How to approach resistant hypertension. Teh-Li Huo, M.D., Ph.D.

Size: px
Start display at page:

Download "How to approach resistant hypertension. Teh-Li Huo, M.D., Ph.D."

Transcription

1 How to approach resistant hypertension Teh-Li Huo, M.D., Ph.D.

2 BP goals No risk factors: <140/85 + risk factors or existing diseases: <130/80 Proteinuria < 0.22 gm/24hr Urine microalb/cr<100mg/g Factors increasing BP: NSAID, anti-depressants CNS stimulants, caffeine Pain, anxiety, hyperthyroid Cushings, some licorice Salt General concept One BP drug decreases ~SBP 15 points (10 to 20) Drug half life If > 2 drugs needed: ACEI+CCB+? ACEI+thiazide+? BB+thiazide+? BB+CCB+? BB+ACEI+? If >3 or 4 drugs (good doses) needed: First to look for: RAS, Pheochromocytoma, hyperaldosteronism

3 Renal Artery Stenosis Pheochromocytoma Mineralocorticoid HTN High sympathetic tone Always exclude hyperthyroid, cushing s, drugs..first Among Resistant HTN

4

5

6

7

8 60 yo WF DM2, HTN, high lipid, CABG Metoprolol 100mg bid HCTZ 25 mg qd Amlodipine 10 mg qd Lisinopril 40 mg qd Isosorbide 60mg bid 140/67, 66, 80kg Clear lung No edema Cr 1.6. egfr 33 Urine microalbumin/cr 845 mg/g What would you do next? CASE 1

9 Additional choices: Alpha 1 blocker Alpha 2 agonist Vasodilator ARB Renin inhibitor Aldosterone blocker Loop diuretics Na channel blocker CNS agents Case 1 Work up? Chemistry Renin ng/ml/hr Aldosterone 52.2 ng/dl Serum metanephrines 24 Urine catecholamines urine TTKG Radiology Renal artery duplex CTA MRA Thin cut abdominal CT through adrenal gland MIBG nuclear scan

10 53 WM HTN x 12 y worsening Normal or Hypokalemia Severe Meniere s disease Kidney stones L adrenal nodule 1cm Nadolol 40 mg qd Amlodipine 10 mg qd Lisinopril/HCTZ 20/12.5 mg bid Terazosin 1 mg qd KCL 20 meq 6 times daily Case 2 136/ kg 5 11 Clear lung, no edema Cr 1.0, K 3.6 U microalb/cr 2.2 Aldosterone 22.3 Renin ordered, not done TTKG 13.2 (normal 3 to 7=(Uk/Sk)/(Uosm/Sosm), k 3.5 to 4.5) Adrenal vein sampling (aldosterone) R: pre ACTH 8, post 12 L: pre 228, post 1826 Periph: pre 15.7, post 40.4

11 Next? Eplerenone 50 mg qd DC KCL L adrenalectomy Post surgery: aldoserone <1.6. BP better. Meniere s better. But BP slowly up again after 1 month. K 2.9 Amiloride 5 mg bid added BP near perfect Case 2 One year later on nadolol, eplerenone, amiloride, 3 agents only BP 120/ kg Cr 0.95, renin 0.38, aldosterone 36.3, TTKG 5.2, K 4.0 Meniere s resolved Final diagnosis? Bilateral adrenal hyperplasia (hyperaldosteronism) L adrenal nodule? Non-functional

12 70 WM DM2, HTN, high lipid, CKD3 Lasix 20 mg qd Amlodipine 10 qd Atenolol 100 bid Benicar 40 mg qd Benazopril 20 mg qd Clonidine patch #3 KCL 10 meq bid 186/ kg Clear lung No edema Cr 1.3, K 3.1 Umicroalb/Cr 39, TTKG 5 Next? Eplerenone 50 mg qd added Aldosterone 2, Renin hr U aldosterone <1 Nl catecholamine, metanephrines US: smaller R kidney MRA: no RAS Abd CT adrenal: R 1 nodule, L 3 nodules BP still high 1 mo later 178/83 Case 3 Next?

13 Amiloride 5 mg bid added BP dropped to 95/40 Finally on 3 agents only BP well controlled Final diagnosis Liddle syndrome (pseudohyperaldosteronism) Mutation of inhibitory subunits of Na Channel in collecting duct leads to constitutive activation of Na channel in collecting duct Active Na reabsorption feedback inhibits aldosterone synthesis, but with renal K leakage-----high TTKG BP easily controlled by Na channel blocker Case 3

14 62 yo HM Severe HTN, BP 210/140 on max dose 7 agents CVA/TIA CKD3 Proteinuria up to 3 gm Atenolol 100 mg qd Amlodipine 10 mg bid Univasc 30 mg qd Cardura 8 mg bid Minoxidil 20 mg tid HCTZ 50 mg qd Spironolactone 100 mg bid Clonidine prn Case 4 K on K supplement Aldosterone 12.1 (up to 71) renin < hr urine: no pheochromocytoma CTA/MRA: No RAS Adrenal vein sampling: possible L adrenal hyperplasia L adrenalectomy help BP for 3 month only Kidney biopsy showed atherosclerosis, no GN Next? Prednisone added BP dropped nicely Finally on 3 agents only plus low dose prednisone

15 Final diagnosis Glucocorticoid-remediable aldosteronism (GRA) an autosomal dominant disorder in which the increase in aldosterone secretion produced by ACTH is no longer transient GRA

16 The genes encoding aldosterone synthase and 11-hydroxylase are 95% identical and are close together on chromosome 8. In individuals with GRA, there is unequal crossing over so that the 5' regulatory region of the 11-hydroxylase gene is fused to the coding region of the aldosterone synthase. The product of this hybrid gene is aldosterone synthase that is ACTH-sensitive in the zona fasciculata of the adrenal gland. Although in normal subjects, ACTH accelerates the first step of aldosterone synthesis, ACTH normally has no effect on the activity of aldosterone synthase. However, in subjects with glucocorticoid-remediable aldosteronism, ACTH increases the activity of existing aldosterone synthase, resulting in an abnormally high rate of aldosterone synthesis andhyperaldosteronism. GRA

17 Difficult HTN with: Low normal serum K (K<4) on ACEI/ARB Unusual higher K supplement on thiazide Sleep apnea More vague symptoms not feel well but no palpitation, no sweating. Hypokalemia with hypomagnesemia, not on diuretics Therapeutic trial of aldosterone blocker Culprits of Mineralocorticoid HTN

Primary Aldosteronism

Primary Aldosteronism Primary Aldosteronism Odelia Cooper, MD Assistant Professor of Medicine Division of Endocrinology, Diabetes, and Metabolism Cedars-Sinai Medical Center HYPERTENSION CENTER Barriers to diagnosing primary

More information

Secondary Hypertension: A Real World Approach

Secondary Hypertension: A Real World Approach Secondary Hypertension: A Real World Approach Evan Brittain, MD December 7, 2012 Kingston, Jamaica Disclosures None Real World Causes Renovascular Hypertension Endocrine Obstructive Sleep Apnea Pseudosecondary

More information

Endocrine. Endocrine as it relates to the kidney. Sarah Elfering, MD University of Minnesota

Endocrine. Endocrine as it relates to the kidney. Sarah Elfering, MD University of Minnesota Endocrine Sarah Elfering, MD University of Minnesota Endocrine as it relates to the kidney Parathyroid gland Vitamin D Endocrine causes of HTN Adrenal adenoma PTH Bone Kidney Intestine 1, 25 OH Vitamin

More information

Hypertension Pharmacotherapy: A Practical Approach

Hypertension Pharmacotherapy: A Practical Approach Hypertension Pharmacotherapy: A Practical Approach Ronald Victor, MD Burns & Allen Chair in Cardiology Director, The Hypertension Center Associate Director, The Heart Institute Hypertension Center 1. 2.

More information

Mineralocorticoids: aldosterone Angiotensin II/renin regulation by sympathetic tone; High potassium will stimulate and ACTH Increase in aldosterone

Mineralocorticoids: aldosterone Angiotensin II/renin regulation by sympathetic tone; High potassium will stimulate and ACTH Increase in aldosterone Disease of the Adrenals 1 Zona Glomerulosa Mineralocorticoids: aldosterone Angiotensin II/renin regulation by sympathetic tone; High potassium will stimulate and ACTH Increase in aldosterone leads to salt

More information

Treating Hypertension from

Treating Hypertension from Treating Hypertension from Initiation to Resistance: A Case Study Approach Michelle Krause, MD Division of Nephrology University of Arkansas for Medical Sciences Central Arkansas Veteran s Healthcare System

More information

HypertensionTreatment Guidelines. Michaelene Urban APRN, MSN, ACNS-BC, ANP-BC

HypertensionTreatment Guidelines. Michaelene Urban APRN, MSN, ACNS-BC, ANP-BC HypertensionTreatment Guidelines Michaelene Urban APRN, MSN, ACNS-BC, ANP-BC Objectives: Review the definition of the different stages of HTN. Review the current guidelines for treatment of HTN. Provided

More information

A CASE OF HYPERTENSION AND ACUTE RENAL FAILURE OBJECTIVES

A CASE OF HYPERTENSION AND ACUTE RENAL FAILURE OBJECTIVES A CASE OF HYPERTENSION AND ACUTE RENAL FAILURE Maricel Pilapil-Pureza WLA Nephrology OBJECTIVES After the presentation, the attendee will be able to: 1. Discuss when to suspect for secondary causes of

More information

RESISTENT HYPERTENSION. Dr. Helmy Bakr Professor and Head of Cardiology Dept. Mansoura University

RESISTENT HYPERTENSION. Dr. Helmy Bakr Professor and Head of Cardiology Dept. Mansoura University RESISTENT HYPERTENSION Dr. Helmy Bakr Professor and Head of Cardiology Dept. Mansoura University Resistant Hypertension Blood pressure remaining above goal in spite of concurrent use of 3 antihypertensive

More information

Primary Aldosteronism: screening, diagnosis and therapy

Primary Aldosteronism: screening, diagnosis and therapy Primary Aldosteronism: screening, diagnosis and therapy Jacques W.M. Lenders, internist DEPT. OF INTERNAL MEDICINE, RADBOUD UNIVERSITY NIJMEGEN MEDICAL CENTER, NIJMEGEN,THE NETHERLANDS DEPT. OF INTERNAL

More information

Getting BP to goal: Virginia L. Hood MB.BS, MPH, FACP

Getting BP to goal: Virginia L. Hood MB.BS, MPH, FACP Getting BP to goal: Virginia L. Hood MB.BS, MPH, FACP Objectives: Outline pathophysiological processes that sustain high BP Design individual treatment strategies for BP not at goal Facilitate patient

More information

How to Recognize Adrenal Disease

How to Recognize Adrenal Disease How to Recognize Adrenal Disease CME Away India & Sri Lanka March 23 - April 7, 2018 Richard A. Bebb MD, ABIM, FRCPC Consultant Endocrinologist Medical Subspecialty Institute Cleveland Clinic Abu Dhabi

More information

Updates in primary hyperaldosteronism and the rule

Updates in primary hyperaldosteronism and the rule Updates in primary hyperaldosteronism and the 20-50 rule I. David Weiner, M.D. Professor of Medicine and Physiology and Functional Genomics University of Florida College of Medicine and NF/SGVHS The 20-50

More information

The endocrine system is made up of a complex group of glands that secrete hormones.

The endocrine system is made up of a complex group of glands that secrete hormones. 1 10. Endocrinology I MEDCHEM 535 Diagnostic Medicinal Chemistry Endocrinology The endocrine system is made up of a complex group of glands that secrete hormones. These hormones control reproduction, metabolism,

More information

Audience Response. Hypertension. Case: Mr. J. Measuring BP. Non-pharmacologic intervention. Case: Mr. J. Session ID: HTN411

Audience Response. Hypertension. Case: Mr. J. Measuring BP. Non-pharmacologic intervention. Case: Mr. J. Session ID: HTN411 Audience Response http://rwpoll.com OR App downloads: Hypertension Chris Knight, MD cknight@uw.edu http://tiny.cc/rwiphone http://tiny.cc/rwdroid Session ID: HTN411 Case: Mr. J 52 y/o male patient comes

More information

Approach to Adrenal Incidentaloma. Alice Y.Y. Cheng, MD, FRCP

Approach to Adrenal Incidentaloma. Alice Y.Y. Cheng, MD, FRCP Approach to Adrenal Incidentaloma Alice Y.Y. Cheng, MD, FRCP Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form

More information

COMPLEX HYPERTENSION. Anita Ralstin, FNP-BC Next Step Health Consultant, LLC

COMPLEX HYPERTENSION. Anita Ralstin, FNP-BC Next Step Health Consultant, LLC COMPLEX HYPERTENSION Anita Ralstin, FNP-BC Next Step Health Consultant, LLC Incidence Of Hypertension About 70 million American adults have high blood pressure. About 33% of the population Only 52% have

More information

Hypertension Update. Objectives 4/28/2015. Beverly J. Mathis, D.O. OOA May 2015

Hypertension Update. Objectives 4/28/2015. Beverly J. Mathis, D.O. OOA May 2015 Hypertension Update Beverly J. Mathis, D.O. OOA May 2015 Objectives Learn new recommendations for BP treatment goals Approach to hypertension in the office Use of hypertensive drugs, and how to tailor

More information

A case of hypokalemia MIHO TAGAWA FIRST DEPARTMENT OF MEDICINE NARA MEDICAL UNIVERSITY

A case of hypokalemia MIHO TAGAWA FIRST DEPARTMENT OF MEDICINE NARA MEDICAL UNIVERSITY A case of hypokalemia MIHO TAGAWA FIRST DEPARTMENT OF MEDICINE NARA MEDICAL UNIVERSITY Case 57 y.o. male CC: Weakness HPI: About 20 years ago, he developed bilateral lower extremity weakness. Laboratory

More information

Systemic Hypertension Dr ahmed almutairi Assistant professor Internal medicine dept

Systemic Hypertension Dr ahmed almutairi Assistant professor Internal medicine dept Systemic Hypertension Dr ahmed almutairi Assistant professor Internal medicine dept Continents 1- introduction 2- classification/definition 3- classification/etiology 4-etiology in both categories 5- complications

More information

Hypertension (JNC-8)

Hypertension (JNC-8) Hypertension (JNC-8) Southern California University of Health Sciences Physician Assistant Program Management and Treatment of Hypertension April 17, 2018, presented by Ezra Levy, Pharm.D.! The 8 th Joint

More information

Approach to patient with hypertension. Dr. Amitesh Aggarwal

Approach to patient with hypertension. Dr. Amitesh Aggarwal Approach to patient with hypertension Dr. Amitesh Aggarwal Definition A systolic blood pressure ( SBP) >139 mmhg and/or A diastolic (DBP) >89 mmhg. Based on the average of two or more properly measured,

More information

Pharmacologic Management of Hypertension

Pharmacologic Management of Hypertension Current Concepts In Management of Fernando Vega, MD Secondary - Definition Renovascular Disease (The kidney doesn t get impressed by blood pressure) Renovascular stenosis Renal artery stenosis Fibromuscular

More information

Jared Moore, MD, FACP

Jared Moore, MD, FACP Hypertension 101 Jared Moore, MD, FACP Assistant Program Director, Internal Medicine Residency Clinical Assistant Professor of Internal Medicine Division of General Medicine The Ohio State University Wexner

More information

Difficult-to-Control & Resistant Hypertension. Anthony Viera, MD, MPH, FAHA Professor and Chair

Difficult-to-Control & Resistant Hypertension. Anthony Viera, MD, MPH, FAHA Professor and Chair Difficult-to-Control & Resistant Hypertension Anthony Viera, MD, MPH, FAHA Professor and Chair Objectives Define resistant hypertension Discuss evaluation strategy for patient with HTN that appears difficult

More information

Endocrine hypertensionmolecules. Marie Freel Caledonian Endocrine Society Meeting 29 th November 2015

Endocrine hypertensionmolecules. Marie Freel Caledonian Endocrine Society Meeting 29 th November 2015 Endocrine hypertensionmolecules and genes Marie Freel Caledonian Endocrine Society Meeting 29 th November 2015 Plan Mineralocorticoid hypertension Myths surrounding Primary Aldosteronism (PA) New developments

More information

Updates in primary hyperaldosteronism and the rule

Updates in primary hyperaldosteronism and the rule Updates in primary hyperaldosteronism and the 20-50 rule I. David Weiner, M.D. C. Craig and Audrae Tisher Chair in Nephrology Professor of Medicine and Physiology and Functional Genomics University of

More information

PHEOCHROMOCYTOMA. Anita Chiu, MD Kings County Hospital Center January 13, 2011

PHEOCHROMOCYTOMA. Anita Chiu, MD Kings County Hospital Center January 13, 2011 PHEOCHROMOCYTOMA Anita Chiu, MD Kings County Hospital Center January 13, 2011 Case Presentation 62 year old female from Grenada with longstanding HTN, DM, CRI Complaints of palpitations for years Abdominal

More information

Management of Hypertension. M Misra MD MRCP (UK) Division of Nephrology University of Missouri School of Medicine

Management of Hypertension. M Misra MD MRCP (UK) Division of Nephrology University of Missouri School of Medicine Management of Hypertension M Misra MD MRCP (UK) Division of Nephrology University of Missouri School of Medicine Disturbing Trends in Hypertension HTN awareness, treatment and control rates are decreasing

More information

Year 2004 Paper two: Questions supplied by Megan 1

Year 2004 Paper two: Questions supplied by Megan 1 Year 2004 Paper two: Questions supplied by Megan 1 QUESTION 96 A 32yo woman if found to have high blood pressure (180/105mmHg) at an insurance medical examination. She is asymptomatic. Clinical examination

More information

Hypertension Cases. Katharine Dahl, MD January 10, 2017

Hypertension Cases. Katharine Dahl, MD January 10, 2017 Hypertension Cases Katharine Dahl, MD January 10, 2017 Dr. Dahl arrives late for her AHD hypertension lecture and you are asked to present the epidemiology of hypertension until she arrives. Which of the

More information

Antihypertensives. Antihypertensive Classes. RAAS Inhibitors. Renin-Angiotensin Cascade. Angiotensin Receptors. Approaches to Hypertension Treatment

Antihypertensives. Antihypertensive Classes. RAAS Inhibitors. Renin-Angiotensin Cascade. Angiotensin Receptors. Approaches to Hypertension Treatment Approaches to Hypertension Treatment Antihypertensives Inhibit Sympathetic impulses Inhibit contractility Inhibit heart rate Inhibit vasoconstriction Inhibit smooth muscle function Inhibit RAAS Inhibit

More information

Difficult to Control HTN: It is not all the same. Structured approach to evaluation and treatment

Difficult to Control HTN: It is not all the same. Structured approach to evaluation and treatment Difficult to Control HTN: It is not all the same. Structured approach to evaluation and treatment Dmitri Vasin M.D. Nephrologist and ASH certified clinical hypertension specialist Bremerton, WA, USA Johnson

More information

Aldosterone synthase inhibitors. John McMurray BHF Cardiovascular Research Centre University of Glasgow

Aldosterone synthase inhibitors. John McMurray BHF Cardiovascular Research Centre University of Glasgow Aldosterone synthase inhibitors John McMurray BHF Cardiovascular Research Centre University of Glasgow Inhibition of aldosterone synthesis is hypothesized to be of benefit to patients with cardiovascular

More information

Difficult to Treat Hypertension

Difficult to Treat Hypertension Difficult to Treat Hypertension According to Goldilocks JNC 8 Blood Pressure Goals (2014) BP Goal 60 years old and greater*- systolic < 150 and diastolic < 90. (Grade A)** BP Goal 18-59 years old* diastolic

More information

Hypertension and the 2017 Guidelines Meeting the Targets in Small Groups. Lisa Ivy APRN

Hypertension and the 2017 Guidelines Meeting the Targets in Small Groups. Lisa Ivy APRN Hypertension and the 2017 Guidelines Meeting the Targets in Small Groups Lisa Ivy APRN The 2017 Guideline is an Update to JNC7 New information regarding BP related risk of CVD Ambulatory BP monitoring

More information

Management of Hypertension

Management of Hypertension Clinical Practice Guidelines Management of Hypertension Definition and classification of blood pressure levels (mmhg) Category Systolic Diastolic Normal

More information

Introductory Clinical Pharmacology Chapter 41 Antihypertensive Drugs

Introductory Clinical Pharmacology Chapter 41 Antihypertensive Drugs Introductory Clinical Pharmacology Chapter 41 Antihypertensive Drugs Blood Pressure Normal = sys

More information

The Work-up and Treatment of Adrenal Nodules

The Work-up and Treatment of Adrenal Nodules The Work-up and Treatment of Adrenal Nodules Lawrence Andrew Drew Shirley, MD, MS, FACS Assistant Professor of Surgical-Clinical Department of Surgery Division of Surgical Oncology The Ohio State University

More information

Hypertension Update Warwick Jaffe Interventional Cardiologist Ascot Hospital

Hypertension Update Warwick Jaffe Interventional Cardiologist Ascot Hospital Hypertension Update 2008 Warwick Jaffe Interventional Cardiologist Ascot Hospital Definition of Hypertension Continuous variable At some point the risk becomes high enough to justify treatment Treatment

More information

ADVANCES IN MANAGEMENT OF HYPERTENSION

ADVANCES IN MANAGEMENT OF HYPERTENSION Prevalence 29%; Blacks 33.5% About 72.5% treated; 53.5% uncontrolled (>140/90) Risk for poor control: Latinos, Blacks, age 18-44 and 80,

More information

Hypertension Management - Summary

Hypertension Management - Summary Who should have blood pressure assessed? Hypertension Management - Summary All patients over the age of 40 years, every 1-3 years in order to determine their cardiovascular risk (ie. Framingham Risk Score)

More information

Pediatric Hypertension. Alisa A. Acosta, MD, MPH Asst. Professor, Renal Section April 5, 2019

Pediatric Hypertension. Alisa A. Acosta, MD, MPH Asst. Professor, Renal Section April 5, 2019 Pediatric Hypertension Alisa A. Acosta, MD, MPH Asst. Professor, Renal Section April 5, 2019 Objectives Recognize the importance of accurate blood pressure measurement in pediatric patients Define pediatric

More information

Endocrine Hypertension

Endocrine Hypertension Endocrine Hypertension 1 No Disclosures Endocrine Hypertension Objectives: 1. Understand Endocrine disorders causing hypertension 2. Understand clinical presentation of Pheochromocytoma and Hyperaldosteronism

More information

Upon completion, participants should be able to:

Upon completion, participants should be able to: Learning Objectives Upon completion, participants should be able to: Describe the causes of secondary hypertension and the prevalence of primary aldosteronism Discuss the diagnostic approach to primary

More information

Endocrine MR. Jan 30, 2015 Michael LaFata, MD

Endocrine MR. Jan 30, 2015 Michael LaFata, MD Endocrine MR Jan 30, 2015 Michael LaFata, MD Brief case 55-year-old female in ED PMH: HTN, DM2, HLD, GERD CC: Epigastric/LUQ abdominal pain, N/V x2 days AF, HR 103, BP 155/85, room air CMP: Na 133, K 3.6,

More information

Potassium A NNA VINNIKOVA, M. D.

Potassium A NNA VINNIKOVA, M. D. Potassium A NNA VINNIOVA, M. D. DIVISION OF NEPHROLOGY Graphics by permission from The Fluid, Electrolyte and Acid-Base Companion, S. Faubel and J. Topf, http://www.pbfluids.com Do you want to hear a Sodium

More information

Incidental Adrenal Nodules Differential Diagnosis

Incidental Adrenal Nodules Differential Diagnosis Adrenal Stuff Richard J. Auchus, MD, PhD, FACE Division of Metabolism, Endocrinology & Diabetes Departments of Internal Medicine & Pharmacology University of Michigan/VA Ann Arbor Incidental Adrenal Nodules

More information

AVS and IPSS: The Basics and the Pearls

AVS and IPSS: The Basics and the Pearls AVS and IPSS: The Basics and the Pearls William F. Young, Jr., MD, MSc Professor of Medicine Mayo Clinic College of Medicine Rochester, MN, USA 2018 Mayo Foundation for Medical Education and Research.

More information

Categories of HTN. Overview of Hypertension. Types of Hypertension

Categories of HTN. Overview of Hypertension. Types of Hypertension Categories of HTN Overview of Hypertension Normal SBP 100 Quick review of the Basics: What is

More information

Hypertension 2015: Recent Evidence that Will Change Your Practice

Hypertension 2015: Recent Evidence that Will Change Your Practice Hypertension 2015: Recent Evidence that Will Change Your Practice Gerald W. Smetana, M.D. Division of General Medicine Beth Israel Deaconess Medical Center Professor of Medicine Harvard Medical School

More information

ADVANCES IN MANAGEMENT OF HYPERTENSION

ADVANCES IN MANAGEMENT OF HYPERTENSION Advances in Management of Robert B. Baron MD Professor of Medicine Associate Dean for GME and CME Declaration of full disclosure: No conflict of interest Current Status of Prevalence 29%; Blacks 33.5%

More information

신장환자의혈압조절 나기영. Factors involved in the regulation of blood pressure

신장환자의혈압조절 나기영. Factors involved in the regulation of blood pressure 신장환자의혈압조절 K/DOQI Clinical practice guidelines on Hypertension and Antihypertensive agents in CKD 나기영 Factors involved in the regulation of blood pressure Renal function curve MAP (mmhg) Central role of

More information

MODERN MANAGEMENT OF HYPERTENSION Where Do We Draw the Line? Disclosure. No relevant financial relationships. Blood Pressure and Risk

MODERN MANAGEMENT OF HYPERTENSION Where Do We Draw the Line? Disclosure. No relevant financial relationships. Blood Pressure and Risk MODERN MANAGEMENT OF HYPERTENSION Where Do We Draw the Line? Disclosure No relevant financial relationships Robert B. Baron, MD MS Professor and Associate Dean UCSF School of Medicine baron@medicine.ucsf.edu

More information

Hypertension in the Era of ACC/AHA: Practice Changing Evidence and Recommendations

Hypertension in the Era of ACC/AHA: Practice Changing Evidence and Recommendations Hypertension in the Era of ACC/AHA: Practice Changing Evidence and Recommendations Gerald W. Smetana, M.D., MACP Division of General Medicine Beth Israel Deaconess Medical Center Professor of Medicine

More information

ENDOCRINE FORMS OF HYPERTENSION. Michael Stowasser

ENDOCRINE FORMS OF HYPERTENSION. Michael Stowasser ENDOCRINE FORMS OF HYPERTENSION Michael Stowasser Hypertension Unit, University Department of Medicine, Princess Alexandra Hospital, Brisbane 4102, Australia. ENDOCRINE FORMS OF HYPERTENSION Mineralocorticoid

More information

Objectives. JNC 7 Is Nice But What s Up With JNC 8? Why Do We Care? Hypertension Background: Prevalence

Objectives. JNC 7 Is Nice But What s Up With JNC 8? Why Do We Care? Hypertension Background: Prevalence JNC 7 Is Nice But What s Up With JNC 8? 37 th Annual CAPA Conference October 4 th 2013 Ignacio de Artola, Jr. M.D. Assistant Professor of Clinical Family Medicine Medical Director, Primary Care Physician

More information

Spectrum of Hypertension & Hypokalemia

Spectrum of Hypertension & Hypokalemia Spectrum of Hypertension & Hypokalemia Farheen K. Dojki, PGY-6 Hypertension Fellow, ASH Hypertension Center Dr. Dojki does not have any relevant financial relationships with any commercial interests. OBJECTIVES:

More information

ADRENAL INCIDENTALOMA. Jamii St. Julien

ADRENAL INCIDENTALOMA. Jamii St. Julien ADRENAL INCIDENTALOMA Jamii St. Julien Outline Definition Differential Evaluation Treatment Follow up Questions Case Definition The phenomenon of detecting an otherwise unsuspected adrenal mass on radiologic

More information

Diseases of the Adrenal gland

Diseases of the Adrenal gland Diseases of the Adrenal gland Adrenal insufficiency Cushing disease vs syndrome Pheochromocytoma Hyperaldostronism What are the layers of the adrenal gland?? And what does each layer produce?? What are

More information

How do I investigate suspected secondary hypertension? Marie Freel RCP Update in Medicine 23 rd November 2016

How do I investigate suspected secondary hypertension? Marie Freel RCP Update in Medicine 23 rd November 2016 How do I investigate suspected secondary hypertension? Marie Freel RCP Update in Medicine 23 rd November 2016 World beaters..! Michel Joffres et al. BMJ Open 2013;3:e003423 Hypertension often poorly controlled

More information

Managing Hypertension in 2016

Managing Hypertension in 2016 Managing Hypertension in 2016: Where Do We Draw the Line? Disclosure No relevant financial relationships Robert B. Baron MD MS Professor and Associate Dean UCSF School of Medicine baron@medicine.ucsf.edu

More information

Chronic Pediatric Hypertension

Chronic Pediatric Hypertension Chronic Pediatric Hypertension Nephrology Grand Round 3/13/2015 Mahmoud Kallash M.D Outline Definition of hypertension (HTN) Challenges in diagnosing HTN Epidemiology Causes and evaluation of HTN Management

More information

The real picture. Prorenin (Renin) PRR AT3 AT4. AT4 receptor. PAI 1 Abassi, Biochem Pharm, 2009

The real picture. Prorenin (Renin) PRR AT3 AT4. AT4 receptor. PAI 1 Abassi, Biochem Pharm, 2009 The real picture. Prorenin (Renin) PRR AT3-8 AT4 AT10-12 AT3 AT4 receptor PAI 1 Abassi, Biochem Pharm, 2009 Resistant Hypertension; Case based discussion Moving Targets? RAAS blockade in hypertensive CKD

More information

Adrenal Mass. Cynthia Kwong SUNY Downstate Medical Center Grand Rounds October 13, 2016

Adrenal Mass. Cynthia Kwong SUNY Downstate Medical Center Grand Rounds October 13, 2016 Adrenal Mass Cynthia Kwong SUNY Downstate Medical Center Grand Rounds October 13, 2016 Case Presentation 65F found to have a 4cm left adrenal mass in 2012 now presents with 6.7cm left adrenal mass PMHx:

More information

Hypertension Update. Sarah J. Payne, MS, PharmD, BCPS Assistant Professor, Department of Pharmacotherapy UNT System College of Pharmacy

Hypertension Update. Sarah J. Payne, MS, PharmD, BCPS Assistant Professor, Department of Pharmacotherapy UNT System College of Pharmacy Hypertension Update Sarah J. Payne, MS, PharmD, BCPS Assistant Professor, Department of Pharmacotherapy UNT System College of Pharmacy Introduction 1/3 of US adults have HTN More prevalent in non-hispanic

More information

Resistant Hypertension Management. Objectives. Steve Gerstner MD FACP Shannon Puckett PharmD BCACP. Hypertension 101 JNC 7

Resistant Hypertension Management. Objectives. Steve Gerstner MD FACP Shannon Puckett PharmD BCACP. Hypertension 101 JNC 7 Management Steve Gerstner MD FACP Shannon Puckett PharmD BCACP Objectives Review recent changes to blood pressure guidelines Apply these principles to general patient populations Understand secondary causes

More information

Preventing and Treating High Blood Pressure

Preventing and Treating High Blood Pressure Preventing and Treating High Blood Pressure: Finding the Right Balance of Integrative and Pharmacologic Approaches Robert B. Baron MD Professor of Medicine Associate Dean for GME and CME Blood Pressure

More information

Update in Hypertension

Update in Hypertension Update in Hypertension Eliseo J. PérezP rez-stable MD Professor of Medicine DGIM, Department of Medicine UCSF 20 May 2008 Declaration of full disclosure: No conflict of interest (I have never been funded

More information

Antihypertensive drugs SUMMARY Made by: Lama Shatat

Antihypertensive drugs SUMMARY Made by: Lama Shatat Antihypertensive drugs SUMMARY Made by: Lama Shatat Diuretic Thiazide diuretics The loop diuretics Potassium-sparing Diuretics *Hydrochlorothiazide *Chlorthalidone *Furosemide *Torsemide *Bumetanide Aldosterone

More information

Blood Pressure. Michelle Bertram- Nephrology- OBH

Blood Pressure. Michelle Bertram- Nephrology- OBH Blood Pressure Michelle Bertram- Nephrology- OBH Hypertension- how common? 29-30% white adults 46-51% uncontrolled Diagnosis Two or more properly measured BP s after an initial screen NICE guidelines also

More information

Antihypertensive Agents

Antihypertensive Agents Antihypertensive Agents Southern California University of Health Sciences Physician Assistant Program Management and Treatment of Hypertension April 7, 08, presented by Ezra Levy, Pharm.D! Usual Dose,

More information

2014 HYPERTENSION GUIDELINES

2014 HYPERTENSION GUIDELINES 2014 HYPERTENSION GUIDELINES Eileen M. Twomey, Pharm.D., BCPS 1 Learning Objectives Describe specific blood pressure thresholds at which antihypertensive therapy should be initiated and blood pressure

More information

Pheochromocytoma AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGY ILLINOIS CHAPTER OCTOBER 13, 2018

Pheochromocytoma AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGY ILLINOIS CHAPTER OCTOBER 13, 2018 Pheochromocytoma AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGY ILLINOIS CHAPTER OCTOBER 13, 2018 Steven A. De Jong, M.D., FACS, FACE Professor and Vice Chair of Surgery Chief, Division of General Surgery

More information

4/3/2018 PHARMACOLOGICAL MANAGEMENT OF HYPERTENSION IN THE PATIENT WITH CKD TONI A. HARPS, APRN-CNS, MSN NEPHROLOGY WHY THIS TOPIC/OBJECTIVES

4/3/2018 PHARMACOLOGICAL MANAGEMENT OF HYPERTENSION IN THE PATIENT WITH CKD TONI A. HARPS, APRN-CNS, MSN NEPHROLOGY WHY THIS TOPIC/OBJECTIVES PHARMACOLOGICAL MANAGEMENT OF HYPERTENSION IN THE PATIENT WITH CKD TONI A. HARPS, APRN-CNS, MSN NEPHROLOGY WHY THIS TOPIC/OBJECTIVES To identify Blood pressure (BP) medications which are used to manage

More information

What in the World is Functional Medicine?

What in the World is Functional Medicine? What in the World is Functional Medicine? An Introduction to a Systems Based Approach of Chronic Disease Meneah R Haworth, FNP-C Disclosure v I am a student of the Institute for Functional Medicine. They

More information

Stages of Chronic Kidney Disease (CKD)

Stages of Chronic Kidney Disease (CKD) Early Treatment is the Key Stages of Chronic Kidney Disease (CKD) Stage Description GFR (ml/min/1.73 m 2 ) >90 1 Kidney damage with normal or GFR 2 Mild decrease in GFR 60-89 3 Moderate decrease in GFR

More information

Management of High Blood Pressure in Adults

Management of High Blood Pressure in Adults Management of High Blood Pressure in Adults Based on the Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC8) James, P. A. (2014, February 05). 2014 Guideline for Management

More information

Section 3, Lecture 2

Section 3, Lecture 2 59-291 Section 3, Lecture 2 Diuretics: -increase in Na + excretion (naturesis) Thiazide and Related diuretics -decreased PVR due to decreases muscle contraction -an economical and effective treatment -protect

More information

Modern Management of Hypertension

Modern Management of Hypertension Modern Management of Hypertension Robert B. Baron MD Professor of Medicine Associate Dean for GME and CME Declaration of full disclosure: No conflict of interest Current Status of Hypertension Prevalence

More information

Towards a Greater Understanding of Cardiac Medications Foundational Cardiac Concepts That Must Be Understood:

Towards a Greater Understanding of Cardiac Medications Foundational Cardiac Concepts That Must Be Understood: Towards a Greater Understanding of Cardiac Medications Foundational Cardiac Concepts That Must Be Understood: Cardiac Output (CO) CO=SVxHR (stroke volume x heart rate) Cardiac output: The amount of blood

More information

Potassium, Aldosterone, and Hypertension: How Physiology Determines Treatment. Jamie Johnston, MD University of Pittsburgh School of Medicine

Potassium, Aldosterone, and Hypertension: How Physiology Determines Treatment. Jamie Johnston, MD University of Pittsburgh School of Medicine Potassium, Aldosterone, and Hypertension: How Physiology Determines Treatment Jamie Johnston, MD University of Pittsburgh School of Medicine No Disclosures Acknowledgements: Evan Ray, MD, PhD Objectives

More information

Case 1. Case 2. What do you think about reducing or discontinuing some of the above now that his LVEF has normalized?

Case 1. Case 2. What do you think about reducing or discontinuing some of the above now that his LVEF has normalized? Case 1 A primary care colleague inquires what to do with a patient (HFrEF in NSR) who has a digoxin level of 2.8ng/ml. Level was obtained at 10am, patient takes all medications at one time upon arising

More information

Modern Management of Hypertension: Where Do We Draw the Line?

Modern Management of Hypertension: Where Do We Draw the Line? Modern Management of Hypertension: Where Do We Draw the Line? Robert B. Baron MD Professor of Medicine Associate Dean for GME and CME Declaration of full disclosure: No conflict of interest Blood Pressure

More information

Antihypertensives. Diagnostic category

Antihypertensives. Diagnostic category Measurement of blood pressure At first assessment, take both arms then choose the one with the higher reading. Beware of orthostatic hypotension. Measure BP in sitting position, and repeat after patient

More information

New Hypertension Guidelines. Kofi Osei, MD

New Hypertension Guidelines. Kofi Osei, MD New Hypertension Guidelines Kofi Osei, MD None Disclosures Objectives The new blood pressure definitions and cardiovascular risk The role to time and location in the diagnosis of hypertension Apply evidence-based

More information

Hypertension and Diabetes. Edward Shahady MD Medical Director Diabetes Master Clinician Program Florida Academy of Family Physicians

Hypertension and Diabetes. Edward Shahady MD Medical Director Diabetes Master Clinician Program Florida Academy of Family Physicians Hypertension and Diabetes Edward Shahady MD Medical Director Diabetes Master Clinician Program Florida Academy of Family Physicians Objectives Describe the prevalence of hypertension and hypertension control

More information

SECONDARY HYPERTENSION

SECONDARY HYPERTENSION SECONDARY HYPERTENSION Grand round for Medical student 25 October 2013 By Rungnapa Laortanakul, MD. OUTLINE Overview of HT Secondary HT Resistance HT Primary aldosteronism Pheochromocytoma Cushing s syndrome

More information

ADRENAL GLAND. Introduction 4/21/2009. Among most important and vital endocrine organ. Small bilateral yellowish retroperitoneal organ

ADRENAL GLAND. Introduction 4/21/2009. Among most important and vital endocrine organ. Small bilateral yellowish retroperitoneal organ Introduction Among most important and vital endocrine organ ADRENAL GLAND D.Hammoudi.MD Small bilateral yellowish retroperitoneal organ Lies just above kidney in gerota s fascia 2 1 The Adrenal Gland Anatomy

More information

Creative blood pressure management: whys and the tricks

Creative blood pressure management: whys and the tricks Creative blood pressure management: whys and the tricks Cynthia D. Caraballo-Hunt, MD Kaiser/OHSU Family Medicine Faculty Beaverton Medical Office NW Permanente, Portland, OR Objectives 1. Describe current

More information

MANAGEMENT OF HYPERTENSION: TREATMENT THRESHOLDS AND MEDICATION SELECTION

MANAGEMENT OF HYPERTENSION: TREATMENT THRESHOLDS AND MEDICATION SELECTION Management of Hypertension: Treatment Thresholds and Medication Selection Robert B. Baron, MD MS Professor and Associate Dean Declaration of full disclosure: No conflict of interest Presentation Goals

More information

LXIV: DRUGS: 4. RAS BLOCKADE

LXIV: DRUGS: 4. RAS BLOCKADE LXIV: DRUGS: 4. RAS BLOCKADE ACE Inhibitors Components of RAS Actions of Angiotensin i II Indications for ACEIs Contraindications RAS blockade in hypertension RAS blockade in CAD RAS blockade in HF Limitations

More information

Chapter 10 Worksheet Blood Pressure and Antithrombotic Agents

Chapter 10 Worksheet Blood Pressure and Antithrombotic Agents Complete the following. 1. A layer of cells lines each vessel in the vascular system. This layer is a passive barrier that keeps cells and proteins from going into tissues; it also contains substances

More information

Case Based Urology Learning Program

Case Based Urology Learning Program Case Based Urology Learning Program Resident s Corner: UROLOGY Case Number 4 CBULP 2010 004 Case Based Urology Learning Program Editor: Associate Editors: Manager: Case Contributors: Steven C. Campbell,

More information

Heart Failure Clinician Guide JANUARY 2018

Heart Failure Clinician Guide JANUARY 2018 Kaiser Permanente National CLINICAL PRACTICE GUIDELINES Heart Failure Clinician Guide JANUARY 2018 Introduction This evidence-based guideline summary is based on the 2018 National Heart Failure Guideline.

More information

Hypertension (HTN) Lecture Note

Hypertension (HTN) Lecture Note Hypertension (HTN) Lecture Note October, 2009 Chuang-Ye Hong, MD, PhD, FACP Wan-Fang Hospital Taipei Medical University Outline Definition Epidemiology Measurement of BP Secondary cause Target organ damage

More information

4/23/2015. Objectives DISCLOSURES

4/23/2015. Objectives DISCLOSURES 2015 PENS Conference Savannah, GA Novel Cases of Congenital Hyperreninemic Hypaldosteronism Jan M. Foote DISCLOSURES I have no actual or potential conflicts of interest in relation to this presentation.

More information

7/7/ CHD/MI LVH and LV dysfunction Dysrrhythmias Stroke PVD Renal insufficiency and failure Retinopathy. Normal <120 Prehypertension

7/7/ CHD/MI LVH and LV dysfunction Dysrrhythmias Stroke PVD Renal insufficiency and failure Retinopathy. Normal <120 Prehypertension Prevalence of Hypertension Hypertension: Diagnosis and Management T. Villela, M.D. Program Director University of California, San Francisco-San Francisco General Hospital Family and Community Medicine

More information

Joshua M. Crasner,DO,FACC,FACOI

Joshua M. Crasner,DO,FACC,FACOI Joshua M. Crasner,DO,FACC,FACOI 50 million people USA SBP>115 incr risk CAD/CVA Q 20mm incr=2x risk JNC-8 almost changed aggressive Tx Pseudo-HTN Hypertension 2015 2 Most common HBP( > 90 %)--multifactorial

More information