1 / 44

Hypertension: How to Manage Challenging Cases

Hypertension: How to Manage Challenging Cases. J. Emilio Exaire, MD. Assistant Professor of Medicine Cardiovascular Section, OUHSC. Hypertension. QUESTION 1. In average, how many hypertensive patients are well controlled (e.g. BP<140/90) a. 90% b. 80% c. 70% d. 60% e. 48%.

jerom
Download Presentation

Hypertension: How to Manage Challenging Cases

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Hypertension: How to Manage Challenging Cases J. Emilio Exaire, MD. Assistant Professor of Medicine Cardiovascular Section, OUHSC

  2. Hypertension

  3. QUESTION 1 • In average, how many hypertensive patients are well controlled (e.g. BP<140/90) a. 90% b. 80% c. 70% d. 60% e. 48%

  4. How big is the problem? • Only 48% are controlled; 37% if patients have renal failure • About 20%-30% have resistant HTN

  5. Case 1 • 56 yr female • First diagnosis of HTN at age 19 • Bipolar disorder • On ACEI only with poor control

  6. Case 1 considerations • Suspicious high for secondary HTN • Never had a renal duplex ultrasound • Step 1: consider adding more drugs • Step 2: order renal US

  7. Re-evaluation • Still HTN • US showed possible bilateral renal artery stenosis

  8. Question 2 • What is the most likely diagnosis? A. Fibromuscular dysplasia B. Medial fibroplasia C. Atherosclerotic renal artery disease D. Essential hypertension

  9. Medial fibroplasia • Smooth highly stenotic lesions in children and adolescents. • Affects proximal, mid or distal portions of the renal artery. • Idiopathic intimal fibroplasia • Respond well to angioplasty.

  10. Medial fibroplasia

  11. After stenting

  12. Learning Points • Always ask for the onset of hypertension • Look for secondary causes, even in adults

  13. Case 2 • 33 year old female • 113 pounds • Severe hypertension of recent onset • Family history for HTN • Negative ultrasound • Positive CT scan for left adrenal mass • Not controlled on ACEI

  14. Case 2

  15. Question 3 • How often are adrenal masses non-functioning? • 80% • 50% • 20% • 10% • They always secret

  16. Case 2 considerations • 80% of adrenal masses are non-functioning (“Incidentaloma”) • The test of choice is an upright plasma aldosterone–to–renin ratio (>30 and a plasma aldosterone concentration of greater than 18 ng/dL is suggestive of primary aldosteronism). • Normal suppression test

  17. (Olmesartan/amlodipine)40/10 mg

  18. Learning points • Onset of hypertension can be in the early 30’s • Although some tests are desirable to rule-out some secondary causes, sometimes, healthy, non-obese patients need only a combination therapy to achieve control.

  19. Case 3 • 64 year female • DM, dyslipidemia, normal coronaries • Severe HTN. • Sleep apnea on CPAP. Compliant. • Taking HCTZ 25 mg, clonidine 0.2 prn, spironolactone 100 mg bid, carvedilol 50 mg bid, olmesartan/amlodipine 40/10 mg daily

  20. Initial BP

  21. Case 3 F/U • Added nisoldipine 20 mg • Normal kidney scan • Complaints of dizzy spells and syncope • Referred to Neurology

  22. Case 3 • Normal CT and MRI • Possible neurocardiogenic syncope • Currently taking: Nisoldipine, carvedilol, olmesartan/amlodipine, spironolactone • Admitted to ER at Shawnee due to hyperkalemia and syncope

  23. How often does the combination of ACEI/ARB + spironolactone result in hyperkalemia? • A. 10% • B. 5% • C <2% • D. 0% • E. 50%

  24. Case 3 • Stopped Azor, spironolactone and carvedilol at the hospital • Only continued nisoldipine, HCTZ with erratic control. • Started: • Metoprolol 100 mg every day. • Aliskiren (Tekturna) 150 mg every day. • Felodipine 20 mg every day.

  25. Case 3 • Reasonable control, less postural hypotension but tachycardic • Decided to increase betablockers, stop tekturna (risk of hyperkalemia) and start a clonidine patch, changed felodipine to olmesartan/amlodipine

  26. Current medications • Clonidine patch 0.2 mg every week. • HCTZ 25 mg every day. • Metoprolol 100 mg b.i.d. • Olmesartan/Amlodipine 40/10 mg every day. Total 5 antihypertensives

  27. 5 antihypertensives

  28. 1 year after • The patient lost 50 pounds. She is down to 2 BP med’s and well controlled!

  29. Learning points • Beware of side effects! • Hyperkalemia • Postural hypotension • Don’t be afraid to titrate up to maximal doses and add drugs or combination pills • Average 3 drugs per patient (4 if renal dysfunction). • Encourage the patients to lose weight!

  30. Questions?

More Related