Transcript Sexy Topics In 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
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Sleep apnea
Primary Hyperaldosteronism
Renal Artery Stenosis
White coat HTN
 Tips for improving adherence
 Resistant hypertension and diuretic use
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
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!!
% Reduction In Relative Risk
Diabetes: Tight Glucose vs Tight BP
Control and CV Outcomes in UKPDS
0
Stroke
DM
Deaths
Any Diabetic
Endpoint
Microvascular
Complications
5%
-10
10%
12%
-20
24%
*
-30
32%
*
-40
-50
32%
*P <0.05 compared to tight glucose control
44%
*
Tight Glucose Control
(Average HA1c 7.9 vs 7.0)
Bakris GL, et al. Am J Kidney Dis. 2000;36(3):646-661.
Reprinted by permission, Harcourt Inc.
37%
*
Tight BP Control
(Average 154/87 vs 144/82)
Slide Source
HypertensionOnline
www.hypertensiononline.org
www.hypertensiononline.org
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?
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
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)
Diagnosis of HTN:
Initial Workup
 The
“Cardiovascular Risk” labs:
 EKG
(get as baseline + evaluate for LVH,
prior MI)
 Lipid panel
 Fasting glucose
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?
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)
Prevalence of Secondary
Causes of Hypertension
COMMON (prevalence) RARE (prevalence)
Sleep Apnea
(? Really Common ?)
Renal Disease (1-8%)
Pheochromocytoma (<0.5%)
Hyperaldosteronism
(1.5-15%)
Renal Artery Stenosis
(3-4%)
Cushing’s Syndrome (0.5%)
Thyroid disease (1-3%)
Carcinoid Syndrome
Coarctation of Aorta (<1%)
Acromegaly
Hypercalcemia
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):
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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)
Primary Hyperaldosteronism
and Hypertension
Primary hyperaldo – excessive secretion aldosterone from tumor or
Hyperplasia  salt retention  increase blood pressure
Primary Hyperaldosteronism

May be present in 1.5 - 15% those with
resistant hypertension
 Etiologies
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Clinical features
 Hypokalemia (although normal K in 30%)
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Adrenal adenoma
Bilateral adrenal hyperplasia
Hypernatremia
Metabolic alkalosis
Workup – AM plasma renin and aldosterone
levels, go to Uptodate
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
Renal Artery Stenosis –
Etiologies

Fibromuscular dysplasia (young women)
 Atherosclerotic (HTN/DM/lipids/FH etc)
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Suspect in resistant hypertension and:
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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
Renal Artery Stenosis and Resistant
HTN – Does Dx/Intervention matter?
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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)
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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
Renal Artery Stenosis and Resistant
HTN – Does Dx/Intervention matter?

BOTTOM LINE: If you suspect RAS,
people who may benefit from intervention:
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Young women (may have dysplasia)
Suspicion for atherosclerotic RAS + any of the
following:
1)
HTN not responsive to treatment, esp if
severely elevated over stable value
2)
Progressive renal failure
3)
Repeated episodes flash pulmonary edema
4)
Age < 60
Workup: At our institution, order MRA
Screening for the rare stuff –
Reasonable to go by Hx/PE
Pheochromocytoma Paroxysmal elevations in
BP, HA, Palpitations,
sweating
Cushings disease
Moon facies, central
obesity, striae, inc glucose
Coarctation of aorta Hypertension in arms but
not legs, decreased
femoral pulse, abnl
murmur/bruits
Acromegaly
Looks like they have
acromegaly
Height:
5’11”
Weight: 129
My
BMI, circa 1991: 17
Back to our patient…
 His
blood pressure is 182/96.
 How many agents would you start him
on?
“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)
Case continued
 So
you start the patient on lisinopril 10
mg daily + HCTZ 25 daily
 When should you check his potassium
and creatinine?
Recommended intervals for Monitoring
Creatinine/K in ACE/ARB tx
After initiation or
change of
ACE/ARB dose
After dose is
stable
GFR > 60
4-12 weeks
GFR 30-59
2-4 weeks
GFR < 30
<2 weeks
6-12 months
3-6
months
1-3 months
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?
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
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
patient: “You will likely need 2 or more
meds to get your BP under control”
 Tell
Medication Adherence –
Possibly helpful tips
on prescription: “take 1 tablet daily
to get blood pressure less than 140/90”
 Write
 Use
fixed-dose combinations
 Benazepril/HCTZ
combo on both CCHP
and MediCal formularies
Other things that can increase
Blood Pressure
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Medications
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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
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?
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
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
What about resistant HTN with
GFR < 50?

HCTZ may not be not effective
Options:
1. Substitiute another thiazide:
 Metolazone 2.5 – 10 daily
2. 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)
Resistant HTN and Diuretics
Spirinolactone for Resistant
Hypertension
Study  patients with uncontrolled HTN and
on 4 agents were given spirinolactone 12.550 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
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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
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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