Download Secondary Hypertension - Primary Aldosteronism -

Resistant Hypertension
- Primary Aldosteronism 내분비 대사 내과
R3 송 란
Resistant, or refractory, hypertension
• Patients with diabetes or renal disease
: antihypertensive medications (including a diuretic)
: full doses of at least three
 blood pressure
: at least140/90 mm Hg or at least 130/80 mm Hg
 Secondary causes (including exogenous substances)
- Approach to evaluation of resistant hypertension -
- N Engl J Med
2006; 355
The effect of age on prevalence of secondary forms of
hypertension in 4429 consecutively referred patients
- J Hypertens. 1994; 12
• Among 4000 patients with resistant hypertension
 Secondary causes
– 10 % of patients overall
– 17 % of patients over the age of 60 years
• Chronic renal parenchymal disease : M/C
• Atherosclerotic renovascular disease
• Primary aldosteronism
• Pheochromocytoma
• sleep apnea
Diagnosis
Diagnostic test
Chronic kidney disease
Estimated GFR
Coarctation of aorta
CT angiography
Cushing syndrome and other
glucocorticoid excess states, including
chronic steroid therapy
History/dexamethasone suppression test
Drug-induced/related causes
History; drug screening
Pheochromocytoma
24-h urinary metanephrine and
normetanephrine
Primary aldosteronism and other
mineralocorticoid excess states
Renovascular hypertension
Sleep apnea
Thyroid/parathyroid disease
24-h urinary aldosterone level or
specific measurements of other
mineralocorticoids
Doppler flow study; magnetic resonance
angiography
Sleep study with O2 saturation
TSH; serum PTH
Primary Aldosteronism
• 2 % of all hypertensives patients 5 ~ 10 %
• Screening test
– plasma aldosterone to renin ratio (ARR) test
• Diagnosis : missed  No hypokalemia
• Type of primary aldosteronism
Types
Relative frequency, %
Solitary adrenal adenoma
65
Bilateral adrenal hyperplasia
30
Unilateral adrenal hyperplasia
2
Glucocorticoid-remediable aldosteronism
<1
Bilateral solitary adrenal adenomas
<1
Adrenal carcinoma
<1
Demographic and Clinical Characteristics of Patients with
Various Types of Primary Aldosteronism
( Continued )
Continued..
- N Engl J Med, 1998; 339
Screening
Spontaneous Hypokalemia
+
HTN
 strong indicator of aldosteronism
But, 20 % : low normal serum potassium level
• Plasma aldosterone(ng/dL) to renin(ng/mL per hour) ratio: ARR
– Timing of the tests : morning
– The posture before blood sampling : upright
– Unit of measurement
– Cutt off value > 30
– 경희의료원 : plasma aldo.  pg/ml  계산값 X 0.1
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345 patients of Hypertension
Essential hypertension (EH) (n=260)
Primary aldosteronism (PA) (n=49)
Secondary HTN other than PA (n=36)
• ARR
– affected by antihypertensive drug use
 no anti-hypertensive therapy
or taking medications least likely to affect it
(e.g. calcium-channel blockers or α-blockers)
- Nat Clin Pract Endocrinol
Metab ,2005;1
Definitive Biochemical Diagnosis
• Diet high in sodium chloride
(2 to 3 g with each meal for two to three days)
 high rate of urinary aldosterone excretion
 < 14 μg in 24 hours : rules out primary aldosteronism
• Intravenous infusion of normal saline
(1.25 liters over a 2 hours period or 2 liters over a 4 hours
period, preferably between 8 a.m. and noon)
 high plasma aldosterone level
 < 8.5 ng/dL(240 pmol/L) (performed in the morning)
: rules out primary aldosteronism
Localizing Test
• Adrenal venous blood sampling with
adrenocorticotropic hormone infusion
 unilateral excess of aldosterone secretion
: aldosteronoma, unilateral adrenal hyperplasia
• Computed tomographic (CT) scanning
– Detect most aldosteronomas ( except very small )
– large adrenal tumor (>3 cm in diameter)
 Possibility adrenal carcinoma
: adrenal steroids (androgens, cortisol, estrogen) in the
plasma or urine : measured
Algorithm for diagnosis and management of primary aldosteronism
- Nat Clin Pract
Endocrinol
Metab ,2005;1