Severe Unexplained Relative Hypotension and Bradycardia in the Emergency Department

A precipitous episode of hypotension with concomitant bradycardia is a true medical emergency especially in patients with chronic hypertension and often requires hospitalization for detailed interrogation of the underlying causes. We describe herein a case of a patient with chronic labile hypertension who presented to the ED with a sharp drop in blood pressure and heart rate which was not simply explained by an antihypertensive overdose but more so by an aggregate of the patient’s multiple chronic medical conditions. This report highlights the complexities of treating simultaneous hypotension and bradycardia and the importance of discerning the underpinnings of the causes including past medical issues, patient medications, and the timeline of key events leading to the issue at hand. 1. Introduction Essential hypertension is generally a medically manageable disease and regimens can often be tailor-made for each patient depending on age, gender, race and ethnicity, and other comorbid conditions. However, long standing hypertension can result in significant vascular remodeling ultimately leading to potentially life-threatening conditions such as heart attacks and strokes and end-organ damage. Among the top two leading causes of kidney transplant in the United States is long-standing and poorly or difficult to control hypertension which eventually leads to kidney failure. In recent years, solid organ transplants have become more successful due to the improvements in surgical techniques and advancements in immunosuppressive drugs. Accordingly, the prevalence of living organ transplants is increasing even though the number of annual transplant surgeries remains constant. This selected patient population must receive careful treatment to preserve their organ transplant especially because of them many have significant comorbid condition. Immunosuppression with calcineurin inhibitors such as tacrolimus and cyclosporin are necessary to preserve renal function and prevent transplant rejection, but ironically these medications have profound nephrotoxic properties [1]. The patient discussed herein has a history of a kidney transplant and a subsequent slowly declining renal function; additionally the patient has significant hypertension which of late had been very difficult to manage. 2. Case Presentation A 68-year-old man presented to the emergency department (ED) complaining of feeling lightheaded, confused, and dizzy and subsequently called for emergency medical service. En route to the ED via ambulance, the patient was noted to have a pulse in the thirties and a