Case Presentation: introduction:Pseudohypotension, a phenomenon where blood pressure readings falsely suggest hypotension, poses a significant diagnostic challenge, especially when associated with subclavian artery stenosis. The condition can lead to misleading interpretations of a patient’s hemodynamic status, impacting clinical decision-making and therapeutic interventions. In this presentation, we explore a case of pseudohypotension due to subclavian artery stenosis, which was initially overlooked in a 66-year-old female patient, highlighting the importance of accurate blood pressure assessment.A 66-year-old female with end-stage renal disease (ESRD) on hemodialysis, diabetes, chronic heart failure, and coronary artery disease (CAD) presented with dyspnea and hyperkalemia. Hospitalization was complicated by post-endoscopic ultrasound (EUS) hypotension, revealing unreliable blood pressure readings in her left arm and lower extremities. Right upper extremity measurements showed hypertensive urgency (>200/100 mmHg), contradicting previous hypotension reports. Imaging revealed left subclavian stenosis and extensive atherosclerosis. Her medical history included multiple admissions for volume overload and an ICU stay with vasopressor use based on unreliable extremity blood pressure readings.
Discussion: Pseudohypotension arises from factors like improper cuff size, technical errors, and changes in peripheral vascular resistance. A key underlying condition is Subclavian Steal Syndrome (SSS), caused by significant stenosis or occlusion of the subclavian artery, often due to atherosclerosis. SSS symptoms include vertebrobasilar insufficiency, arm claudication, differential blood pressure readings, and pseudoshock without organ dysfunction.In this patient, ESRD complications and inadequate dialysis were worsened by pseudohypotension from unreliable lower extremity readings. The use of midodrine exacerbated her hypertension, causing recurrent pulmonary edema and increased volume overload. This case underlines the necessity for awareness of pseudohypotension in patients with subclavian artery stenosis, especially those with complex conditions like ESRD. Accurate blood pressure measurement is essential for proper management and avoiding unnecessary interventions. Treatment strategies for SSS and related issues include statin and antiplatelet therapy for asymptomatic patients and revascularization for symptomatic ones.
Conclusions: This case underscores the importance of accurate blood pressure assessment in patients with subclavian artery stenosis. Unrecognized pseudohypotension can lead to misdiagnosis, inappropriate treatment, and exacerbation of underlying conditions. Comprehensive knowledge of this phenomenon is crucial for internal medicine practitioners to ensure accurate diagnosis and optimal patient care.