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A CASE OF MALIGNANT HYPERTENSION

A CASE OF MALIGNANT HYPERTENSION. DR ANN HOLMES GPST2. CASE. Px, 56, c/o loss of central vision R eye, blurred vision L +mild generalised headache.

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A CASE OF MALIGNANT HYPERTENSION

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  1. A CASE OF MALIGNANT HYPERTENSION DR ANN HOLMES GPST2

  2. CASE • Px, 56, c/o loss of central vision R eye, blurred vision L +mild generalised headache. • ∆hypertension 5yrs ago but had stopped taking tablets entirely 12/12 ago due to £ issues. Previously on 3 meds but can’t recall names. Feels well otherwise. PMH unremarkable. Smokes 5/day; <14U ETOH • GP refers: BP 200/130, ?papilloedema

  3. Ophthalmoscopy: frank papilloedema-Gd IV hypertensive retinopathy • ECG: LVH • Urine dipstix: protein++++, trace blood • Hb13; ur9,creat240,eGFR14 glucose N LFTs N, neuro exam NAD • Mild leg pitting oedema

  4. Moved to HDU, arterial line, catheterised, labetolol+GTN infusions • Further investigations: cortisol, TFTs, nephritic screen, myeloma screen, urine alb:creat ratio, urgent renal USS+CT head, renin-angiotensinogen levels, urine 24hr metanephrine+catecholamines, lipid profile • Renal, endocrine+ophthalmology teams informed • Renal artery angiography

  5. HDU for 6/7 whilst BP slowly reduced. • Antihypertensives recommenced with omission of ACE inhibitors.

  6. ∆ Malignant hypertension secondary to severe renal artery stenosis: • R 100% occlusion; L 80% • Candidate for possible revascularization • How common is it?

  7. In 1964, Holley et al data from 295 autopsies performed in their institution during a 10-month period.The mean age at death was 61 years. The prevalence rate of renal artery stenosis was 27% of 256 cases identified as having history of hypertension, while 56% showed significant stenosis (>50% luminal narrowing), and, among normotensive patients, 17% had severe renal artery stenosis (>80% luminal narrowing). Among those older than 70 years, 62% had severe renal artery stenosis. Similar results with other studies.

  8. Causes of Renovascular hypoperfusion • Atheroma>90% • Takayasu’s arteritis>60% in Indian subcontinent+Far East • Fibromuscualar hyperplasia • Rarely:PAN,AVM,neurofibramatosis • NB Renal artery stenosis prevalence cauc:black 2:1

  9. Numerous referrals with high BP >180 systolic and headache… • Definition of malignant hypertension?

  10. Severe hypertension with WITH papilloedema + end organ damage • Primary care: Urine dipstix key ?proteinuria+/-blood; ophthalmoscopy. ECG • NOT diagnosed on numbers alone

  11. <1% hypertensives develop: rare • Cause: Essential hypertension in 80% Blacks, 2-30% Caucasians; renal disease the rest • High BPloss of autoregulation; endothelial injury, vascular smooth muscle hypertrophy+collagen depositionluminal narrowing with ischaemia+infarction of end organs • Concurrent pressure triggered natriuresis+SNS stimulationfurther BP • Mortality 90% at 1yr if untreated

  12. NICE hypertension 2011 • Severe hypertension (syst>180 or diastol>110) at diagnosis: • Same day referral if accelerated hypertension with papilloedema/retinal haems + BP>180/110 or suspect phaeochromocytoma • Otherwise assess for end organ damage, don’t wait for ambulatory BP/serial BD home recordings+consider starting treatment with A/C +review

  13. A/C if <55 +C+D;stepwise addition of therapy • Review 1/52ly or sooner post med change for progress aiming for <140/90 if <80 (<150/90 if >80; 130/80 if DM • Then further diuretic/low dose spironolactone dep on K/-blocker if not tolerated • Monitor U+Es within 1/12 • Refer if not controlled on 4 meds

  14. Check compliance • Px education-address lifestyle issues • CVD risk factor assess+manage

  15. references • http://www.patient.co.uk/doctor/Renal-Vascular-Disease.htm • http://emedicine.medscape.com/article/245023-overview • Clinical opthalmology 3rd edn:Kanski p369 • NICE guidelines 2011 hypertension

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