EVALUATION

The initial diagnostic evaluation should include an ECG andchest radiograph. The ECG may be normal in infants or thosewith mild stenosis. In contrast, older patients are often found tohave left ventricular hypertrophy and T wave and ST segmentabnormalities (Figure 1). Occasionally, the ECG in infants mayreveal right ventricular hypertrophy (Roa, 1995).

Chest radiographs are especially helpful in older adults,revealing cardiomegaly and rib-notching from large collateralvessels. These are identified by the scalloping appearance of theposterior ribs. The classic “3” sign may be present from theimposed contour of the prominent aortic knob and the abnor-mal descending aorta. This gives the left mediastinal contour theappearance of the outline of the number 3 (Figure 2; Roa, 1995;Rothman, 1998).

Two-dimensional echocardiograms are useful for evaluationof cardiac function and identification of coexisting cardiacanomalies; they can confirm aortic coarctation in infants. Inadults and older children, however, additional noninvasive test-ing is needed with magnetic resonance imaging or trane-sophageal echocardiography (Roa, 1995; Rothman, 1998).

Although not mandatory, angiography of the aorta is oftenneeded to demonstrate anatomical variables, severity of the pres-sure gradient, and extent of collateral circulation. A pressure gra-dient over 20 mmHg across the stenosis confirms significantstenosis (Roa, 1995; Rothman, 1998).

JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS 37

Figure 3. Transaxillary Thoracic Aortogram (TTA)Figure 2. PA and Lateral Chest Radiograph

TREATMENT

Prompt referral to a cardiothoracic surgeon for evaluation isessential. Severe hypertension or congestive heart failure are indi-cations for urgent intervention. It is recommended that asymp-tomatic patients should have the stenosis corrected between 2-5years of age. Delayed repair is often associated with persistentpostoperative hypertension and decreased life expectancy(Leandro et al., 1992; Rothman, 1998). Various surgical tech-niques are used and guided by the patient’s age, as well asanatomical and pathologic variables. These procedures includeend-to-end anastamosis, flap aortoplasty, prosthetic patch aorto-plasty, and tubular bypass grafting. Balloon angioplasty is oftenused very successfully as an alternative treatment (Jenkins, &Ward, 1999; Roa, 1995).

CONCLUSION

Underserved immigrant populations may not have had accessto adequate pediatric or adult health screening and should beconsidered higher risk for occult congenital disorders. Mostmigrant farm workers live below the poverty level in the U.S.and have poor access to or inability to afford healthcare. Migrantfarm workers are often uninsured or are covered by state medicalassistance programs. Unfortunately, most migrant healthcareclinics have limited resources and hospital related costs are oftennot reimbursed.

Early detection and treatment for coarctation of the aorta isparamount for long-term survival. All patients with hypertensionshould have aortic coarctation considered in the differential diag-

nosis. A high index of suspicion should be used when evaluatingelevated upper extremity blood pressures in children, youngadults, and patient’s with Turner’s syndrome. Aortic coarctationin the adult population can usually be detected by a thorough his-tory and physical examination and a chest radiograph. All hyper-tensive patients should have a thorough evaluation to rule outsecondary causes of hypertension in a timely manner.

REFERENCESBordeleau, L., Cwinn, A., Turek, M., Barron-Klauninger, K., & Victor, G., (1998).

Aortic dissection and Turner’s syndrome: Case report and review of the lit-erature. The Journal of Emergency Medicine, 16, 593-596.

Hodes, H.L., Steinfeld, L., & Blumenthal, S. (1959). Congenital cerebralaneurysms and coarctation of the aorta. Archives of Pediatrics, 76, 28-43.

Jenkins, N.P., & Ward, C. (1999). Coarctation of the aorta: Natural history and out-come after surgical treatment. Quarterly Journal of Medicine, 92, 365-371.

Leandro, J., Balfe, J.W., Smallhorn, J.F., & Benson, L. (1992). Coarctation ofthe aorta and hypertension. Child Nephrology and Urology, 12, 124-127.

McCrindle, B.W. (1999). Coarctation of the aorta. Current Opinion in Cardiology,14, 448-452.

Roa, P.S. (1995). Coarctation of the aorta. Seminars in Nephrology, 15, 87-105.Rothman, A. (1998). Coarctation of the aorta: An update. Current Problems in

Pediatrics, 28, 33-60.Whooley, C.F., Sparks, E.H, & Boudoulas, H. (1998). Aortic pain. Progress in

Cardiovascular Diseases, 40, 563-589.