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Hypertension Flashcards

1
Q

Who should you screen for renovascular HTN and how?

A
  1. 2 or more of:
    1. Sudden/worsening HTN and age <30 or >55
    2. Abdominal bruit
    3. Resistant HTN >= 3 meds
    4. Cr >=30% with ACE/ARB
    5. Recurrent pulm edema with HTN surges
    6. Other atherosclerotic vascular disease (esp if smoker or dyslipidemia)
  2. Screening tests:
    1. Captopril-enhanced radioisotope renal scan (eGFR >60)
      1. avoid: low sens/spec in low risk patients or bilateral disease
    2. Doppler US
    3. CT angio
    4. MR angio (eGFR >30)
    5. Conventional renal arteriography…
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2
Q

Management of RAS

A
  • Tx:
    • Optimal conservative/medical therapy
      • Salt restriction, exercise, weight loss
      • Increase HTN meds
      • Vascular RF management (statin, ASA)
    • Angioplasty and stenting only if:
      • Uncontrolled HTN on maximal meds
      • Progressive renal decline
      • Acute pulmonary edema
    • Angioplasty without stenting for FMD-related RAS
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3
Q

Who should be investigated for FMD-RAS

A
  1. At least 1 of:
    1. >1.5 cm unexplained asymmetry in kidney size
    2. Abdo bruit
    3. FMD in another territory
    4. Family hx
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4
Q

How can you screen for FMD-RAS?

A

MRA or CTA

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5
Q

How do you treat FMD-related RAS?

A
  1. Conservative lifestyle measures (low Na diet, etc.)
  2. Antihypertensives (multifocal disease respond well, focal do not).
  3. Revascularization (Renal artery angioplasty without stenting. Consider surgical revascularization if complex lesions) if any of:
    1. Recent onset of HTN (esp if younger)
    2. Resistant HTN >=3 meds
    3. Bilat or unilat FMD to solitary kidney with progressive renal decline
    4. Hypertensive children
  4. ASA
  5. +/- statin if another indication (not just for renal FMD)
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6
Q

Who should get surgical revascularization (vs. IR) for RAS?

A
  • Complex lesions less amenable to plasty/stenting
  • Complex aneurysm
  • Re-stenosis despite 2 unsuccessful attempts of plasty
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7
Q

What are complications of angioplasty?

A
  • Puncture site hematoma
  • Renal artery dissection
  • Renal artery thrombosis
  • Renal artery perforation
  • AKI due to atheroembolic disease
  • Re-stenosis
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8
Q

What did the ASTRAL and CORAL trials show?

Limitations?

A

No benefit with of angioplasty over medical therapy.

Selectino bias (patients who physicianss felt should get plastied were not enrolled)

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9
Q

Causes of HTN, other than secondary causes of HTN

A
  • Primary/Essential
  • White Coat
  • Masked
  • Measurement error (cuff size etc)
  • Pain/Nausea
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10
Q

What is type 1 hyperaldosteronism and its clinical features?

A
  • Type I FH / Glucocorticoid-remediable aldosteronism (GRA)
    • Autosomal dominant. Mutation in CYP11B1/CYP11B2 resulting in aldosterone synthetase becoming responsive to ACTH, zona fasciculata then secretes aldosterone inappropriately.
    • Clinical features:
      • Suspect if +FHx and HTN before age 21.
      • Potassium usually normal in50% (compared to hypoK in adrenal adenomas).
      • Early cerebrovascular complications (hemorhagic strokes/ruptured intracranial aneurysms)
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11
Q

Diagnosis of type 1 familial hyperaldosteronism?

A
  • Diagnosis:
    • High plasma aldosterone, low plasma renin (but aldo-renin ratio not typically as high as aldosterone-producing adenomas)
    • High 18-oxocortisol and 18-hydroxycortisol
    • Genetic testing
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12
Q

Treatment of type 1 familial hyperaldosteronism?

How to differentiate with type 2?

A
  • Steroids
  • Type 2 is NOT suppressible by steroids
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13
Q

What factors increase the likelihood of renal artery stenosis?

A
  • Sudden onset or worsening HTN and age >55 or <30
  • Systolic-diastolic abdominal bruit
  • HTN resistance to >= 3 drugs
  • Cr increase >= 30% with ACE/ARB
  • Recurrent pulmonary edema with HTN surges
  • Asymmetric kidneys
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14
Q

3 things you look at on ambulatory blood pressure monitoring report

A
  • Average Daytime BP – 135/85 cutoff
  • Nocturnal Dip – BP should fall by > 10% (<10% incr risk of CV events)
  • Average 24 hr BP – 130/80 cutoff
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15
Q

Hypertensive pt with PRA 83ng/mU after saline loading. What are 2 associated electrolyte abnormalities and 2 tests for further evaluation?

A
  • High plasma renin activity
  • Hypokalemia and metabolic alkalosis
  • US doppler (RAS), CT adrenals, TTE (coarct aorta)
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16
Q

Metabolic changes expected sith Conn’s syndrome

A
  1. Hypertension
  2. Hypokalemia
  3. Metabolic syndrome
  4. T2DM
  5. Increased cardiovascular risk
17
Q

NON-pharmacolgic factors that affect PRA/PAC for hyperaldo testing

A
  • HypoK – suppresses aldosterone
  • Severe HTN
  • Salt restriction – stimulates renin
  • Volume depletion – stimulates renin
  • Time of day (renin highest in the morning)
  • Posture – if upright, blood goes to legs and sensed by JGA so renin increased
18
Q

What is Liddle’s syndrome and manifestations

A

Autosomal dominant, mutation of ENaC -> increased activity

HTN, hypokalemia, metabolic alkalosis, present at young age

Low renin activity

19
Q

Treatment for Liddle’s syndrome

A

Amiloride or triampterene

(MRA is not effective b/c not aldosterone-mediated)

20
Q

Young patient, HTN, hypokalemia, metabolic alkalosis - DDx?

A
  • Hyperaldosteronism
    • Primary (high aldo, low renin)
      • Adrenal adenoma
      • Adrenal hyperplasia
      • Adrenal carcinoma
      • Familial hyperaldosteronism
    • Secondary (high renin or high ACTH)
      • Renovascular disease
        • RAS, FMD, coarctation
      • Renin-secreting tumors
      • ACTH-tumor eg. pituitary, Cushin’gs
    • NON-Aldosterone mineralocoritcoid excess (low renin, low aldo)
      • Congenital adrenal hyperplasia
      • Syndrome of apparent mineralocorticoid excess
      • Chronic licorice ingestion
      • Liddle’s syndrome
      • Deoxycorticostereone-producing adrenal tumor
21
Q

Treatment of pheochromocytoma?

A

Surgical resection

Combined alpha and beta blockade pre-operatively

Alpha blockade with phenoxybenzamine first, then start beta blockade slowly

22
Q

Pre-op management for pheochromocytoma

A
  1. Start alpha-blocker phenyoxybenzamine ~2wks preop first
  2. High Na diet to counteract catecholamine-induced volume expansion and orthostasis with alpha blocker
  3. Start short-acting beta-blocker propranolol and titrate to long-acting, at least 2-3 days pre-op
23
Q

BP targets

  • CKD diabetic or non-diabetic
  • Transplant recipient
  • IgA
  • ADPKD
A

CKD diabetic or non-diabetic - SBP <120 (SPRINT, KDIGO 2021) *note SPRINT did not include GFR <20

  • Tx <130/80 (KDIGO 2021)
  • IgA <125/75 (STOP IgA)
  • ADPKD <110/70
24
Q

SPRINT trial inclusinon and exclusion crtieria

A
  • Inclusion criteria:
    • Age ≥50
    • BP ≥130
    • At least 1 CV risk factor:
      • Presence of clinical or subclinical CVD other than stroke
      • CKD (eGFR 20-59)
      • A Framingham Risk Score for 10-year cardiovascular disease risk ≥15%
      • Age >75
  • Exclusion:
    • Secondary HTN
    • One-minute standing SBP <110 mm Hg
    • Proteinuria >1g/d
    • DM
    • History of stroke
    • Polycystic kidney disease
    • Glomerulonephritis
    • eGFR <20 ml/min/1.73 m2 or ESKD
    • Cardiovascular event or procedure or hospitalization for unstable angina within last 3 months
    • HF past 6 months or LVEF <35%
    • A medical condition likely to limit survival to <3 years or a malignancy other than nonmelanoma skin cancer within the last 2 years
    • Organ transplant
25
Q

What causes of hypertension would you recommend a low Na diet?

A

Essential HTN

Renovascular HTN

Endocrine/hyperaldosteronism

26
Q

Primary prevention strategies for HTN

A
  1. Exercise - 30-60 min moderate intensity 4-7x/week
  2. Weight reduction - BMI 18.5-24.9, waist circumoference <102 cm males, <88 cm females
  3. Alcohol - abstain or <2 drinks/day
  4. Diet - high fruits/veg/low-fat dairy/whole-grain foods rich in fibre, plant protein
  5. Sodium - <2000 mg/day
  6. Higher K intake if not at risk for hyperkalemia
  7. Stress mangement

CHEP 2020 guidelines

N (8 decks)

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