secondary hypertension - dr. britt
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Secondary Hypertension:
A Real World Approach
Evan Brittain, MD
December 7, 2012Kingston, Jamaica
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Disclosures
• None
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Real World Causes
• Renovascular Hypertension
• Endocrine
•
Obstructive Sleep Apnea• “Pseudosecondary” Hypertension
– Pseudo-resistant HTN
–
Drug-induced
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Index of Suspicion
Historical
• Recent onset (early or late)
• Loss of control
• Resistant/accelerating
Signs and Symptoms
• Tachycardia/blanching
• Evidence of PVD
(bruit, differential BP)
• Specific drug intolerance
(e.g. ACEI)
• Unprovoked hypokalemia
• Daytime sleepiness
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Age-Based Approach
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AgePercent with
Underlying Cause Most Common Etiologies
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Age-Based Approach
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AgePercent with
Underlying Cause Most Common Etiologies
≤ 18 years 10-15• Coarctation
• Renal parenchymal
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Age-Based Approach
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AgePercent with
Underlying Cause Most Common Etiologies
≤ 18 years 10-15• Coarctation
• Renal parenchymal
19-39 years 5
• Fibromuscular Dysplasia
• Thyroid disease• Renal Parenchymal
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Age-Based Approach
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AgePercent with
Underlying Cause Most Common Etiologies
≤ 18 years 10-15• Coarctation
• Renal parenchymal
19-39 years 5
• Fibromuscular Dysplasia
• Thyroid disease• Renal Parenchymal
40-64 years 8-12
• Hormone-induced Aldosteronism
Cushing’s
Pheo Thyroid
• Obstructive Sleep Apnea
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Age-Based Approach
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AgePercent with
Underlying Cause Most Common Etiologies
≤ 18 years 10-15• Coarctation
• Renal parenchymal
19-39 years 5
• Fibromuscular Dysplasia
• Thyroid disease• Renal Parenchymal
40-64 years 8-12
• Hormone-induced Aldosteronism
Cushing’s
Pheo
Thyroid• Obstructive Sleep Apnea
65+ years 17• Renal Artery Stenosis
• Renal Failure
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Coarctation of the Aorta
• Diagnosed by HTN and murmur
• Bilateral brachial or
brachial/femoral BP differential
•
MRI preferred imaging method
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Coarctation of the AortaDiagnostic Strategies
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Real World Causes
• Renovascular Hypertension
• Endocrine
•
Obstructive Sleep Apnea• “Pseudosecondary” Hypertension
– Pseudo-resistant HTN
–
Drug-induced
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Renovascular HTNClinical Features
• Atherosclerotic RAS
– Older men
– Ostial or proximal 1/3 of vessel
– Stenosis ≠ HTN
• Suspected when:
– New HTN < 30 or > 55 years old
– Unexplained renal dysfunction
– Rapid decline in renal function after
starting ACEI/ARB – Recurrent “flash” pulmonary edema
• Atrophic kidney
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ACC/AHA 2011 Peripheral Arterial Disease Guidelines
J Am Coll Cardiol Intv 2009;2:161 –74
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Renovascular HTNPathophysiology
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Anaesthesia and Intensive Care Medicine. Vol. 7: 8, 298 –302
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Renovascular HTN:Diagnostic Strategies
Screening and Diagnosis: – Duplex ultrasound
– CT angiography
– MR angiography
Angiography still goldstandard
– High suspicion remains
– Suspected FMD
–
Contrast dose
May want to sample renalvein renin activity
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Renovascular HTN:Diagnostic Contrast Use
Radiocontrast (CT)- Higher risk in Cr > 1.5mg/dL and DM (Very low risk with normal GFR)
- Use non-ionic low osmolal agents
- Avoid volume depletion, pre-hydrate if CKD
- Onset 12-24hrs, usually transient
Gadolinium (MRI)- Nephrogenic Systemic Fibrosis
- Moderate to severe renal failure
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Kidney International (2007) 72, 260 –264;
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Renovascular HTN:Management
Goals:
- Improvement in BP, preservation of renal function, decrease CV
morbidity
Unilateral:
- HTN control: ACEI/ARB ± others
- May cause decline in GFR and mild rise in Cr
- Revascularization
Bilateral:
- HTN control: ACEI/ARB ± thiazide diuretic- Revascularization
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Renovascular HTN:Fibromuscular Dysplasia
Clinical Features- Young women
- usually distal 2/3 of vessel
HTN control:- ACEI/ARB, then thiazide
- May drop GFR and increase Cr (usually mild)
Angioplasty:- Indications: young, intolerant/resistant HTN
- Duplex US after 6 months, then yearly
- Surgery reserved for unamenable lesions or failed
PTA
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J Am Coll Cardiol Intv 2009;2:161 –74
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Real World Causes
• Renovascular Hypertension
• Endocrine
•
Obstructive Sleep Apnea• “Pseudosecondary” Hypertension
– Pseudo-resistant HTN
–
Drug-induced
VanderbiltHeart.com
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Hormone-Related Hypertension
• Hyperaldosteronism
• Thyroid
•
Cushing’s • Pheochromocytoma
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Primary Hyperaldosteronism:Clinical Features
Two common forms:
– Bilateral idiopathic hyperaldosteronism
– Aldosterone-producing adenoma
Diagnostic Clues – HTN
– Unprovoked or inappropriate
hypokalemia
– Hypernatremia = volume expansion
– Low k + low Na = volume depletion and
secondary aldosteronism
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cvphysiology.com
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Primary Hyperaldosteronism:Diagnostic Strategies
Serum aldosterone/renin ratio(ARR)
- If > 20 and aldosterone > 15ng/dL salt suppression test
- False positive: Beta-blockers,clonidine
- False negative: diuretics, DHPCCBs, ACEI/ARBs
Localization: Adrenal CT
- Bilateral or large unilateral
- Small, hypodense
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HyperaldosteronismManagement
Goal: normalization of aldosterone
receptor blockade
Unilateral hypersecretion
- Adrenalectomy
Bilateral adrenal hyperplasia
- Aldosterone antagonist
(spironolactone, eplerenone)
- Monitor K, Cr, and BP frequently in
first 4-6 weeks
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Growth Hormone & IGF Research. Vol 13; 2003: S102 –S108
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Real World Causes
• Renovascular Hypertension
• Endocrine
•
Obstructive Sleep Apnea• “Pseudosecondary” Hypertension
– Pseudo-resistant HTN
–
Drug-induced
VanderbiltHeart.com
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Obstructive Sleep ApneaClinical Features
Symptoms
• Daytime sleepiness
• Snoring
• Witnessed apneas
• Poor concentration
Signs
• Obesity
• Large Neck
• Systemic HTN
• Arrhythmias
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N Engl J Med 2000;342:1378-84
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Obstructive Sleep ApneaDiagnostic Strategies
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http://www.mysleepapneatest.com/diagnosing-osa.aspx
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Obstructive Sleep ApneaManagement
Continuous positive airway
pressure (CPAP)
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Circulation. 2003;107:68-73.
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Real World Causes
• Renovascular Hypertension
• Endocrine
•
Obstructive Sleep Apnea• “Pseudosecondary” Hypertension
– Pseudo-resistant HTN
–
Drug-induced
VanderbiltHeart.com
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“Pseudo-resistant” HTN
Improper measurement
- Cuff size
- White-coat effect
Patient compliance- Lack of understanding/education
- Mistrust
- Poor adherence
- Cost
Physician causes
- Inadequate doses, inappropriate combinations
- Inertia
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Drug-Induced Hypertension
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Drug Class Common Examples
Estrogen Oral contraceptives
Herbal remedies Ephedra, gensing, ma huang,
licoriceIllicit Cocaine, amphetamines
NSAIDs COX-2 inhibitors, naproxen
Psychiatric Buspirone, lithium, TCAs
Steroid Prednisone, methylprednisolone
Sympathomemetic Decongestants, diet pills
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Thank you for your attention
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