Hypertension

Yongen Chang, MD, PhD Division of Nephrology and Hypertension Department of Medicine UCI August 2016

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Diagnosis of HTN and pre-HTN Evaluation Workup (end orgen damage, secondary workup, when to refer) Secondary HTN Bp goal Therapy (pharmacological, life style, OSA, correct secondary causes) Cases

Diagnosis of HTN and pre-HTN n 

7th Joint National Committee (JNC 7) JNC 7 Category

SBP/DBP (mmHg)

Normal

140/90

-- Stage 1 -- Stage 2

140-159/90-99 >160/100

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JNC 8 did not change the definition but threshold for treatment defined.

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Average of at least 2 readings per visit, obtained at 3 separate visits each 2 to 4 weeks apart Annals of Internal Medicine 2008

White Coat HTN n  n  n 

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Increase in Bp primarily in the medical care environment 20-35% of patients diagnosed with HTN Home Bp and/or ambulatory Bp monitoring to differentiate from “true” HTN Pharmacological treatment is not recommended Recommend life style modification and regular follow up

Ambulatory Blood Pressure Monitoring n  n 

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A 24hr portable device that patient wears during regular activites. Measures Bp every 15-20 min during the day and every 30-60min during the night. Provides the most accurate assessment of Bp MediCare and MediCaid pays for only one indication: u  White coat HTN Other potential indications: u  Detect variabilities in Bp u  Nocturnal HTN u  Evaluate efficacy of drug effect over 24hrs u  Diagnosis and treatment of HTN during pregnancy

Initial Evaluation - History n  n  n  n  n 

Cardiac history, DM, CKD, sleap apnea Family history Smoking, diet, life style Onset Review of medications including over the counter: NSAIDS, migraine medications (caffeine), OCP, steroids.

Initial Evaluation - Exam n 

Look for signs of secondary HTN and end organ damage

Annals of Internal Medicine 2008

Initial Evaluation Signs of secondary HTN u  u  u  u  u  u  u  u  u 

Early onset HTN at young age (55 years old New difficulties in controlling Bp HTN requiring 3 or more medications Spontaneous hypokalemia Severe vascular disease (coronary, carotid, peripheral vessels) Abdominal bruit Radial femoral pulse delay à coarctation of the aorta Weight loss à pheochromocytoma or thyroid diseases

Annals of Internal Medicine 2008

Workup End organ damage and Comorbidities

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Renal panel, urine studies Serum glucose Lipid panel Hb and Hct EKG +/- echocardiogram

Initial Workup for Secondary HTN u  •  •  •  •  •  u  o  o  u  o  o  u  o  o 

Endocrine disorders: Hyperthyroidism Cushing syndrome Primary Hyperaldosteronism/Renin secreting tumors Pheochromocytoma TSH, Cortisol, Aldosterone/Renin ratio, Plasma/Urine catecholamines Renal artery stenosis: Doppler renal US, Renal US, Captopril renography MRA, angiogram Renal parenchymal disorders: Commonly seen in CKD patients Serum Cr, Renal US, urine studies Others: Liddle syndrome, SAME etc. Associated electrolyte disorders

Primary Hyperaldosteronism u  u  u  u 

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Plasma aldosterone/renin ratio > 20 AND Plasma aldosteron >15 ng/dL Stop aldosterone antagonists and amiloride 6 weeks before testing ACEI, ARB and diuretics can falsely elevated renin level thus decreasing aldosterone/renin ratio. Confirmatory tests: salt loading test Imaging: CT or MRI with contrast High rate of nonfunctioning adenomas (4% of general population on CT) 30 ng/dL, adenoma > 1cm and hypodense ( 1cm and hypodense (40 years with adrenal adenoma OR Patients with no adrenal adenoma found on imaging à adrenal vein sampling first

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Adrenal Vein Sampling u  u 

Cortisol and aldosterone Adrenal veins and IVC

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LI= (Aldosterone/cortisoladrenal vein)/(aldosterone/ cortisolcontralateral adrenal vein)

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LI >4 indicates lateralization LI