Background White coat uncontrolled hypertension (WCUH), defined as drug-treated hypertension but with increased blood pressure in the office and normal ambulatory blood pressure, should be assessed in patients with uncontrolled hypertension to prevent overtreatment. We report a case of an extreme WCUH found by ambulatory blood pressure monitoring (ABPM). Case Summary A 66-year-old woman was a regular patient in Cardiology Outpatient Clinic, Indonesian Army Central Hospital Gatot Soebroto with uncontrolled hypertension, CAD post-PCI, and insulin-dependent type 2 diabetes mellitus. The patient was overweight (BMI was 24.56 kg/m2) with dyslipidemia and uncontrolled blood glucose. Despite aggressive treatment with ARB, CCB, beta-blockers, diuretic, and clonidine, the patient had persistent hypertension with mean office systolic blood pressure >160/90 mmHg. Echocardiography showed concentric left ventricular hypertrophy. ABPM result found extreme variability of blood pressure with the average 24-hour blood pressure of 93.6/59 mmHg (mean daytime blood pressure was 90/55 mmHg and mean night-time blood pressure was 98.7/65.2 mmHg), intermittent hypotension, and reverse dipper pattern. The blood pressure once dropped to the lowest point of 69/44 mmHg, and the highest was 211/186 mmHg. Based on this result, we classified the patient’s condition as WCUH and adjusted the antihypertensive regiment. Discussion This case emphasizes the need to evaluate the presence of WCUH by ABPM in patients with uncontrolled hypertension so antihypertensive drugs could be adjusted accordingly and prevent hypotension.

Background Myocardial injury caused by viral myocarditis may occur during COVID-19 infections. This condition may lead to cardiomyopathy as the chronic sequela. We report a case of an adolescent COVID-19 survivor without underlying heart disease presented with dilated cardiomyopathy.  Case Summary A 16-year-old male patient was referred to Cardiology Outpatient Clinic, Indonesian Army Central Hospital Gatot Soebroto. The patient presented with a chief complaint of fatigue and just recovered from mild to moderate COVID-19 one month before the visit. There was no prior history of heart disease. Physical examination was within normal limit, but laboratory findings showed highly elevated NT-proBNP (7705 pg/mL) and D-dimer (1850 ng/mL). ECG revealed normal sinus rhythm with poor R wave progression. Echocardiography detected all chamber dilatation, eccentric left ventricular hypertrophy, global hypokinetic, moderate mitral regurgitation, and reduced ejection fraction (22%). The patient was diagnosed with new-onset dilated cardiomyopathy as a COVID-19 sequela and we initiated treatment with ARB (candesartan), beta-blocker (bisoprolol), diuretics (furosemide and spironolactone), rivaroxaban, and trimetazidine. During a follow-up visit three months later, the patient’s recovery was stable. Discussion  The occurrence of new-onset cardiomyopathy in our previously healthy young patient highlights the possible mechanism of COVID-19 as a single cause of myocardial injury without underlying heart disease. Comprehensive evaluation and optimal treatment should be taken during hospitalization and post-discharge period to prevent further complications. Additional examinations such as cardiac magnetic resonance and endomyocardial biopsy should be done to provide definitive confirmation.

Background White coat uncontrolled hypertension (WCUH), defined as drug-treated hypertension but with increased blood pressure in the office and normal ambulatory blood pressure, should be assessed in patients with uncontrolled hypertension to prevent overtreatment. We report a case of an extreme WCUH found by ambulatory blood pressure monitoring (ABPM). Case Summary A 66-year-old woman was a regular patient in Cardiology Outpatient Clinic, Indonesian Army Central Hospital Gatot Soebroto with uncontrolled hypertension, CAD post-PCI, and insulin-dependent type 2 diabetes mellitus. The patient was overweight (BMI was 24.56 kg/m2) with dyslipidemia and uncontrolled blood glucose. Despite aggressive treatment with ARB, CCB, beta-blockers, diuretic, and clonidine, the patient had persistent hypertension with mean office systolic blood pressure >160/90 mmHg. Echocardiography showed concentric left ventricular hypertrophy. ABPM result found extreme variability of blood pressure with the average 24-hour blood pressure of 93.6/59 mmHg (mean daytime blood pressure was 90/55 mmHg and mean night-time blood pressure was 98.7/65.2 mmHg), intermittent hypotension, and reverse dipper pattern. The blood pressure once dropped to the lowest point of 69/44 mmHg, and the highest was 211/186 mmHg. Based on this result, we classified the patient’s condition as WCUH and adjusted the antihypertensive regiment. Discussion This case emphasizes the need to evaluate the presence of WCUH by ABPM in patients with uncontrolled hypertension so antihypertensive drugs could be adjusted accordingly and prevent hypotension.

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Terapi imunoterapi memiliki peran menjanjikan dalam pengobatan pasien terbaru. Penerapan terapi sel untuk pengobatan penyakit kardiovaskular berpotensi mencapai tujuan terapi regenerasi kardiovaskular. Status terapi saat ini untuk kardiovaskular tidak memadai sehingga pengembangan alternatif yang aman dan efisien sangat diperlukan. Laporan kasus bertujuan membuktikan bahwa vaksin regeneratif makrofag dapat menjadi pilihan terapi untuk pasien kardiomiopati yang tidak memiliki pilihan terapi lain untuk perawatan. Metode dengan regeneratif makrofag dipilih berasal dari manusia yang dikembangkan menjadi vaksin untuk pasien kardiomiopati. Komponen darah monosit pasien dipisahkan dari komponen darah lain dan diberi perlakukan selama 4 hari. Monosit diprogram menjadi regeneratif makrofag. Ekokardiografi transthorakal dilakukan sebelum dan satu bulan setelah imunoterapi untuk mendukung tampilan klinis pasien. Pemeriksaan elektrokardiografi, x-ray thorax dan ekokardiografi dilakukan. Hasil elektrokardiografi sebelum dan sesudah terapi menunjukkan multipel ventrikel ekstrasistol. Hasil ekokardiografi sebelum terapi menunjukkan hipertrofi ventrikel kiri, disfungsi diastolik, ventrikel hipokinetik dengan ejeksi fraksi yang rendah (44%). Hasil terapi vaksin regeneratif makrofag pada pasien menunjukkan terdapat perubahan bermakna pemeriksaan ekokardiografi yaitu hipertrofi ventrikel kiri, normokinetik, disfungsi diastolik, dan peningkatan ejeksi fraksi (56%). Imunoterapi vaksin regeneratif makrofag menghasilkan perubahan bermakna status klinis dan ekokardiografi.