Secondary Hypertension: A Real World Approach
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1 Secondary Hypertension: A Real World Approach Evan Brittain, MD December 7, 2012 Kingston, Jamaica
2 Disclosures None
3 Real World Causes Renovascular Hypertension Endocrine Obstructive Sleep Apnea Pseudosecondary Hypertension Pseudo-resistant HTN Drug-induced
4 Index of Suspicion Historical Recent onset (early or late) Loss of control Resistant/accelerating Signs and Symptoms Tachycardia/blanching Evidence of PVD (bruit, differential BP) Specific drug intolerance (e.g. ACEI) Unprovoked hypokalemia Daytime sleepiness
5 Age-Based Approach Age Percent with Underlying Cause Most Common Etiologies
6 Age-Based Approach Age Percent with Underlying Cause 18 years Most Common Etiologies Coarctation Renal parenchymal
7 Age-Based Approach Age Percent with Underlying Cause Most Common Etiologies 18 years years 5 Coarctation Renal parenchymal Fibromuscular Dysplasia Thyroid disease Renal Parenchymal
8 Age-Based Approach Age Percent with Underlying Cause Most Common Etiologies 18 years years years 8-12 Coarctation Renal parenchymal Fibromuscular Dysplasia Thyroid disease Renal Parenchymal Hormone-induced Aldosteronism Cushing s Pheo Thyroid Obstructive Sleep Apnea
9 Age-Based Approach Age Percent with Underlying Cause Most Common Etiologies 18 years years years years 17 Coarctation Renal parenchymal Fibromuscular Dysplasia Thyroid disease Renal Parenchymal Hormone-induced Aldosteronism Cushing s Pheo Thyroid Obstructive Sleep Apnea Renal Artery Stenosis Renal Failure
10 Coarctation of the Aorta Diagnosed by HTN and murmur Bilateral brachial or brachial/femoral BP differential MRI preferred imaging method
11 Coarctation of the Aorta Diagnostic Strategies
12 Real World Causes Renovascular Hypertension Endocrine Obstructive Sleep Apnea Pseudosecondary Hypertension Pseudo-resistant HTN Drug-induced
13 Atherosclerotic RAS Older men Ostial or proximal 1/3 of vessel Stenosis HTN Renovascular HTN Clinical Features Suspected when: New HTN < 30 or > 55 years old Unexplained renal dysfunction Rapid decline in renal function after starting ACEI/ARB Recurrent flash pulmonary edema J Am Coll Cardiol Intv 2009;2: Atrophic kidney ACC/AHA 2011 Peripheral Arterial Disease Guidelines
14 Renovascular HTN Pathophysiology Anaesthesia and Intensive Care Medicine. Vol. 7: 8,
15 Screening and Diagnosis: Duplex ultrasound CT angiography MR angiography Angiography still gold standard High suspicion remains Suspected FMD Contrast dose May want to sample renal vein renin activity Renovascular HTN: Diagnostic Strategies
16
17 Radiocontrast (CT) Renovascular HTN: Diagnostic Contrast Use - Higher risk in Cr > 1.5mg/dL and DM (Very low risk with normal GFR) - Use non-ionic low osmolal agents - Avoid volume depletion, pre-hydrate if CKD - Onset 12-24hrs, usually transient Gadolinium (MRI) - Nephrogenic Systemic Fibrosis - Moderate to severe renal failure Kidney International (2007) 72, ;
18 Goals: Renovascular HTN: Management - Improvement in BP, preservation of renal function, decrease CV morbidity Unilateral: - HTN control: ACEI/ARB ± others - May cause decline in GFR and mild rise in Cr - Revascularization Bilateral: - HTN control: ACEI/ARB ± thiazide diuretic - Revascularization
19 Clinical Features - Young women - usually distal 2/3 of vessel Renovascular HTN: Fibromuscular Dysplasia HTN control: - ACEI/ARB, then thiazide - May drop GFR and increase Cr (usually mild) Angioplasty: - Indications: young, intolerant/resistant HTN - Duplex US after 6 months, then yearly - Surgery reserved for unamenable lesions or failed PTA J Am Coll Cardiol Intv 2009;2:161 74
20 Real World Causes Renovascular Hypertension Endocrine Obstructive Sleep Apnea Pseudosecondary Hypertension Pseudo-resistant HTN Drug-induced
21 Hormone-Related Hypertension Hyperaldosteronism Thyroid Cushing s Pheochromocytoma
22 Primary Hyperaldosteronism: Two common forms: Bilateral idiopathic hyperaldosteronism Aldosterone-producing adenoma Clinical Features Diagnostic Clues HTN Unprovoked or inappropriate hypokalemia Hypernatremia = volume expansion Low k + low Na = volume depletion and secondary aldosteronism cvphysiology.com
23 Primary Hyperaldosteronism: Diagnostic Strategies Serum aldosterone/renin ratio (ARR) - If > 20 and aldosterone > 15ng/dL salt suppression test - False positive: Beta-blockers, clonidine - False negative: diuretics, DHP CCBs, ACEI/ARBs Localization: Adrenal CT - Bilateral or large unilateral - Small, hypodense
24 Hyperaldosteronism Goal: normalization of aldosterone receptor blockade Management Unilateral hypersecretion - Adrenalectomy Bilateral adrenal hyperplasia - Aldosterone antagonist (spironolactone, eplerenone) - Monitor K, Cr, and BP frequently in first 4-6 weeks Growth Hormone & IGF Research. Vol 13; 2003: S102 S108
25 Real World Causes Renovascular Hypertension Endocrine Obstructive Sleep Apnea Pseudosecondary Hypertension Pseudo-resistant HTN Drug-induced
26 Obstructive Sleep Apnea Clinical Features Symptoms Daytime sleepiness Snoring Witnessed apneas Poor concentration Signs Obesity Large Neck Systemic HTN Arrhythmias
27 N Engl J Med 2000;342:
28 Obstructive Sleep Apnea Diagnostic Strategies
29 Obstructive Sleep Apnea Management Continuous positive airway pressure (CPAP) Circulation. 2003;107:68-73.
30 Real World Causes Renovascular Hypertension Endocrine Obstructive Sleep Apnea Pseudosecondary Hypertension Pseudo-resistant HTN Drug-induced
31 Pseudo-resistant HTN Improper measurement - Cuff size - White-coat effect Patient compliance - Lack of understanding/education - Mistrust - Poor adherence - Cost Physician causes - Inadequate doses, inappropriate combinations - Inertia
32 Drug-Induced Hypertension Drug Class Estrogen Herbal remedies Illicit NSAIDs Psychiatric Steroid Sympathomemetic Common Examples Oral contraceptives Ephedra, gensing, ma huang, licorice Cocaine, amphetamines COX-2 inhibitors, naproxen Buspirone, lithium, TCAs Prednisone, methylprednisolone Decongestants, diet pills
33 Thank you for your attention
34
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