Abdulkareem Alsuwaida, FRCPC, MSc Associate Professor King Saud University
Case A 65-year-old women is referred for further
evaluation of her BP. Type 2 diabetes for 5 years and high BP for 12 years. Her somatic complaints include fatigue and dry mouth. She has no known history of hypertension targetorgan damage, and her medications are: HCTZ 25 OD – Valsartan 160mg OD _Diltiazem LA
300mg OD_Clonidine 0.2 mg BID_Metaprolol 100 mg OD_Metformin 1000 mg BID_Simvastatin 20 mg OD
Case She has no remarkable family history other than
hypertension in both parents. Examination
Normal heart sounds and no peripheral edema Mild arteriolar narrowing in the fundus. Seated BP was 156/90 mmHg and 158/90 mmHg in the
right arm (similar to the left arm), with a regular heart rate of 70 beats/min. No change onstanding Urinalysis normal
What would you do next?
?
Start aldactone 25 mg once daily 2. Order ABPM 3. Send Renin and Aldosterone levels 4. Renal angioram is mandatory to role out renal artery stenosis 1.
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What would you do next? 1.
Start aldactone 25mg once daily
2. Order ABPM 3. Send Renin and Aldosterone levels 4. Renal angioram is manadatory to role out renal
artery stenosis
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First step is to confirm true resistance Use of the correct BP measurement technique Exclude apparent resistance: White coat hypertension Treatment adherence.
Resistant Hypertension • Blood pressure remaining above goal in spite of concurrent use of 3 antihypertensive agents of different classes. • Ideally, 1 of the 3 agents should be a diuretic & all agents should be prescribed at optimal dose amounts.
Case Study (cont…) Detailed reports of home BP readings confirmed that
out-of-the-office BPs were above 150 mmHg systolic, indicating true resistance Fatigue and dry mouth were attributed to the Alpha receptor-blocker and the alpha2-agonist, supporting the adherence she claimed to her BP regimen.
Case Study : Decision Point
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Because the patient has resistant HTN. What would you do to get this patient to the target BP?
1. Evaluate the life style factors and exclude interfering substances 2. Switch from an ARB to an ACE inhibitor 3. Proceed to renal angiogram 4. Renal denervation
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Case Study : Decision Point
?
Because the patient has resistant HTN. What would you do to get this patient to the target BP? 1. Evaluate the life style factors and exclude interfering substances 2. Switch from an ARB to an ACE inhibitor 3. Proceed to renal angiogram 4. Renal denervation
Step 2. Examine Life Style Factors Life Style Obesity High salt intake Heavy alcohol ingestion
Interfering Substances NSAID , cocaine, amphetamines, other illicit drugs Oral contraceptive hormones Ciclosporin, tacrolimus Erythropoietin Corticosteroids Liquorice
Step 2. Examine Life Style Factors Our patient was well aware of sodium content (she
carefully read labels). She is 178 cm tall and weighed 94.5 kg (BMI 30.1 kg/m2. She had lost 10 kg without significant BP benefit and took medications faithfully. No alcohol ingestion.
The most appropriate next steps include all of the following Except: CT of adrenal gland 2. Sleep study 3. Plasma Renin/Aldosterone ratio 4. CT angiogram or MRA of renal arteries 1.
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The most appropriate next steps include all of the following Except: 1. CT of adrenal gland 2. Sleep study 3. Plasma Renin/Aldosterone ratio 4. CT angiogram or MRA of renal arteries
Secondary Causes of Resistant Hypertension Common • Obstructive sleep apnea • Renal parenchymal disease • Primary aldosteronism • Renal artery stenosis
Secondary Causes of Resistant Hypertension Uncommon Pheochromocytoma Cushing’s disease
Hyperparathyroidism
Aortic coarctation
Intracranial tumor
Primary Aldosteronism ď‚— Primary aldosteronism is common in patients
with resistant HTN with a prevalence of 20%-30%. ď‚— Serum potassium levels is commonly normal in patients confirmed to have 1ry aldosteronism, suggesting that hypokalemia is a late manifestation
Calhoun et al, Hypertension 2008
Our patient No renal bruits noted on examination. Plasma metanephrine assay, where values were in the
normal range Computed tomography angiogram of the abdominal vessels was negative (both for renal vascular disease Sleep study was normal Plasma renin activity 0.10 ng/ml per h (normal 1.5 to 3.5 ng/ml per h) Aldosterone: 8 ng/dl (normal 3 to 15 ng/dl).
What is the most appropriate next step in the management of this patient?
?
Renal denervation 2. Add mineralocorticoid receptor antagonist. 3. Rheos® System (CVRx) for baroreceptor stimulation 4. Add combination of ACE/ARB 1.
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What is the most appropriate next step in the management of this patient?
?
Renal denervation 2. Add mineralocorticoid receptor antagonist. 3. Rheos速 System (CVRx) for baroreceptor stimulation 4. Add combination of ACE/ARB 1.
Why Aldosterone Blockade ? ď‚— The reason for this drug choice is: ď‚— Low renin activity in the patient despite administration of several drugs that typically increase renin. This suggests a sodium surfeit and the possibility that more aggressive diuresis could be of benefit ď‚— The addition of spironolactone as a fourth-line agent in the ASCOT trial resulted in a substantial improvement in systolic BP (and the choice was an empiric one, not based on hormonal data)
Case Study (cont…) BP reached target Clonidine and metaprolol DC Slight increase in creatinine (from 1.3 mg/dl up to 1.5
mg/dl) but no change in potassium values.
Take Home Messages Resistant hypertension affects 10% of the hypertensive
patient population. Exclude white-coat HTN and pseudo-resistant HTN. Non-compliance to anti-hypertensive therapy remains the most common cause of resistant HTN Primary hyperaldosteronism is not as uncommon Normal potassium in resistant hypertension do not exclude the possible presence of hyperaldosteronism Low-renin resistant HTN responds to aldosterone blockade when other drugs are apparently inadequately effective
Thanks