CR III - Secondary Hypertension

Question 1

What are 6 clinical clues that suggest secondary hypertension?

Answer 1

Severe/resistant to 3 drugs
Acute rise in pt with stable BP
<30 years and not obese
Malignant HTN
Electrolyte disorders present
Before puberty

Question 2

What are the 4 common causes of secondary hypertension?

Answer 2

Primary Kidney Disease
Renovascular HTN (Renal artery stenosis)
Primary Hyperaldosteronism
Obstructive Sleep Apnea

Question 3

Recurrent acute pulmonary edema could point you to:

Answer 3

Renal artery stenosis

Question 4

What is the gold standard for Renal Artery Stenosis? What is easiest?

Answer 4

Gold standard - CTA or MRA

Easiest - doppler ultrasound

Question 5

What are the 3 treatments for renal artery stenosis?

Answer 5

Stop smoking
Anti-hypertensive agent
Surgery

Question 6

What does HTN and hypokalemia suggest?

Answer 6

Primary hyperaldosteronism

Question 7

What should be done in all patients with primary aldosteronism?

Answer 7

Adrenal scan

Question 8

What can be used to diagnose primary aldosteronism? What value is indicative?

Answer 8

PAC/PRA (PRC) - plasma aldosterone:plasma renin
Ratio >20
PAC >15ng/dL

Question 9

What two things will interfere with a PAC/PRA test? How do you overcome this?

Answer 9

Mineralocorticoid receptor antagonists - hold spiralactone and diuretics 6-weeks before
ACEI and ARB increase PRC - hold for 2 weeks

Question 10

What 2 things must be normalized in someone with primary aldosteronism? Surgery? If not surgery?

Answer 10

Normalize K and BP
Yes, consider surgery
If not surgical candidate or bilateral dz - spironolactone

Question 11

What is used to diagnose OSA? What is the treatment?

Answer 11

Sleep study - polysomnogram

CPAP machine - treatment

Question 12

What are 3 uncommon causes of secondary hypertension?

Answer 12

Pheochromocytoma
Cushing’s Syndrome
Coarctation of the aorta

Question 13

What is the classic triad of symptoms for pheochromocytoma?

Answer 13

Headache
Sweating
Tachycardia

Question 14

What is found in the plasma or urine to diagnose pheochromocytoma?

Answer 14

Free metanephrines (or unfractionated in urine)

Question 15

What is metanephrines metabolized to?

Answer 15

Vanillylmandelic acid (VMA)

Question 16

What is the treatment of choice for pheochromocytoma?

Answer 16

Surgery

Question 17

What two things must be treated prior to surgery for a phrochromocytoma?

Answer 17

HTN and volume contraction

Question 18

What must be given first in hyperstensive treatment in someone with a pheochromocytoma? 2nd?

Answer 18

Alpha-blockade first - for 2 weeks

Beta blockage after - to treat tachy

Question 19

What are symptoms suggestive of Cushing’s syndrome?

Answer 19

Moon faces
Glucose intolerance
Abdominal striae
Hirsutism - unwanted male hair
Central obesity/weight gain

Question 20

What three tests can be used to check for Cushing’s Syndrome? Which one is done most?

Answer 20

Late-night salivary cortisol test - positive if cortisol presence (not suppressed at night like normal)
24hr urinary free cortisol - postive if 3x normal
Low-dose dexamethasone suppression test - 1mg given at 11pm should suppress cortisol - positive if cortisol present in morning

Question 21

What is a normal cortisol level at 8am?

Answer 21

<2mcg/dL

Question 22

What is the treatment for Cushing’s syndrome?

Answer 22

Normalize hypothalmic-pituitary-adrenal function

FInd and remove ACTH tumor

Question 23

What is the second major cause of HTN in young children?

Answer 23

Coarctation of the aorta

Question 24

What 4 drugs can cause coarctation of the aorta?

Answer 24

Birth control pills
NSAIDs
Decongestants
Nicotine