Download 5. Secondary hypertension

CLINICAL APPROACHES TO
SECONDARY HYPERTENSION
DEFINITION
• Essential, primary, or idiopathic hypertension
is defined as high BP in which secondary
causes or mendelian (monogenic)
forms are not present
• High BP – repeatedly measured BP exceeding
140/90 mmHg, i.e. a systolic BP above 140
and/or diastolic BP above 90
Aetiology of Hypertension
• Primary – 90-95% of cases – also termed “essential”
of “idiopathic”
• Secondary – about 5% of cases
– Renal or renovascular disease
– Endocrine disease
•
•
•
•
Phaeochomocytoma
Cushings syndrome
Conn’s syndrome
Acromegaly and hypothyroidism
– Coarctation of the aorta
– Iatrogenic
• Hormonal / oral contraceptive
• NSAIDs
Aetiology of Hypertension
• Primary – 90-95% of cases – also termed “essential”
of “idiopathic”
• Secondary – about 5% of cases
– Renal parenchymal (2-5%)
or renovascular disease
– Endocrine disease
•
•
•
•
Phaeochomocytoma
Cushing syndrome
Conn syndrome
Acromegaly and hypothyroidism
– Coarctation of the aorta
– Iatrogenic
• Hormonal / oral contraceptive
• NSAIDs
Renal parenchymal disease
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•
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Acute and chronic glomerulonephritis
Polycystic kidney disease
Diabetic nephropathy
Pyelonephritis
Obstructive uropathy
Neoplasms
Renal trauma
Radiation nephritis
Hypertension in parenchymal renal disease:
CONCLUSIONS
• Hypertension may result from renal disease
that reduces functioning nephrons;
• Evidence shows a clear relationship between
high blood pressure and end-stage renal
disease;
• BP should be controlled to 130/85 mmHg
(125/75 mmHg in patients with proteinuria in
excess of 1g/24 h)
Aetiology of Hypertension
• Primary – 90-95% of cases – also termed “essential”
of “idiopathic”
• Secondary – about 5% of cases
– Renal parenchymal
or renovascular disease (0.3-3%)
– Endocrine disease
•
•
•
•
Phaeochomocytoma
Cushings syndrome
Conn’s syndrome
Acromegaly and hypothyroidism
– Coarctation of the aorta
– Iatrogenic
• Hormonal / oral contraceptive
• NSAIDs
RENAL ARTERY STENOSIS
(RAS)
• Atherosclerotic RAS (>90% of cases):
involves the ostium and the proximal portion of the
main renal artery with plaque extending into the
perirenal aorta
• Fibromuscular dysplasia (10% of cases):
typically seen in young and middle-aged females.
As opposed to atherosclerotic RAS, fibromuscular
dysplasia typically affects the distal two thirds of
the main renal artery
RENAL ARTERY STENOSIS:
screening and diagnostic studies
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Renal duplex sonography
Magnetic resonance angiography
Renal artery arteriography
Captopril renography
RENAL ARTERY STENOSIS:
treatment
• BP control
• Antiplatelet, lipid-lowering therapy, and
beta-blockers, if appropriate
• No ACE-inhibitors in severe RAS !
RENAL ARTERY STENOSIS:
treatment
Percutaneous or surgical revascularization, if:
● Resistant or poorly controlled hypertension
and unilateral or bilateral renal artery stenosis
● Renal artery stenosis and recurrent flash pulmonary
edema for which there is no readily explainable cause
● Chronic renal failure and bilateral renal artery stenosis
or renal artery stenosis to a solitary functioning
kidney
● Sonographic renal longitudinal length >7cm
Aetiology of Hypertension
• Primary – 90-95% of cases – also termed “essential”
of “idiopathic”
• Secondary – about 5% of cases
– Renal or renovascular disease
– Endocrine disease
• Phaeochomocytoma (0.1-0.6 %)
• Cushings syndrome
• Conn’s syndrome
• Acromegaly and hypothyroidism
– Coarctation of the aorta
– Iatrogenic
• Hormonal / oral contraceptive
• NSAIDs
The left ventricle is markedly thickened in this patient
with severe hypertension that was untreated for many
years. The myocardial fibers have undergone
hypertrophy.
This left ventricle is very thickened (slightly over 2 cm in
thickness), but the rest of the heart is not greatly enlarged.
This is typical for hypertensive heart disease. The
hypertension creates a greater pressure load on the heart to
induce the hypertrophy.
PHEOCHROMOCYTOMA
diagnostic techniques
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•
•
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Biochemical tests
High pressure liquid chromatography:
Plasma catecholamines: noradrenaline,
adrenaline;
Free plasma fractionated metanephrines:
normetanephrine, metanephrine;
Urinary catecholamines (24h)
Urinary fractionated metanephrines (24h)
Spectrophotometry:
Total metanephrines (24h urine);
Vanillylmandelic acid (24h urine)
PHEOCHROMOCYTOMA
imaging techniques
• Duplex sonography;
• Magnetic resonance imaging (MRI);
• Computed romography (CT);
• 123I – meta-iodo-benzyl-guanidine
scanning (123I-MIBG)
PHEOCHROMOCYTOMA: laparoscopic removal
Preoperative Management (10-14 days)

Purpose: to prevent catecholamine induced, serious, and
potentially life-threatening complications during surgery, including
hypertensive crises, cardiac arrhythmias, pulmonary oedema, and
cardiac ischemia;
 BP should be reduced to below 160/90 mm Hg for at least 24h;
 orthostatic hypotension should be present, but blood pressure
in the upright position should not fall below 80/45 mm Hg;
 there should be no more than one ventricular extrasystole every
5 min;
 and the electrocardiogram should show no S-T segment
changes and T-wave inversions for 1 week;
PHEOCHROMOCYTOMA:
Management
• Phenoxybenzamine, a long acting alpha-adrenergic blocker, is the
mainstay of medical treatment to control BP. A total dose of 1 mg/kg is
sufficient in most patients.
• An alpha-blocker Doxazosin in increasing doses from 1 to 16 mg
once a day.
•A beta-adrenoceptor blocker (eg,propranolol 40 mg three times daily
or atenolol 25–50 mg once daily) could be included after several days of
alpha-adrenergic blockade.
• Adequate salt and fluid intake lowers the risk of orthostatic
hypotension.
PHEOCHROMOCYTOMA:
Management
•Should substantial rises in blood pressure still take place
during surgery, these can be controlled by bolus or by
continuous infusion of phentolamine, sodium nitroprusside,
or a shortacting calcium antagonist (eg, nicardipine);
• Tachyarrhythmias can be treated by infusion of a
shortacting -adrenoceptor blocker (eg, esmolol).
Aetiology of Hypertension
• Primary – 90-95% of cases – also termed “essential”
of “idiopathic”
• Secondary – about 5% of cases
– Renal or renovascular disease
– Endocrine disease
• Phaeochomocytoma
• Cushings syndrome
• Conn’s syndrome (0.3-1%)
• Acromegaly and hypothyroidism
– Coarctation of the aorta
– Iatrogenic
• Hormonal / oral contraceptive
• NSAIDs
Primary Hyperaldosteronism
• Screening for hyperaldosteronism should include
plasma aldosterone and plasma renin activity
measured in morning samples
• Plasma aldosterone:renin ratio: normally <20;
diagnostic cut-off value >30;
• Aldosterone excretion rate during salt loading, captopril,
or spironolactone test (the captopril test may be less
useful in blacks because of the high prevalence of low
plasma renin activity)
• Adrenal CT, MRI
Primary Hyperaldosteronism
Should be differentiated from
• Secondary hyperaldosteronism in patients
with renal failure, CHF, essential hypertension
• Monogenic forms of hypertension
(pseudohyperaldosteronism):
 Liddle’s syndrome (autosomal-dominant disorder,
characterized by low-renin, low-aldosterone, lowpotassium volume-expanded hypertension)
 Gordon’s syndrome (autosomal-dominant
disorder, characterized by low-renin, low-aldosterone,
high-potassium volume-expanded hypertension)
Primary Hyperaldosteronism
TREATMENT
1. Medical
• Spironolactone, a competitive aldosterone antagonist
• Amiloride, a potassium-sparing diuretic
• Glucocorticoids (in glucocorticoid-remediable form)
2. Surgical, if appropriate
Aetiology of Hypertension
• Primary – 90-95% of cases – also termed “essential”
of “idiopathic”
• Secondary – about 5% of cases
– Renal or renovascular disease
– Endocrine disease
• Phaeochomocytoma
• Cushing’s syndrome (0.1-0.6%)
Conn’s syndrome
• Acromegaly and hypothyroidism
– Coarctation of the aorta
– Iatrogenic
• Hormonal / oral contraceptive
• NSAIDs
Hypothyroidism
•
Both hypertension (particularly diastolic) and
hypotension are common;
Hyperthyroidism
•
Accompanied by systolic hypertension,
especially in the elderly;
Acromegaly
•
25-50% exhibit elevated blood pressure
• Coarctation
of the Aorta
with
Dissection
• Coarctation
of the Aorta
Case 1
•
A 28-year old female is seen in the emergency
department with symptoms of severe periodic
headaches, sweating, and nausea with
vomiting. She also complains of feeling lightheaded while standing. Her BP on
presentation is 240/136, with a HR of 92. On
standing, the patient has a BP of 204/98, with
a HR of 136. On ophthalmologic examination
the patients has mild blurring of the optic
discs without hemorrhage. What is the best
medication for the management of this
patient’s hypertension?
Case 1
•
What is the best medication for the
management of this patient’s hypertension?
A.
B.
C.
D.
E.
Phentolamine
Fenoldopam
Esmolol
Nicardipine
Diazoxide
Case 1
•
What is the best medication for the
management of this patient’s hypertension?
A.
B.
C.
D.
E.
Phentolamine – correct answer
Fenoldopam
Esmolol
Nicardipine
Diazoxide
Case 1
•
What test would best determine the
patient’s diagnosis?
A. Plasma catecholamines
B. 24-h urine collection for 5-hydroxyindolacetic acid
C. Abdominal CT-scan
D. 24-h urine collection for metanephrines
and vanillylmandelic acid
E. Adrenal vein sampling for renin levels
Case 1
•
What test would best determine the
patient’s diagnosis?
A. Plasma catecholamines
B. 24-h urine collection for 5-hydroxyindolacetic acid
C. Abdominal CT-scan
D. 24-h urine collection for metanephrines and
vanillylmandelic acid – correct answer
E. Adrenal vein sampling for renin levels
Case 2
•
A 28-year old female has hypertension that is
difficult to control. She was diagnosed at age
26. Since that time she has been on
increasing amounts of medication. Her
current regimen consists of atenolol 50 mg
bid, lisinopril 40 mg qd, clonidine 0.1 mg bid,
and amlodipine 5mg qd. Physical examination
is unremarkable. Laboratory studies reveal a
potassium of 2.8 mmol/l. Fasting blood
glucose is 5.27 mmol/l. What is the likely
diagnosis?
Case 2
•
What is the likely diagnosis?
A.
B.
C.
D.
E.
Congenital adrenal hyperplasia
Fibromuscular dysplasia
Cushing’s syndrome
Conn’s syndrome
Pheochromocytoma
Case 2
•
What is the likely diagnosis?
A.
B.
C.
D.
E.
Congenital adrenal hyperplasia
Fibromuscular dysplasia
Cushing’s syndrome
Conn’s syndrome – correct answer
Pheochromocytoma
Case 2
•
What is the best way to diagnose the disease?
A.
B.
C.
D.
E.
Renal vein renin levels
24-h urine collection for metanephrines
MRI of the renal arteries
24-h urine collection for cortisol
Plasma aldosterone/renin ratio
Case 2
•
What is the best way to diagnose the disease?
A.
B.
C.
D.
E.
Renal vein renin levels
24-h urine collection for metanephrines
MRI of the renal arteries
24-h urine collection for cortisol
Plasma aldosterone/renin ratio – correct answer
Thank you for attention!