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Resistant and Secondary Hypertension

Resistant and Secondary Hypertension. Oliver Z. Graham, MD “Hypertension Specialist” Department of Internal Medicine. What I am going to talk about. Why BP control is important Initial workup of newly diagnosed HTN Secondary hypertension Sleep apnea Primary Hyperaldosteronism

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Resistant and Secondary Hypertension

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  1. Resistant and Secondary Hypertension Oliver Z. Graham, MD “Hypertension Specialist” Department of Internal Medicine

  2. What I am going to talk about • Why BP control is important • Initial workup of newly diagnosed HTN • Secondary hypertension • Sleep apnea • Primary Hyperaldosteronism • Renal Artery Stenosis • White coat HTN • Tips for improving adherence • Resistant hypertension and diuretic use

  3. Benefits of Lowering BP • Antihypertensive therapy has been associated with: • 35-40% reduction in stroke • 20-25% reduction in MI • 50% reduction in heart failure

  4. Treating HTN – A Clear Reduction in MORTALITY • If patient with BP 140-159/90-99, (and other cardiac RF) achieving a 12 mm Hg decrease in SBP over 10 years will prevent one death for every 11 patients treated!! • In the presence of CVD or target-organ damage, same tx will prevent one death for every 9 patients treated!!

  5. A Case Study… • A 55 year old Hispanic man comes to your clinic for a first visit. He recently immigrated from Mexico several years ago, he was on some medications for blood pressure previously but has not taken anything for several years. • PE 5’ 8” 190 pounds BP 172/105 HR 82 • What are you looking for on PE? • What kind of screening labs do you order?

  6. New Hypertensive Patient –The Physical Examination • Test accuracy of reading (check cuff size, check other arm, repeat office reading or home reading) • “fundoscopic evaluation” • Thorough exam heart/lung/JVP • Auscultate for abdominal bruit (renal artery stenosis?) • Femoral pulses (coarctation?) • LE edema

  7. Diagnosis of HTN:Initial Workup • The “cheap screening for secondary hypertension” labs: • Creatinine • Sodium, Potassium (hyperaldosteronism) • U/A (nephrotic syndrome, nephritic syndrome) • Calcium (secondary hyperparathyroidism) • CBC (polycythemia) • UTox (CCRMC special) • Consider TSH (both hyper and hypothyroidism associated with hypertension)

  8. Diagnosis of HTN:Initial Workup • The “Cardiovascular Risk” labs: • EKG (get as baseline + evaluate for LVH, prior MI) • Lipid panel • Fasting glucose

  9. Back to case study…. • Repeat SBP 182/96, Obese (BMI 35). CV/lungs WNL. No abd bruit. No edema. • Na 141 K 4.2 Creat 1.2 U/A neg, except 30 protein. Spot urine protein 0.14 g/24 hours. EKG – LVH. CBC, Calcium, TSH, WNL. Utox neg. Fasting Glucose 145, HA1c 8.1 • Would you do a secondary HTN workup? If so, what would you focus on?

  10. Risk factors for secondary hypertension • Poor response to therapy • An acute rise of BP over a previously stable value • Confirmed onset of hypertension before 20 or after 50 years (need accurate hx) • Age < 30 in non-obese, non-black patients with a negative family hx • Stage 3 HTN (>180/110)

  11. Prevalence of Secondary Causes of Hypertension

  12. Obstructive Sleep Apnea • In one study, 83% of those with resistant HTN had sleep apnea • Intervention Studies (using CPAP in pts with sleep apnea + resistant HTN): • Two studies show decrease SBP 10-15 • Other studies showed little or no reduction after CPAP administration • BOTTOM LINE: Reasonable to screen those with resistant hypertension, especially if with risk factors (obesity, daytime somulence, apnea history)

  13. Primary Hyperaldosteronism and Hypertension Primary hyperaldo – excessive secretion aldosterone from tumor or Hyperplasia  salt retention  increase blood pressure

  14. Primary Hyperaldosteronism • May be present in 1.5 - 15% those with resistant hypertension • Etiologies • Adrenal adenoma • Bilateral adrenal hyperplasia • Clinical features • Hypokalemia (although normal K in 30%) • Hypernatremia • Metabolic alkalosis • Workup – AM plasma renin and aldosterone levels, go to Uptodate

  15. Hypertension and renal artery stenosis less blood flow • Decreased blood to kidney  kidney “senses” diminished BP • Activation renin/angiotension system  vasoconstriction Aldosterone secretion  salt retention

  16. Renal Artery Stenosis –Etiologies • Fibromuscular dysplasia (young women) • Atherosclerotic (HTN/DM/lipids/FH etc) • Suspect in resistant hypertension and: • Elevation Cr with admin ACE/ARB • Unilateral small kidney on imaging • Abdominal bruit • Repeated episodes flash pulmonary edema • Acute rise in BP over previously stable value

  17. Renal Artery Stenosis and Resistant HTN – Does Dx/Intervention matter? • RAS from fibromuscular dysplasia responds well to angioplasty (HTN improved in 20-80%) • RAS from atherosclerosis: sustained response to intervention “unusual” (lesions usually too diffuse) • NEJM study: 106 pts randomized to angioplasty vs med tx. No difference in BP control or renal insufficiency noted at 1 year • No good studies using angioplasty + stents • Complications from intervention include atheroembolism  dialysis

  18. Renal Artery Stenosis and Resistant HTN – Does Dx/Intervention matter? • BOTTOM LINE: If you suspect RAS, people who may benefit from intervention: • Young women (may have dysplasia) • Suspicion for atherosclerotic RAS + any of the following: • HTN not responsive to treatment, esp if severely elevated over stable value • Progressive renal failure • Repeated episodes flash pulmonary edema • Age < 60 Workup: At our institution, order MRA

  19. Screening for the rare stuff – Reasonable to go by Hx/PE

  20. Height: 5’11” • Weight: 129 • My BMI, circa 1991: 17

  21. Back to our patient… • His blood pressure is 182/96. • How many agents would you start him on?

  22. “The Rule of 10’s” • Each BP med will reduce SBP by about 10 mmHg • Per JNC recommendations: • If BP > 20/10 of goal, consider initial treatment with TWO agents (one should probably be diuretic)

  23. Case continued • So you start the patient on lisinopril 10 mg daily + HCTZ 25 daily • When should you check his potassium and creatinine?

  24. Recommended intervals for Monitoring Creatinine/K in ACE/ARB tx

  25. Back to our patient… • A sleep study was ordered given the patient’s obesity. • He comes back for followup, and is on HCTZ 25 daily, Lisinopril 20 daily. His BP in office is 174/96 • What are some other features that may be contributing to the patient’s hypertension?

  26. White Coat Hypertension • May be responsible for 30% those with resistant hypertension • Appears that BP values obtained at home correlate better with target organ involvement • If a consideration – have patient check BP at home, have therapy target those values

  27. Medication Adherence –Possibly helpful tips • Appropriately educate patient/family about benefits of good BP control • Have patient check BP at home periodically and bring in logbook • Use “Rule of 10’s” to guide expectations • Tell patient: “You will likely need 2 or more meds to get your BP under control”

  28. Medication Adherence –Possibly helpful tips • Write on prescription: “take 1 tablet daily to get blood pressure less than 140/90” • Use fixed-dose combinations • Benazepril/HCTZ combo on both CCHP and MediCal formularies

  29. Other things that can increase Blood Pressure • Medications • NSAIDS (inc SBP by approx 4 mmHg) • Cocaine, Amphetamines • Phenylephrine • Anabolic Steroids • Erythropoietin • Oral Contraceptives • Excessive EtOH (>3-4 drinks/day) • High Salt Diet • Obesity

  30. Another patient comes in…. • A 65 YO woman is seen in your clinic for f/u of longstanding HTN. She is on HCTZ 12.5 mg, Toprol XL 200 mg daily, amlodipine 10 daily, lisinopril 40 daily. Her BP is 162/94. Creat 1.4 (GFR 45), no protienuria. Utox neg. She emphatically states that she takes her medications as directed. What is your next step in managing her HTN?

  31. Diuretics – Cornerstone of HTN therapy • Most patients with resistant hypertension have inappropriate sodium/fluid retention  EFFECTIVE DIURETIC THERAPY ESSENTIAL for HTN control • 60% of those with resistant HTN improve BP by add/increasing diuretic therapy

  32. What is the proper HCTZ dose? • In uncomplicated patients without resistant HTN or renal disease, no real benefit in HTN control with increase from 12.5 vs 25/50 daily • Those with resistant HTN and normal renal function – may need increase in HCTZ 12.5  25  50

  33. What about resistant HTN with GFR < 50? • HCTZ may not be not effective Options: • Substitiute another thiazide: • Metolazone 2.5 – 10 daily • Substitute for loop diuretic: • Lasix 20-80 BID or Bumex 0.5-2 BID (Dosed BID because of short half life) • Toresemide 2.5 – 5 daily (longer half life, more expensive)

  34. Resistant HTN and Diuretics

  35. Spirinolactone for Resistant Hypertension • Study  patients with uncontrolled HTN and on 4 agents were given spirinolactone 12.5-50 mg daily • Avg BP reduction at 6 months: • 25/12 (!!) • Degree of antihypertensive benefit similar in subjects with and without primary hyperaldosteronism • **Follow K very closely, esp in renal failure • Probably avoid in Creatinine > 2

  36. My bullet points… • Blood pressure control is a worthwhile endeavor and improves mortality more than most other stuff you do in clinic • Strongly consider sleep apnea screening in hypertensive patients • Think of primary hyperaldosteronism in those with hypertension and low K • Renal artery stenosis relatively common, but unclear if invasive procedures work

  37. My bullet points, continued • “Rule of 10’s” guideline helpful for guidance tx • OK to follow home BPs if patient with white coat HTN • Try combination medication and writing BP goals on prescription to improve adherence • If patient has resistant hypertension, ensure s/he is on proper diuretic dose • HCTZ may not work at GFR < 50 • Spirinolactone may be really great

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