Management of Management of Hypertension:Hypertension:

An Overview & UpdateAn Overview & Update

11/12/1111/12/11Marcus Weiser, DOMarcus Weiser, DO

PGY3PGY3Chief ResidentChief Resident

Via Christi Family MedicineVia Christi Family Medicine

OutlineOutline

ClassificationClassification CausesCauses History, PE, initial testingHistory, PE, initial testing Antihypertensive agentsAntihypertensive agents Monotherapy & combination therapyMonotherapy & combination therapy

HypertensionHypertension

Sustained elevation of arterial Sustained elevation of arterial systemic blood pressuresystemic blood pressure

Single most common diagnosis at US Single most common diagnosis at US family physician office visits (coded family physician office visits (coded at 11.1%)at 11.1%)

Age 20-50 usually affectedAge 20-50 usually affected 29% of US adults29% of US adults Prevalence increases with agePrevalence increases with age

HypertensionHypertension

Baseline high blood pressure at age 50 Baseline high blood pressure at age 50 reduces life expectancy by about 5 reduces life expectancy by about 5 years.years.11

AssociationsAssociations Erectile dysfunction, ophthalmologic Erectile dysfunction, ophthalmologic

conditions, osteoporosis, anxiety, chronic conditions, osteoporosis, anxiety, chronic kidney disease, obstructive sleep apnea, kidney disease, obstructive sleep apnea, coronary artery disease, cerebrovascular coronary artery disease, cerebrovascular disease, peripheral arterial disease, disease, peripheral arterial disease, congestive heart failure, dementiacongestive heart failure, dementia

TypesTypes

Prehypertension (SBP 120-139 or DBP 80-89)Prehypertension (SBP 120-139 or DBP 80-89) Stage I (SBP 140-159 or DBP 90-99)Stage I (SBP 140-159 or DBP 90-99)

Confirm within 2 monthsConfirm within 2 months Stage II (SBP > 159 or DBP > 99)Stage II (SBP > 159 or DBP > 99)

Evaluate within 1 month (within 1 week if > Evaluate within 1 month (within 1 week if > 180/110)180/110)

Type I (vasoconstriction, high renin, high SBP)Type I (vasoconstriction, high renin, high SBP) Treat with ACE, ARB, BBTreat with ACE, ARB, BB

Type II (Na dependent, low renin, high DBP)Type II (Na dependent, low renin, high DBP) Treat with diuretics, CCBTreat with diuretics, CCB

ICD-10 codesICD-10 codes I10 essential (primary) hypertension I10 essential (primary) hypertension

ICD-10-CA modification in Canada ICD-10-CA modification in Canada I10.0 benign hypertension I10.0 benign hypertension I10.1 malignant hypertension I10.1 malignant hypertension

I11 hypertensive heart disease I11 hypertensive heart disease I11.0 hypertensive heart disease with (congestive) heart failure I11.0 hypertensive heart disease with (congestive) heart failure I11.9 hypertensive heart disease without (congestive) heart failure I11.9 hypertensive heart disease without (congestive) heart failure ICD-10-CA modification in Canada - 4th character extensions were deleted to allow for use of dual classification for ICD-10-CA modification in Canada - 4th character extensions were deleted to allow for use of dual classification for

added specificity added specificity I12 hypertensive renal disease I12 hypertensive renal disease

I12.0 hypertensive renal disease with renal failure I12.0 hypertensive renal disease with renal failure I12.9 hypertensive renal disease without renal failure I12.9 hypertensive renal disease without renal failure ICD-10-CA modification in Canada - 4th character extensions were deleted to allow for use of dual classification for ICD-10-CA modification in Canada - 4th character extensions were deleted to allow for use of dual classification for

added specificity added specificity I13 hypertensive heart and renal disease I13 hypertensive heart and renal disease

I13.0 hypertensive heart and renal disease with (congestive) heart failure I13.0 hypertensive heart and renal disease with (congestive) heart failure I13.1 hypertensive heart and renal disease with renal failure I13.1 hypertensive heart and renal disease with renal failure I13.2 hypertensive heart and renal disease with both (congestive) heart failure and renal failure I13.2 hypertensive heart and renal disease with both (congestive) heart failure and renal failure I13.9 hypertensive heart and renal disease, unspecified I13.9 hypertensive heart and renal disease, unspecified ICD-10-CA modification in Canada - 4th character extensions were deleted to allow for use of dual classification for ICD-10-CA modification in Canada - 4th character extensions were deleted to allow for use of dual classification for

added specificity added specificity I15 secondary hypertension I15 secondary hypertension

I15.0 renovascular hypertension I15.0 renovascular hypertension I15.1 hypertension secondary to other renal disorders I15.1 hypertension secondary to other renal disorders I15.2 hypertension secondary to endocrine disorders I15.2 hypertension secondary to endocrine disorders I15.8 other secondary hypertension I15.8 other secondary hypertension I15.9 secondary hypertension, unspecified I15.9 secondary hypertension, unspecified ICD-10-CA modification in Canada ICD-10-CA modification in Canada

5th digits assigned to specify 5th digits assigned to specify 0 benign or unspecified 0 benign or unspecified 1 malignant 1 malignant

R03.0 elevated blood-pressure reading, without diagnosis of hypertension R03.0 elevated blood-pressure reading, without diagnosis of hypertension

CausesCauses CKD (any cause)CKD (any cause) Renal Artery StenosisRenal Artery Stenosis Cushing SyndromeCushing Syndrome Primary Primary

HyperaldosteronismHyperaldosteronism Hyper/HypothyroidismHyper/Hypothyroidism HyperparathyroidismHyperparathyroidism PheochromocytomaPheochromocytoma Obstructive Sleep Obstructive Sleep

ApneaApnea Coarctation of the AortaCoarctation of the Aorta Black LicoriceBlack Licorice

MedicationsMedications BP Cuff too smallBP Cuff too small Arm positionArm position CaffeineCaffeine NicotineNicotine Substance Substance

Abuse/IntoxicationAbuse/Intoxication Short sleep durationShort sleep duration Alcohol UseAlcohol Use Salt intake?Salt intake? Impatience, hostilityImpatience, hostility

HistoryHistory SymptomsSymptoms MedicationsMedications

Corticosteroids, OCPs, NSAIDs, venlafaxine, Corticosteroids, OCPs, NSAIDs, venlafaxine, buspirone, carbamazepine, clozapine, buspirone, carbamazepine, clozapine, bromocriptine, cyclosporin, tacrolimus, EPObromocriptine, cyclosporin, tacrolimus, EPO

Past Medical HistoryPast Medical History DM, CAD, CHF, DSLD, Thyroid/Renal DzDM, CAD, CHF, DSLD, Thyroid/Renal Dz

Social HistorySocial History Dietary sodium, stress, smoking, alcohol Dietary sodium, stress, smoking, alcohol

intake, activity level, St. John’s wort, ergot-intake, activity level, St. John’s wort, ergot-containing herbal preparations, cocaine, containing herbal preparations, cocaine, anabolic steroids, narcotic withdrawal, meth, anabolic steroids, narcotic withdrawal, meth, PCPPCP

Physical ExamPhysical Exam Proper blood pressure measurementProper blood pressure measurement

Seated in chair with back in calm, quiet, warm Seated in chair with back in calm, quiet, warm room for at least 5 minutes. Bare arm elevated room for at least 5 minutes. Bare arm elevated so elbow is level with heart. No smoking or so elbow is level with heart. No smoking or caffeine 1 hour priorcaffeine 1 hour prior

Cuff width > 2/3 arm diameterCuff width > 2/3 arm diameter Cuff length > 2/3 arm circumferenceCuff length > 2/3 arm circumference Average of 2 measurementsAverage of 2 measurements

Carotid bruitsCarotid bruits Cardiac auscultationCardiac auscultation AbdomenAbdomen ExtremitiesExtremities

Initial TestingInitial Testing Serum PotassiumSerum Potassium Serum CreatinineSerum Creatinine Fasting Blood GlucoseFasting Blood Glucose Fasting Lipid PanelFasting Lipid Panel UrinalysisUrinalysis ElectrocardiogramElectrocardiogram

- Uniformly recommended by - Uniformly recommended by 4 expert panels (CHEP, 4 expert panels (CHEP, ESH/ESC, ICSI, JNC7)ESH/ESC, ICSI, JNC7)

HematocritHematocrit Serum CalciumSerum Calcium Serum SodiumSerum Sodium Serum Uric AcidSerum Uric Acid Urine Albumin/Creatinine Urine Albumin/Creatinine

RatioRatio

- Recommended by some, not - Recommended by some, not all 4 panelsall 4 panels

Additional Testing to ConsiderAdditional Testing to Consider

PTHPTH TSHTSH 24 hour urine metanephrine24 hour urine metanephrine Plasma AldosteronePlasma Aldosterone Plasma ReninPlasma Renin Dexamethasone supression testDexamethasone supression test Sleep studySleep study RAS imagingRAS imaging

AgentsAgents

Ace-inhibitors (ACEs)Ace-inhibitors (ACEs) Angiotensin Receptor Blockers (ARBs)Angiotensin Receptor Blockers (ARBs) Calcium Channel Blockers (CCBs)Calcium Channel Blockers (CCBs) Beta Blockers (BBs)Beta Blockers (BBs) Thiazide Diuretics (TZD)Thiazide Diuretics (TZD) Loop Diuretics (Loops)Loop Diuretics (Loops) Aldosterone AntagonistsAldosterone Antagonists Alpha BlockersAlpha Blockers Other agentsOther agents

ACEs & ARBsACEs & ARBs

Special IndicationsSpecial Indications ACEACE

CHF (SOLVD, AIRE, TRACE)CHF (SOLVD, AIRE, TRACE) Post-MI (SAVE)Post-MI (SAVE) Diabetes (UKPDS, HOPE)Diabetes (UKPDS, HOPE) CKD (REIN, AASK, CAPTOPRIL)CKD (REIN, AASK, CAPTOPRIL) Recurrent Stroke Prevention (PROGRESS)Recurrent Stroke Prevention (PROGRESS) High CAD Risk (ALLHAT, HOPE, ANBP2)High CAD Risk (ALLHAT, HOPE, ANBP2)

ARBARB CHF (Val-HeFT)CHF (Val-HeFT) DiabetesDiabetes CKD (RENAAL, IDNT, CAPTOPRIL)CKD (RENAAL, IDNT, CAPTOPRIL)

ACEs & ARBsACEs & ARBs

ContraindicationsContraindications Pregnancy, Angioedema, Renovascular Pregnancy, Angioedema, Renovascular

Disease, Hyperkalemia, Acute Renal FailureDisease, Hyperkalemia, Acute Renal Failure MonitorMonitor

Creatinine, PotassiumCreatinine, Potassium AgentsAgents

Benazepril or Lisinopril (20mg to 40mg PO Benazepril or Lisinopril (20mg to 40mg PO daily)daily)

Enalapril, RamiprilEnalapril, Ramipril Losartan, Olmesartan, ValsartanLosartan, Olmesartan, Valsartan

Calcium Channel BlockersCalcium Channel Blockers

Special IndicationsSpecial Indications High CAD risk (ALLHAT, CONVINCE)High CAD risk (ALLHAT, CONVINCE) MigrainesMigraines Raynaud’sRaynaud’s Angina (non-dihydropyridine)Angina (non-dihydropyridine) Atrial Fibrillation (non-dihydropyridine)Atrial Fibrillation (non-dihydropyridine) Atrial Flutter (non-dihydropyridine)Atrial Flutter (non-dihydropyridine)

Calcium Channel BlockersCalcium Channel Blockers

ContraindicationsContraindications 22ndnd or 3 or 3rdrd degree heart block degree heart block

AgentsAgents Amlodipine (5mg to 10mg PO daily)Amlodipine (5mg to 10mg PO daily) Nifedipine, Nicardipine, FelodipineNifedipine, Nicardipine, Felodipine

Beta BlockersBeta Blockers Special IndicationsSpecial Indications

CHF (MERIT-HF, COPERNICUS, CIBIS)CHF (MERIT-HF, COPERNICUS, CIBIS) Post-MI (BHAT, CAPRICORN)Post-MI (BHAT, CAPRICORN) Angina, Atrial Fibrillation, Atrial Flutter, Tremor, MigraineAngina, Atrial Fibrillation, Atrial Flutter, Tremor, Migraine

ContraindicationsContraindications Asthma, COPD, 2Asthma, COPD, 2ndnd or 3 or 3rdrd degree heart block, Depression, degree heart block, Depression,

Acute CHFAcute CHF Avoid abrupt cessationAvoid abrupt cessation AgentsAgents

Metoprolol (50mg to 200mg PO BID)Metoprolol (50mg to 200mg PO BID) Carvedilol (3.125mg to 25mg PO BID)Carvedilol (3.125mg to 25mg PO BID) Atenolol, Nebivolol, Labetalol, Esmolol, Propranolol, Atenolol, Nebivolol, Labetalol, Esmolol, Propranolol,

TimololTimolol

Beta BlockersBeta BlockersInappropriate first-line treatmentInappropriate first-line treatment

JNC8JNC8 Worse BP control (LIFE)Worse BP control (LIFE) Worse CV outcome prevention (LIFE)Worse CV outcome prevention (LIFE) Increased mortality (ASCOT)Increased mortality (ASCOT) Higher risk of stroke Higher risk of stroke 22

More side effects More side effects 22

Increased risk of type II diabetes Increased risk of type II diabetes 33

Thiazide DiureticsThiazide Diuretics

Special IndicationsSpecial Indications High CAD risk (ALLHAT)High CAD risk (ALLHAT) Recurrent stroke prevention Recurrent stroke prevention

(PROGRESS)(PROGRESS) DM without proteinuria (ALLHAT)DM without proteinuria (ALLHAT) EdemaEdema OsteoporosisOsteoporosis

Thiazide DiureticsThiazide Diuretics

ContraindicationsContraindications Stage IV CKD, Gout, Hyponatremia, Acute Stage IV CKD, Gout, Hyponatremia, Acute

Renal FailureRenal Failure MonitorMonitor

Creatinine, Potassium, SodiumCreatinine, Potassium, Sodium AgentsAgents

Chlorthalidone (12.5mg to 25mg PO daily)Chlorthalidone (12.5mg to 25mg PO daily) Hydrochlorothiazide, Indapamide, Hydrochlorothiazide, Indapamide,

MetolazoneMetolazone

Thiazide equivalence?Thiazide equivalence?

Chlorthalidone vs HCTZChlorthalidone vs HCTZ Chlorthalidone use has sharply declined Chlorthalidone use has sharply declined

over the last 20 years for reasons over the last 20 years for reasons unknown unknown 44

ACCOMPLISHACCOMPLISH

Chlorthalidone vs HCTZChlorthalidone vs HCTZ

Amlodipine appears superior to HCTZAmlodipine appears superior to HCTZ

ALLHATALLHAT

Secondary Secondary OutcomeOutcome

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

Amlodipine Chlorthalidone

6 year CHFrate

Chlorthalidone vs HCTZChlorthalidone vs HCTZ

Amlodipine appears superior to HCTZAmlodipine appears superior to HCTZ Chlorthalidone appears superior to Chlorthalidone appears superior to

AmlodipineAmlodipine

ALLHATALLHAT

Secondary Secondary OutcomeOutcome

Lower rate of Lower rate of combined CVD combined CVD with Chlorthalidonewith Chlorthalidone

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

Lisinopril Chlorthalidone

Stroke rate

CHF rate

Chlorthalidone vs HCTZChlorthalidone vs HCTZ

Amlodipine appears superior to HCTZAmlodipine appears superior to HCTZ Chlorthalidone appears superior to Chlorthalidone appears superior to

AmlodipineAmlodipine Chlorthalidone appears superior to Chlorthalidone appears superior to

LisinoprilLisinopril

ACE-I Beats Diuretic (ANBP2)ACE-I Beats Diuretic (ANBP2)

Rate of events per Rate of events per yearyear

0.00%

0.20%

0.40%

0.60%

0.80%

1.00%

1.20%

1.40%

Enalapril HCTZ

MI

CHF

TIA orStroke

Chlorthalidone vs HCTZChlorthalidone vs HCTZ

Amlodipine appears superior to HCTZAmlodipine appears superior to HCTZ Chlorthalidone appears superior to Chlorthalidone appears superior to

AmlodipineAmlodipine Chlorthalidone appears superior to Chlorthalidone appears superior to

LisinoprilLisinopril Enalapril appears superior to HCTZEnalapril appears superior to HCTZ

Thiazide equivalence?Thiazide equivalence? Chlorthalidone vs HCTZChlorthalidone vs HCTZ

Chlorthalidone use has sharply declined over the last Chlorthalidone use has sharply declined over the last 20 years for reasons unknown 20 years for reasons unknown 44

No evidence that HCTZ improves cardiovascular No evidence that HCTZ improves cardiovascular outcomesoutcomes

Large body of evidence in major trials (ALLHAT) Large body of evidence in major trials (ALLHAT) showing cardiovascular event reduction and showing cardiovascular event reduction and outcome benefit with chlorthalidoneoutcome benefit with chlorthalidone

Chlorthalidone has much longer half-life, is 1.5-Chlorthalidone has much longer half-life, is 1.5-2.0 times more potent, and has slightly more 2.0 times more potent, and has slightly more hypokalemia (7-8% patients require treatment hypokalemia (7-8% patients require treatment 5,65,6))

Thiazide DiureticsThiazide Diuretics

Chlorthalidone superior reduction of Chlorthalidone superior reduction of nighttime BP, compared to HCTZ nighttime BP, compared to HCTZ 77

13.5 mmHg vs 6.4 mmHg13.5 mmHg vs 6.4 mmHg Chlorthalidone (12.5-25mg) vs HCTZ (25-Chlorthalidone (12.5-25mg) vs HCTZ (25-

50mg)50mg)

AgentsAgents Chlorthalidone (12.5mg to 25mg PO daily)Chlorthalidone (12.5mg to 25mg PO daily) Hydrochlorothiazide, Indapamide, Hydrochlorothiazide, Indapamide,

MetolazoneMetolazone

Loop DiureticsLoop Diuretics

Special IndicationsSpecial Indications CHF, EdemaCHF, Edema

ContraindicationsContraindications Gout, Acute Renal FailureGout, Acute Renal Failure

MonitorMonitor Creatinine, ElectrolytesCreatinine, Electrolytes

AgentsAgents Torsemide (5mg to 10mg PO daily)Torsemide (5mg to 10mg PO daily) Furosemide, BumetanideFurosemide, Bumetanide

Aldosterone AntagonistsAldosterone Antagonists

Special IndicationsSpecial Indications CHF (RALES)CHF (RALES) Post-MI (EPHESUS)Post-MI (EPHESUS)

ContraindicationsContraindications Gout, Hyperkalemia, Acute Renal FailureGout, Hyperkalemia, Acute Renal Failure

MonitorMonitor Creatinine, PotassiumCreatinine, Potassium

Agents (ASCOT)Agents (ASCOT) Spironolactone (25mg to 50mg once daily)Spironolactone (25mg to 50mg once daily) Amiloride, TriamtereneAmiloride, Triamterene

ASCOTASCOT

Patients with uncontrolled Patients with uncontrolled hypertension on 3 antihypertensive hypertension on 3 antihypertensive agentsagents

Spironolactone 25mg once daily Spironolactone 25mg once daily added as 4added as 4thth agent agent

Mean BP drop of 22/10 at one year Mean BP drop of 22/10 at one year follow-upfollow-up

Alpha BlockersAlpha Blockers

Special IndicationsSpecial Indications BPHBPH

ContraindicationsContraindications High CV risk (ALLHAT)High CV risk (ALLHAT)

AgentsAgents Doxazosin, Prazosin, TerazosinDoxazosin, Prazosin, Terazosin

Other AgentsOther Agents

ClonidineClonidine MethyldopaMethyldopa HydralazineHydralazine TekturnaTekturna MinoxidilMinoxidil Isosorbide dinitrate/mononitrateIsosorbide dinitrate/mononitrate

Low . . . but how low is too low?Low . . . but how low is too low?

Treatment goal < 140/90Treatment goal < 140/90 < 130/80 in diabetics per JNC7 < 130/80 in diabetics per JNC7

recommendationrecommendation ACCORD, INVESTACCORD, INVEST

BP targets below 140/90 overall do BP targets below 140/90 overall do not improve morbidity or mortalitynot improve morbidity or mortality

DBP < 70 increases risk of death, MI, DBP < 70 increases risk of death, MI, strokestroke

Lifestyle ModificationsLifestyle ModificationsFirst-Line TreatmentFirst-Line Treatment

Sodium Restriction (2-8 mmHg)Sodium Restriction (2-8 mmHg) DASH (8-14 mmHg)DASH (8-14 mmHg)

Fruits, vegetables, low-fat dairy, Fruits, vegetables, low-fat dairy, reduced fatreduced fat

Aerobic physical activity (4-9 mmHg)Aerobic physical activity (4-9 mmHg) Weight ReductionWeight Reduction

(5-20 mmHg per 10 kg lost)(5-20 mmHg per 10 kg lost) Moderate alcohol (2-4 mmHg)Moderate alcohol (2-4 mmHg) Smoking CessationSmoking Cessation

*From JNC7 Express Report, 2003*From JNC7 Express Report, 2003

Monotherapy vs Multi-Drug TherapyMonotherapy vs Multi-Drug Therapy

Sequential Sequential treatmenttreatment

Avoid excessive Avoid excessive dosingdosing

First-line agentsFirst-line agents

Avoid similar Avoid similar agentsagents

Avoid excessive Avoid excessive dosingdosing

Other agentsOther agents

Monotherapy – 1Monotherapy – 1stst line agents line agents

1. Thiazide1. Thiazide Chlorthalidone 12.5mg daily, titrate to Chlorthalidone 12.5mg daily, titrate to

25mg?25mg? 2. ACE/ARB2. ACE/ARB

Benazepril or Lisinopril 20mg dailyBenazepril or Lisinopril 20mg daily Titrate up to 40mg, possibly beyondTitrate up to 40mg, possibly beyond

3. Calcium Channel Blocker 3. Calcium Channel Blocker (dihydropyridine)(dihydropyridine) Amlodipine 5mg dailyAmlodipine 5mg daily Titrate up to 10mg once dailyTitrate up to 10mg once daily

MonotherapyMonotherapy Sequential treatmentSequential treatment

Try one agent, titrate upTry one agent, titrate up If inadequate control, switch instead of addIf inadequate control, switch instead of add

Each first-line agent will normalize BP in 30-50% Each first-line agent will normalize BP in 30-50% of patients of patients 8,98,9

49.1% chance a different agent will control Stage 49.1% chance a different agent will control Stage I Hypertension following failure of initial agent I Hypertension following failure of initial agent 1010

May prevent unnecessary multi-drug May prevent unnecessary multi-drug treatmenttreatment

JNC7 recommendation for uncontrolled JNC7 recommendation for uncontrolled stage I hypertension on monotherapy is to stage I hypertension on monotherapy is to optimize dose or add 2optimize dose or add 2ndnd medication medication Addition of a second drug from a different class Addition of a second drug from a different class

should be initiated when use of a single drug in should be initiated when use of a single drug in adequate doses fails to achieve the BP goaladequate doses fails to achieve the BP goal

Combination TherapyCombination Therapy

Consider combination for Stage 2Consider combination for Stage 2 Add if sequential monotherapy failsAdd if sequential monotherapy fails Drugs for each compelling indicationDrugs for each compelling indication ACCOMPLISHACCOMPLISH Include a diureticInclude a diuretic Consider Spironolactone as 4Consider Spironolactone as 4thth agent agent

(ASCOT)(ASCOT) First-line agentsFirst-line agents

ACCOMPLISHACCOMPLISH

ACCOMPLISHACCOMPLISH

ACCOMPLISH

Combination TherapyCombination Therapy

Drugs for each compelling indicationDrugs for each compelling indication ACCOMPLISHACCOMPLISH Include a diureticInclude a diuretic First-line agentsFirst-line agents Consider Spironolactone as 4Consider Spironolactone as 4thth agent agent

(ASCOT)(ASCOT)

Resistant HypertensionResistant Hypertension

Uncontrolled on 3 medicationsUncontrolled on 3 medications Controlled on 4 or more medicationsControlled on 4 or more medications Must include a diureticMust include a diuretic

CausesCauses CKD (any cause)CKD (any cause) Renal Artery StenosisRenal Artery Stenosis Cushing SyndromeCushing Syndrome Primary Primary

HyperaldosteronismHyperaldosteronism Hyper/HypothyroidismHyper/Hypothyroidism HyperparathyroidismHyperparathyroidism PheochromocytomaPheochromocytoma Obstructive Sleep Obstructive Sleep

ApneaApnea Coarctation of the AortaCoarctation of the Aorta LicoriceLicorice

MedicationsMedications BP Cuff too smallBP Cuff too small Arm positionArm position CaffeineCaffeine NicotineNicotine Substance Substance

Abuse/IntoxicationAbuse/Intoxication Short sleep durationShort sleep duration Alcohol UseAlcohol Use Salt intake?Salt intake? Impatience, hostilityImpatience, hostility

Who do I screen for secondary Who do I screen for secondary causes of hypertension?causes of hypertension?

Resistant HypertensionResistant Hypertension Early or Late onsetEarly or Late onset History & Physical ExamHistory & Physical Exam Abnormal initial labsAbnormal initial labs

Low potassiumLow potassium High calciumHigh calcium

Abnormal subsequent monitoringAbnormal subsequent monitoring Increase Cr > 20% after starting ACE/ARBIncrease Cr > 20% after starting ACE/ARB

Additional Testing to ConsiderAdditional Testing to Consider

PTHPTH TSHTSH 24 hour urine metanephrine24 hour urine metanephrine Plasma AldosteronePlasma Aldosterone Plasma ReninPlasma Renin Dexamethasone supression testDexamethasone supression test Sleep studySleep study RAS imagingRAS imaging

CasesCases

31 yo healthy AAM, BMI 31, BP 31 yo healthy AAM, BMI 31, BP 132/99132/99 BenazeprilBenazepril ChlorthalidoneChlorthalidone LosartanLosartan MetoprololMetoprolol

CasesCases

77 yo 100 lb WF with hyperlipidemia77 yo 100 lb WF with hyperlipidemia BP 159/82BP 159/82

BenazeprilBenazepril MetoprololMetoprolol HCTZHCTZ SpironolactoneSpironolactone

CasesCases

58 yo M, GFR 48, proteinuria, BP 58 yo M, GFR 48, proteinuria, BP 150/95150/95 LisinoprilLisinopril HCTZHCTZ TorsemideTorsemide AmlodipineAmlodipine

CasesCases

47 yo M with depression/gout, BP 47 yo M with depression/gout, BP 162/96162/96 ChlorthalidoneChlorthalidone BenazeprilBenazepril AmlodipineAmlodipine MetoprololMetoprolol

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