#21 Press - Secondary Hypertension

Question 1

Why do we care about secondary causes of hypertension if they are only 5-10% (maybe 10-15%) of the cases?

Answer 1

Because they are treatable

Question 2

What might tip you off that your patient has secondary hypertension?

Answer 2

• Severe or refractory hypertension
• Acute rise in BP when previously it was stable
• Age less than 30 years in a non-obese, non-black patient with negative family history.

Question 3

30 year old black woman comes in with hypertension after having years of normal BP. Here is her imaging. What do you suspect?

Answer 3

Fibrotic dysplasia

beaded

Question 4

47 year old man comes in with uncontrolled hypertension and known atherosclerosis. What might you find on his renal imaging?

Answer 4

Renal artery stenosis

Question 5

What clinical clues would you use to work up a patient? (i.e. reasonable cause so insurance will pay)

Answer 5

Refractory or resistant HTN despite multiple anti-HTN meds

Acute rise in blood pressure over previously stable

Acute elevation in the plasma [creatinine] after instituting ACEi/ARB

Unexplained atrophic kidney or asymmentry (>1.5cm) in size

systolic-diastolic abdominal bruit

recurrent CHF

Question 6

What treatments are available for renal artery stenosis?

Answer 6

• Medical therapy (unilateral renal artery stenosis) - ACEi or CCB
• Angioplasty w/ or w/o a stent
• Surgery

Question 7

You suspect renal artery stenosis in your patient. What would expect the serum aldosterone and plasma renin levels to be?

Answer 7

hyperaldosterone

hyperreninemic

Kidney is tricked into thinking it is in a volume contracted state which will cause renin and aldosterone production to increase.

Question 8

What imaging would you order if you suspected renal artery stenosis?

Answer 8

Renal artery duplex

MRA

Renal flow scan

Arteriogram (*gold standard but nephrotoxic)

Question 9

Renin secreting tumors will cause renin and aldosterone levels to ____________________?

Answer 9

Increase

High Renin

High aldosterone

HYPOkalemic

Question 10

Which zones in the adrenal cortex could be responsible for secondary hypertension?

Answer 10

GFR

Zona Glomerulosa - aldosterone (Hyperaldosteronism)

Zona Fasciculata - Cortisol (Cushing’s)

Zona Reticularis

Question 11

HA comes into the office with hypertension. Labs come back and show hypokalemia, metabolic alkalosis and mild hypernatremia. What do you suspect?

Answer 11

1* hyperaldosteronism

PAC/PRA > 20 (Aldo high, renin low)

Negative feedback for renin

Question 12

PAC/PRA is greater than 20 and you have confirmed with a 24 hour urine for aldosterone (14mcg/day) that your patient has 1* hyperaldosteronism. How might you treat this patient?

Answer 12

Adenoma - surgery

Bilateral adrenal hyperplasia - spironolactone or eplerenone

Question 13

Labs come back with high random cortisol [>15 ug/dL] and low plasma ACTH concentration. What would you suspect and how would you treat them?

Answer 13

Cushing’s Syndrome

Surgery

Question 14

You patient has been diagnosed with pheochromocytoma after a 24 hour urine collection for catecholamines and metabolites (VMA and metanephrines) and a CT. How would you treat the patient pre-operatively?

Answer 14

Alpha blocker - Phenoxybenzamine 7-10 days before surgery

THEN

Beta blocker - propanolol 2-3 days before surgery

Question 15

Child visits the office with hypertension in the upper extremities and deminished femoral pulses and low arterial blood in the lower extremities. What would you expect and what would you do to confirm?

Answer 15

Coarctation of the Aorta

Confirm with echo

CXR on older children and adults may show rib notching