resistant hypertension -update and management
TRANSCRIPT
DR SUBHASH DUKIYACARDIOLOGY, JIPMER
Refractory hypertension
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Resistant hypertension (RHTN) is defined as high blood pressure (BP) that requires 4 or more medications for treatment. As defined, RHTN includes patients whose BP is controlled or uncontrolled after use of 4 or more medications.
patients with RHTN who never achieve BP control in spite of maximum medical therapy (i.e., refractory hypertension)
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What Is Resistant Hypertension?
In Compliant PatientOn life style change
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Prevalence of Resistant Hypertension*ALLHAT, CONVINCE, LIFE, INSIGHT
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Causes of Resistant Hypertension 7
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Strong Associates of Resistant Hypertension 9
Pseudo Resistant Hypertension
“White Coat” hypertension (not without risk) Uncompressible arteries of old age(Osler’s Pseudo HT) Measurement issues – small cuff (< 80% of arm) BP Recorded without 5-10 minutes of rest Non-compliance with drug treatment 40% patients discontinue Rx in the first year No life style modification practiced
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24 hr. Ambulatory BP Monitoring (ABPM)To distinguish white coat and pseudo hypertension, home BP and ABPM
Masked hypertension11
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Genetics and Resistant Hypertension
Mostly Polygenic
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Secondary and Resistant Hypertension 14
Whom We Should Watch for Sec HT? 15
Evaluation of Resistant Hypertension
Good blood pressure recording technique – cuff size Strict compliance with treatment recommendations Evaluation for secondary causes of resistant hypertension Ambulatory BP monitoring (ABPM) – to exclude “White Coat” Assessment for TOD – CKD, Retinopathy, LVH – is essential History of drug intake that can cause resistant hypertension Day time sleepiness, loud snoring, apnoeic spells - OSAS
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Common Causes of Secondary Hypertension 17
Relative Prevalence of Secondary Hypertension
Primary or Essential Hypertension 93-95%
Secondary Causes 5-7%
Renal Hypertension 3-5%
Parenchymal 2-3%
Reno vascular 1-2%
Endocrine: Conn’s, Cushing’s, Pheochromocytoma 0.3-1.0%
Oral Contraceptive Pills (OCP) 0.5%
Miscellaneous 0.5%
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Mechanisms for Secondary Hypertension 19
Secondary Hypertension: Renal Causes
Renal Artery Stenosis (RAS) Chronic Kidney Disease (CKD)
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Secondary Hypertension: Renal Causes
Mainly Tunica Media affected Intimal Atherosclerotic Plaques
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Renal Artery Stenosis (RAS) and RHT
Atherosclerotic (intimal) Reno vascular disease is 90% Fibro muscular (media) hyperplasia is 10% Duplex USG, MR angiography, Renal CT, Renal
Scintigraphy MR Angiography is highly sensitive for detecting RAS 15% of patients of CAG show asymptomatic RAS Renal revascularization, stenting are the Rx of choice
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Secondary Hypertension: Adrenal Causes
Excess Mineralocorticoid Activity Excess Glucocorticoid Activity
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Primary Aldosteronism and RHT
20% of cases of RHT have Primary Aldosteronism Suppression of Renin Activity, Low K+ and Mg++, Met Alkalosis
Higher 24 hour urinary aldosterone excretion In the background of higher dietary sodium intake General increase in R-A-S activity due to obesity AT II independent Aldosterone excess Stimulated by adipocyte derived secretagogues
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Cushing’s Syndrome and RHT
70% to 80% of patients with Cushing's have RHT Excessive stimulation of nonselective mineralocorticoid R IRS, DM and OSAS which coexist may contribute TOD is more severe in Cushing's syndrome Routine antihypertensive drugs are not effective MR Antagonist - Eplerenone or Spironolactone are effective Surgical excision of ACTH or Cortisol producing tumour
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Pheochromocytoma and RHT
Small but important cause of Secondary RHT Prevalence is 0.1% to 0.6% of hypertensives Increased BP variability – A CV risk factor by itself Episodic Hypertension, Palpitation, Headache and Sweating Dysglycemia and abnormal GTT are usually associated Has a diagnostic Specificity of 90% Plasma free metanephrine and normetanephrine Has 99% sensitivity and 89% specificity
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D.Dx. of Corticoid Induced Hypertension
Type of HT Serum K
Pl Renin
Aldosterone Increase in others
Primary Hyper Aldosteronism Low Low High
Glucocorticoid Remediable (GRA) Normal Low High 18 OH-C, THC in Urine
Mineralocorticoid Excess (apparent) Low Low Low THC+ 5THC in Urine
Deoxycorticosterone Low Low Low Pl Deoxycorticosterone
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Other Causes of Secondary Hypertension
Coarctation, PAN and Aortitis, PTHT Prolonged uses of External Agents
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Secondary Hypertension: Evaluations 29
Drug Treatment of Resistant Hypertension
If a correctable cause is found, treat that Aggressive drug therapy – Optimizing the current Rx. Effective Diuresis – Furosemide BID/Torsemide OD MRA antagonists, Spironolactone, Triamterene,
Amiloride Hydralazine or Minoxidil + β-Blocker and a diuretic Transdermal Clonidine
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Some Practical Points of Rx. of RHT 31
Future Options For Resistant Hypertension
Direct Renin Inhibitors (Aliskiren) Neutral Endopeptidase (NEP) Inhibitors (Omapatrilat) Aldosterone Synthase Inhibitors Clonidine Extended Release Endothelin Antagonists (Darusentan) Novel Combinations Algorithms
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Non Pharmacological Approaches
The following procedures are invasive and irreversible Implantable pulse generators – perivascular carotid
sinus leads to be surgically implanted Renal Denervation – particularly in those with renal
origin of the disease – Promising results
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Take home message
High prevalence gjmresistant HTNDrug adherenceR/O sec. causeLife style changesOptimize drugs
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Thank you
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