SECONDARY HYPERTENSION.pptxcivil service nepal

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1. SECONDARY HYPERTENSION Dr Rifat Siddiqui FCPS Resident Internal Medicine

2. The American Heart Association has recommended guidelines to define normal and high blood pressure [ 5 ]  : Normal: Systolic lower than 120 mm Hg, diastolic lower than 80 mm Hg Elevated BP : Systolic 120-129 mm Hg, diastolic lower than 80 mm Hg Hypertension Stage 1 : Systolic 130-139 mm Hg, diastolic 80-89 mm Hg Hypertension Stage 2 : Systolic 140 mm Hg or greater, diastolic 9 0 mm Hg or greater

3. Who are at risk? Advancing Age Sex (men and postmenopausal women) Family history of cardiovascular disease Sedentary life style & psycho-social stress Smoking ,High cholesterol diet, Low fruit consumption,high salt inake Obesity & wt. gain Co-existing disorders such as diabetes, and hyperlipidaemia High intake of alcohol

4. CLINICAL MENIFESTATIONS:

5. TYPES OF HYPERTENSION: Essential hypertension 90% No underlying cause Secondary hypertension (10%) Underlying cause

6. When to suspect secondary hypertension clinicallly ? Absence of family history of hypertension • Severe hypertension > 180/110 mm Hg with onset at age < 20 years, or > 50 years • Difficult-to-treat or resistant hypertension with significant end-organ, damage features • Presents with combination of pain (headache), palpitation, pallor, and perspiration - 4 P's of phaeochromocytoma Persons with Short and thick neck - Obstructive Sleep Apnoea Polyuria, nocturia, proteinuria or hematuria - indicative of renal diseases

7. Contd.. •Absence of peripheral pulses, brachiofemoral delay and abdominal or peripheral vessel bruits • History of polycystic renal disease or palpable enlarged, kidneys Cushingoid features, multiple neurofibromatosis Significant elevation of plasma creatinine with use of, ACE inhibitors • Hypertension in children • History of snoring, daytime somnolence, obesity

8. Blood Pressure Determinants : Cardiac output: Increased with renal salt/water retention • Total peripheral resistance : Key vessels: arterioles Increased by vasoconstrictors (i.e. catecholamines) Increased by sympathetic nervous system, BP = CO X TPR

9. Causes of secondary hypertension : RENAL DISEASE: Renal parenchymal disease: Polycystic disease Chronic nephritis Glomerulonephritis Diabetic nephropathy Hydronephrosis • Reno-vascular disease Renin producing tumor Primary sodium retention

10. VASCULAR CAUSE : Coarctation of aorta N eurological : Increased intracranial pressure Porphyria Familial dysautonomia (Riley Day) Lead poisoning Guillain-Barre syndrome

11. ENDOCRINE : Hypothyroidism Hyperthyroidism Adrenal: Cushing's syndrome Congenital adrenal hyperplasia Primary aldosteronism Pheochromocvtoma Hypercalcemia Carcinoid Extra-adrenal Exogenous hormones: Estrogen Mineralocorticoids Sympathomimetics Tyramine + MAO inhibitors

12. DRUGS/TOXINS PREGNANCY STRESS: Postoperative Burn Pain Hypoglycemia Alcohol withdrawal

13. There are two forms of kidney diseases causing hypertension a) Renal parenchymal & b) Renovascular causes Renal parenchymal diseases : Chronic glomerulonephritis Chronic interstitial nephritis Pyelonephritis Nephrocalcinosis Neoplasms Glomerulosclerosis Analgesic nephropathy Polycystic kidney disease Obstructive nephropathy

14. RENOVASCULAR HYPERTENSION Etiology: Atherosclerosis Takayasu's arteritis Fibromuscular dysplasia Other causes: Aortic/renal dissection Thrombotic/cholesterol emboli Post transplantation stenosis Post radiation

15. Renal Artery Stenosis: • Vascular disease of renal arteries • Decreased blood flow to kidneys • Key exam finding: renal bruit

16. Renal artery stenosis contd.. Increased renin, salt-water retention =HTN Often unilateral stenosis Normal kidney compensates Results: No signs of volume overload

17. ADPKD Autosomal dominant polycystic kidney disease • Genetic disorder • Mutations of PKD1 or PKD2 • Presents in adulthood with HTN and renal cysts • Increased RAAS activity

18. Fibromuscular Dysplasia : Vascular disease - obstruction to flow, • Common among women, • Often occurs in 40s-50s, • Non-atherosclerotic, non-inflammatory, • Often involves medial layer fibroplasia, • Stenosis and aneurysms of vessels ("string of beads"), • Most common in renal and carotid arteries, • Can lead to renal artery stenosis

19. Coarctation of aorta : consists of localized narrowing of the aortic arch, just distal to the origin of the left subclavian artery. Congenital defect, male>female Clinical presentation: •Differential systolic BP in arms and legs •May have differential BP in arms if defect is proximal to Left, subclavian artery •Diminished/absent femoral artery pulse •Often asymptomatic •Associated with Turners syndrome, bicuspid Aortiv valve

20. Primary Aldosteronism : Excessive levels of aldosterone secretion, Not due to increased activity of RAAS system, Adrenal adenoma (Conn's syndrome), Bilateral idiopathic adrenal hyperplasia Increased Na reabsorption distal nephron Incr ECV -> incr CO – Hypertension Increased K excretion -> hypokalemia

21. Primary Aldosteronism contd.. Clinical features, Resistant hypertension Hypokalemia Normal volume status on physical exam, Diagnosis Renin-independent aldosterone secretion Low plasma renin activity High aldosterone levels Drugs of choice: Spironolactone/Eplerenone Aldosterone antagonists

22. Liddle Syndrome : • Genetic disorder, •Increased activity of ENaC • Similar clinical syndrome to hyperaldosteronism: Hypertension Hypokalemia, • Aldosterone levels low

23. Pheochromocytoma •Catecholamine-secreting tumor • Epinephrine, norepinephrine, dopamine • Usually arises from adrenal gland and unilateral • Triad: Palpitations, headache, episodic sweating • Most patient have hypertension • Diagnosis: Catecholamines breakdown products, • Metanephrines • Vanillylmandelicacid (VMA)

24. Cushing's Syndrome : • Excess cortisol • Often from steroid administration • Other causes, •Cushing's Disease (pituitary oversecretes ACTH) Tumors (i.e. small cell lung cancer secretes ACTH) • Adrenal tumor secretes cortisol, • Cortisol -> hypertension Increased vascular sensitivity to adrenergic agonists

25. Obstructive Sleep Apnea: • Sleep-related breathing disorder • Apnea during sleep Polysomnography is diagnostic • Often associated with hypertension • Treatment may reduce BP Use of c-pap improves hypertension.

26. DRUGS CAUSING HYPERTENSION : NSAIDs Estrogens Wt loss agents: sibutramine,phentermine Immunosuppressants: cyclosporine, tacrolimus,steroids Antiparkinsonian: bromocriptine MAOinhibitors : phenelazine Anabolic steroids: testosterone Stimulants: nicotine, amphetamines Sympathomimetics

27. NSAIDs: Ibuprofen, naproxen, indomethacin, ketorolac, diclofenac Nonsteroidal anti-inflammatory drugs, Inhibit cyclooxygenase in kidneys, Decrease synthesis of prostaglandins, PGE-2: renal vasodilator

28. ORAL CONTRACEPTIVE PILLS: Estrogen & progesterone analogs Cause mild increase in blood pressure

29. Pseudoephedrine : Nasal decongestant Alpha-1 agonist vasoconstriction– decrease nasal blood flow

30. Evaluating secondary causes of hypertension : Causes Diagnostic evaluation OSA Sleep study Hyperaldosteronism Plasma aldosterone level Renovascular(renal artery stenosis or FMD) Renal artery duplex doppler ultrasound, CT or MRA Primary kidney disease or nephrotic syndrome Renal USG, lab tests to discern underlying cause Hyperthyroidism TFT Cushing syndrome Dexamethasone suppression test, 24h urine free cortisol Pheochromocytoma 24h urine metanephrines , abdominal cross-sectional imaging Coarction of aorta Echocardiography, CT or MRA

31. Management of secondary hypertension: Withdraw/replace BP-raising medications Management of endocrine causes typically requires specialist involvement Consider revascularization for renovascular hypertension Anti-hypertensive therapy will frequently be required

32. OTHER TYPES OF HYPERTENSION : WHITE COAT HYPERTENSION: High blood pressure readings are found when measured by the physician, but not when the patient measures at home. Evidence of anxiety-induced, sympathetic phenomena such as tachycardia, perspiration, cold, hands, tremor, and/or pupil dilation will usually be present

33. Isolated systolic hypertension : It's not uncommon to have either a systolic, number that's elevate while the diastolic, number remains normal. It's less common for patients to have, elevated diastolic number. This condition, known as isolated systolic hypertension.

34. Persistent Hypertension Characterized by a diastolic blood, pressure above 110 to 120 mm Hg. It results when hypertension is, unresponsive to treatment and become a, truly severe emergency condition as the, pressure continues to rise unchecked.

35. Malignant Hypertension : Severe elevation of bp (diastolic greater thn 120) Rare form ,often fatal Rapidly progressive over 1 to 2 years Renal failure, retinal haemorrhages , ischaemia

36. Resistant hypertension: Blood pressure that remains above goal inspite of the concurrent use of three antihypertensive agents of different classes including a diuretic. All agents should prescribed at optimal dose amounts.

37. Refractory hypertension : Refractory hypertension ( RfHTN ) is defined as  blood pressure (BP) that is uncontrolled despite using ≥ 5 antihypertensive medications of different classes , including a long-acting thiazide diuretic and a mineralocorticoid receptor antagonist.

38. Hypertensive urgency: Severe hypertension without end organ damage. Usually greater than 180/120

39. Hypertensive Emergency : Severe hypertension with end organ damage. BP usually >180/120 Patient longstanding HTN, stops meds Neurologic impairment Retinal hemorrhages, encephalopathy Renal impairment Acute renal failure, Hematuria, proteinuria, Cardiac ischemia A ssociated with MAHA E ndothelial injury-thrombus formation

40. Control of hypertension: Non pharmacological measures: Weight reduction Dietary sodium reduction Vegetarian and vegan diet The DASH diet Reduction of alcohol consumption Smoking cessation Exercise

41. Control of HTN contd.. Pharmacological measures: Beta blockers Thiazides Calcium blockers Dihydropyridines Non-dihydropyridines ACEi /ARB

42. • Discontinue offending medications if possible • Renal artery stenosis: management may include antihypertensives and/or angioplasty and stenting • FMD :therapy with ACE inhibitor or ARB, angioplasty may be necessary • Hyperaldosteronism: Spironolactone, ACE inhibitor and/or ARB; surgery may be, curative in cases of adrenal adenoma

43. • Liddle syndrome: Low sodium diet and triamterene or amiloride • Gordon syndrome :Low sodium diet and thiazide diuretics • Phaeochromocytoma : Adrenalectomy and combined alpha/beta blockers • Obstructive sleep apnea : weight loss and CAP while sleeping • Aortic coarctation: may require surgery • Renal parenchymal disease : Treatment depends on the type of disease ACE inhibitors and/or ARBs are usually recommended for BP control and renoprotection

44. REFERENCES: MANUAL OF HYPERTENSION of the European Society of Hypertension UpToDate Harrison’s principles of internal medicine