DOCSLIB.ORG

Hypertension Management in Cardio-Oncology

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Hypertension Management in Cardio-Oncology Journal of Human Hypertension (2020) 34:673–681 https://doi.org/10.1038/s41371-020-0391-8 REVIEW ARTICLE Hypertension management in cardio-oncology 1 1 1 1,2 Hani Essa ● Rebecca Dobson ● David Wright ● Gregory Y. H. Lip Received: 16 June 2020 / Revised: 8 July 2020 / Accepted: 24 July 2020 / Published online: 3 August 2020 © The Author(s), under exclusive licence to Springer Nature Limited 2020 Abstract Cancer is one of the leading causes of death worldwide. During the last few decades prognosis has improved dramatically and patients are living longer and suffering long-term cardiovascular consequences of chemotherapeutic agents. Cardiovascular disease is a leading cause of morbidity and mortality in cancer survivors second only to recurrent cancer. In some types of cancer, cardiovascular disease is a more common cause of death than the cancer itself. This has led to a new sub-specialty of cardiology coined cardio-oncology to manage this specific population. Hypertension is one of the most common cardiovascular disease seen in this cohort. The aetiology of hypertension in cardio-oncology is complex and multifactorial based on the type of chemotherapy, type of malignancy and intrinsic patient factors such as age and pre- existing comorbidities. A variety of different oncological treatments have been implicated in causing hypertension. The effect can be transient whilst undergoing treatment or can be delayed occurring decades after treatment. A tailored 1234567890();,: 1234567890();,: management plan is recommended given the plethora of agents and their differing underlying mechanisms and speed of this mechanism in causing hypertension. Management by a multidisciplinary team consisting of oncology, general practice and cardiology is advised. There are currently no trials comparing antihypertensives in this specific cohort of patients. In the absence of evidence demonstrating otherwise, hypertension in cardio-oncology should be managed utilising the same treatment guidelines for the general population. Introduction overall lifetime risk of nearly 40% of developing cancer in the US. Cancer is one of the leading causes of death worldwide. In Cardio-oncology is a relatively new clinical field focus- the United States (US) cancer is the second most common ing on the diagnosis, prevention and treatment of the car- cause of death with an estimated toll of 606,520 in 2020. diovascular consequences of cancer and its treatment. Advances in oncological treatment have led to improved Approximately 75% of cancer survivors have chronic health survival of patients with a year on year decline in mor- problems [2]. CVD is the leading cause of morbidity and tality between 1991 and 2017 in the US [1]. The increase mortality in this population second only to recurrent in cancer survivors has been accompanied by increasing malignancy [2]. The risk of CVD in cancer survivors is cardiovascular disease (CVD) morbidity and mortality 800% higher than that of the general population [2]. The due to downstream side effects of treatment and an relative risk of coronary artery disease and heart failure is increasing age of patients due to improved survival. The over 1000% more in cancer survivors as compared with overall societal burden of CVD in oncology is likely to their cancer free sibling [2]. Cancer treatments in general increase with an increasing aging population and an share various detrimental effects in common, especially upregulation of cardiovascular risk factors [3]. This can lead to both short- and long-term cardiovascular complications. The increasing recognition of this resulted in the building of the world’s first cardio-oncology unit in the MD Anderson * Gregory Y. H. Lip Center in the US in 2000. Following this, the international [email protected] cardio-oncology society was born in 2009 [4]. fi 1 Liverpool Centre for Cardiovascular Science, University of Although the eld of cardio-oncology has received Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK increasing attention in recent years, many aspects of both 2 Aalborg Thrombosis Research Unit, Department of Clinical radiation-induced and cancer drug-induced CVD are still to Medicine, Aalborg University, Aalborg, Denmark be fully elucidated. As the field advances, insights into 674 H. Essa et al. fi Cancer patients is therefore dif cult to estimate given the hetero- treatment geneity present. However, retrospective data in patients without a prior diagnosis of hypertension have demon- strated that around 33% of patients will develop hyperten- sion [8]. This is particularly more profound in patients treated with angiogenesis inhibitors, where rates of hyper- tension close to 70% have been reported with some thera- Cancer cell pies [9]. The overall lack of data in prevalence suggests widespread under-diagnosis and undertreatment [10]. Death Table 1 grades the severity of hypertension occurring secondary to anticancer therapies based on the latest Hypertension Heart failure version of US Common Terminology Criteria for Adverse Accelerated atherosclerosis Valvular heart disease Thromboembolic disease Cardiac arrhythmias Events [11]. This rating system categorises “any unfa- Pulmonary hypertension Coronary artery disease Pericardial disease vourable symptom, sign or disease associated with the use of a medical treatment or procedure that may or may Fig. 1 Cancer treatment and its stigmata on the cardiovascular system. not be considered related to or caused by the medical treatment or procedure”. This rating system is often uti- lised in analysis of hypertension secondary to oncology mechanisms of cardiovascular toxicities and hypertension treatment. have become more evident. There are currently ten main The focus of this article is to review the literature with CVD stigmata of cancer treatments, these are (Fig. 1): regards to the development and management of hyperten- sion in cardio-oncology. Specifically, the article will focus ● Left ventricular systolic dysfunction on hypertension as a consequence of cancer therapy rather ● Arterial hypertension than hypertension induced by cancer. ● Pulmonary hypertension ● Valvular disease ● Cardiac arrhythmias Aetiology of hypertension in relation to ● Thromboembolic disease oncology treatments ● Peripheral vascular disease ● Stroke Table 2 demonstrates biologically plausible pathways for ● Coronary artery disease various agents in causing hypertension. ● Pericardial disease Angiogenesis inhibitors Essential hypertension is a leading cause of morbidity and mortality worldwide. The relationship between blood Angiogenesis is an essential process in the natural course of pressure (BP) and CVD is continuous, but for the sake of cancer, as it mediates tumour growth and metastasis. pragmatism hypertension is defined by the European Angiogenesis inhibitors generally exert their effect via Society of Cardiology (ESC) as a BP ≥ 140/90 [5]. The inhibition of a component of the vascular endothelial overall prevalence of hypertension in adults is around growth factor (VEGF) signalling pathway via two main 30–45% and this increases with increasing age, with a mechanisms. The first directly inhibit VEGF ligand’s ability prevalence of >60% in people aged >60 years [6]. to bind to its target receptor and includes bevacizumab and Hypertension has been reported to be the most common ramucirumab. These medications are classified as VEGF comorbidity in cancer patients [7]. Hypertension is a well- inhibitors. The second class inhibit tyrosine kinases which recognised cause of CVD morbidity and mortality and is would be activated by the VEGF ligand–receptor interac- implicated in strokes, coronary heart disease, peripheral tions and includes agents such as sunitinib and sorafenib. arterial disease, heart failure and renal disease. These medications are classified as tyrosine kinase The relationship between hypertension and cancer is inhibitors (TKI). multifaceted. Risk factors for hypertension can be risk Angiogenesis inhibitors are a well-recognised cause of factors for specific tumours e.g. smoking and lung cancer. CVD including hypertension. All commercially available Improving cancer survival is leading to an older population angiogenesis inhibitors have been implicated in the devel- at more risk of developing hypertension. In cancer patients, opment of hypertension to varying degrees [12]. VEGF specific treatments and some cancers lead to the develop- signalling inhibitor-induced elevation in BP appears to be ment of hypertension. The prevalence of hypertension in not an adverse event of the therapy, but rather a mechanism- Hypertension management in cardio-oncology 675 Table 1 Classification of the Grade 1 2 3 4 5 severity of hypertension occurring secondary to Description Systolic BP Systolic BP Systolic BP ≥ 160 Life-threatening Death anticancer therapies in adults for 120–139 mm Hg 140–159 mm Hg or mm Hg or consequences (e.g. based on the latest version of US hypertension or diastolic BP diastolic BP 90–99 diastolic BP ≥ 100 malignant Common Terminology Criteria 80–89 mm Hg mm Hg if mm Hg; medical hypertension, for Adverse Events [11]. previously within intervention transient or normal limits; indicated; more permanent change in baseline than one drug or neurologic deficit, medical more intensive hypertensive crisis); intervention therapy than urgent intervention indicated; recurrent previously used indicated or persistent (≥24 indicated h); symptomatic increase by >20 mm Hg (diastolic) or to >140/90 mm Hg; monotherapy indicated initiated [14]. Table 3
Load more

Recommended publications
  • Hypertensive Emergency
    Presentation of hypertensive emergency Definitions surrounding hypertensive emergency Hypertension: elevated blood pressure (BP), usually defined as BP >140/90; pathological both in isolation and in association with other cardiovascular risk factors Severe hypertension: systolic BP (SBP) >200 mmHg and/or diastolic BP (DBP) >120 mmHg Hypertensive urgency: severe hypertension with no evidence of acute end organ damage Hypertensive emergency: severe hypertension with evidence of acute end organ damage Malignant/accelerated hypertension: a hypertensive emergency involving retinal vascular damage Causes of hypertensive emergency Usually inadequate treatment and/or poor compliance in known hypertension, the causes of which include: Essential hypertension o Age o Family history o Salt o Alcohol o Caffeine o Smoking o Obesity Secondary hypertension o Renal . Renal artery stenosis . Glomerulonephritis . Chonic pyelonephritis . Polycystic kidney disease o Endocrine . Cushing’s syndrome . Conn’s syndrome . Acromegaly . Hyperthyroidism . Phaeochromocytoma o Arterial . Coarctation of the aorta o Drugs . Alcohol . Cocaine . Amphetamines o Pregnancy . Pre-eclamplsia Pathophysiology of hypertensive emergency Abrupt rise in systemic vascular resistance Failure of normal autoregulatory mechanisms Fibrinoid necrosis of arterioles Damage to red blood cells from fibrin deposits causing microangiopathic haemolytic anaemia Microscopic haemorrhage Macroscopic haemorrhage Clinical features of hypertensive emergency Hypertensive encephalopathy o
    [Show full text]
  • Major Clinical Considerations for Secondary Hypertension And
    & Experim l e ca n i t in a l l C Journal of Clinical and Experimental C f a o r d l i a o Thevenard et al., J Clin Exp Cardiolog 2018, 9:11 n l o r g u y o Cardiology DOI: 10.4172/2155-9880.1000616 J ISSN: 2155-9880 Review Article Open Access Major Clinical Considerations for Secondary Hypertension and Treatment Challenges: Systematic Review Gabriela Thevenard1, Nathalia Bordin Dal-Prá1 and Idiberto José Zotarelli Filho2* 1Santa Casa de Misericordia Hospital, São Paulo, Brazil 2Department of scientific production, Street Ipiranga, São José do Rio Preto, São Paulo, Brazil *Corresponding author: Idiberto José Zotarelli Filho, Department of scientific production, Street Ipiranga, São José do Rio Preto, São Paulo, Brazil, Tel: +5517981666537; E-mail: [email protected] Received date: October 30, 2018; Accepted date: November 23, 2018; Published date: November 30, 2018 Copyright: ©2018 Thevenard G, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abstract Introduction: In this context, secondary arterial hypertension (SH) is defined as an increase in systemic arterial pressure (SAP) due to an identifiable cause. Only 5 to 10% of patients suffering from hypertension have a secondary form, while the vast majorities have essential hypertension. Objective: This study aimed to describe, through a systematic review, the main considerations on secondary hypertension, presenting its clinical data and main causes, as well as presenting the types of treatments according to the literary results.
    [Show full text]
  • How to Document and Code for Hypertensive Diseases in ICD-10 THIS INSTALLMENT in FPM’S ICD-10 SERIES EXPLAINS the GUIDELINES for CODING HYPERTENSION
    How to Document and Code for Hypertensive Diseases in ICD-10 THIS INSTALLMENT IN FPM’S ICD-10 SERIES EXPLAINS THE GUIDELINES FOR CODING HYPERTENSION. Kenneth D. Beckman, MD, MBA, CPE, CPC ecause ICD-10 can be a distressing topic, let’s start or kidney disease. That code is I10, Essential (primary) with some good news: Hypertension has a limited hypertension. number of ICD-10 codes – only nine codes for pri- As in ICD-9, this code includes “high blood pressure” mary hypertension and five codes for secondary but does not include elevated blood pressure without a B hypertension. This makes the task of coding hypertension diagnosis of hypertension (that would be ICD-10 code relatively simple – well, at least compared to some of the R03.0). If a patient has progressed from elevated blood other ICD-10 complexities. pressure to a formal diagnosis of hypertension, a good Another positive change in ICD-10 is that the new documentation practice would be to include the reason for code set drops the previous reference to benign and progressing the formal diagnosis. Similarly, a single mildly malignant hypertension. As physicians, we are well aware elevated blood pressure reading should be coded with the that hypertension is never truly “benign,” and the removal R03.0 until the formal diagnosis is established. of this antiquated term is a welcome improvement in the Although various sources define hypertension slightly lexicon of diseases. differently, the provider should document elevated systolic But, of course, nothing is easy in ICD-10, and there are pressure above 140 or diastolic pressure above 90 with at several things you need to be aware of before we dig into least two readings on separate office visits.
    [Show full text]
  • Chapter 13. Secondary Hypertension
    Hypertension Research (2014) 37, 349–361 & 2014 The Japanese Society of Hypertension All rights reserved 0916-9636/14 www.nature.com/hr GUIDELINES (JSH 2014) Chapter 13. Secondary hypertension Hypertension Research (2014) 37, 349–361; doi:10.1038/hr.2014.16 OVERVIEW AND SCREENING approximately 5–10% of hypertensive patients,984,985 and it is the most Hypertension related to a specific etiology is termed secondary frequent in endocrine hypertension. In addition, frequent etiological hypertension, markedly differing from essential hypertension, of factors for secondary hypertension include renal parenchymal hyper- which the etiology cannot be identified, in the condition and tension and renovascular hypertension. A study reported that sleep therapeutic strategies. Secondary hypertension is often resistant hyper- apnea syndrome was the most frequent factor for secondary hyper- tension, for which a target blood pressure is difficult to achieve by tension.517 The number of patients with secondary hypertension standard treatment. However, blood pressure can be effectively may further increase with the widespread diagnosis of sleep apnea reduced by identifying its etiology and treating the condition. There- syndrome. fore, it is important to suspect secondary hypertension and reach an Generally, the presence of severe or resistant hypertension, juvenile appropriate diagnosis. hypertension and the rapid onset of hypertension suggest the possi- Frequent etiological factors for secondary hypertension include bility of secondary hypertension. In such hypertensive patients, a close renal parenchymal hypertension, primary aldosteronism (PA), reno- inquiry on medical history, medical examination and adequate vascular hypertension and sleep apnea syndrome. Renal parenchymal examinations must be performed, considering the possibility of hypertension is caused by glomerular diseases, such as chronic secondary hypertension.
    [Show full text]
  • Hypertension) Happens When Your Blood Moves Through Your Arteries at a Higher Pressure Than Normal
    High Blood Pressure familydoctor.org/condition/high-blood-pressure What is high blood pressure? Blood pressure is the force of your blood as it flows through the arteries in your body. Arteries are blood vessels that carry blood from your heart to the rest of your body. When your heart beats, it pushes blood through your arteries. As the blood flows, it puts pressure on your artery walls. This is called blood pressure. High blood pressure (also called hypertension) happens when your blood moves through your arteries at a higher pressure than normal. Many different things can cause high blood pressure. If your blood pressure gets too high or stays high for a 1/5 long time, it can cause health problems. Uncontrolled high blood pressure puts you at a higher risk for stroke, heart disease, heart attack, and kidney failure. There are 2 types of high blood pressure. Primary hypertension. This is also called essential hypertension. It is called this when there is no known cause for your high blood pressure. This is the most common type of hypertension. This type of blood pressure usually takes many years to develop. It probably is a result of your lifestyle, environment, and how your body changes as you age. Secondary hypertension. This is when a health problem or medicine is causing your high blood pressure. Things that can cause secondary hypertension include: Kidney problems. Sleep apnea. Thyroid or adrenal gland problems. Some medicines. What are the symptoms of high blood pressure? Most people who have high blood pressure do not have symptoms.
    [Show full text]
  • Hypertension
    HYPERTENSION Hypertension - more commonly also known as high blood pressure, and often abbreviated as HTN - is a chronic medical condition that is caused by a persistent elevation of the pressure inside the circulatory system. Hypertension is one of the most common health problems in the world and in the United States. Approximately 30% or more of American adults have hypertension and unfortunately, many do not know they have the disease. Even worse are the facts that 1) Many people who have high blood pressure do know they have the disease but do not seek treatment - they ignore the disease, hoping it will go away; 2) Many people being treated for high blood pressure do not comply with the treatment plan, and; 3) Many people who know they have hypertension and are being treated do not have good control of their blood pressure. Learning Break: Hypertension is some times informally called the “disease of thirds.” These figures are not precise, but one-third of the people who have hypertension do not know they have the disease. One third-of those who have hypertension and are aware they have it do not seek treatment. And one-third of the people who have hypertension and are being treated do not comply well with the treatment plan. Hypertension is a very serious disease that has significant complications and consequences. There is no cure for most cases of hypertension, but with life style alterations and if need be, the proper medications, it can be controlled. Some cases of hypertension are due to kidney damage, hormonal disease, or other medical problems but in 95% of all cases of hypertension, the exact cause of the disease is not known.
    [Show full text]
  • An Approach to the Young Hypertensive Patient
    CME ARTICLE An approach to the young hypertensive patient P Mangena,1 MB ChB, FCP (SA); S Saban,2 MB ChB, MFamMed, FCFP (SA); K E Hlabyago,3 BSc (Education), MSc, MB ChB, MMed (Family Medicine); B Rayner,1 MB ChB, MMed, FCP (SA), PhD 1 Division of Nephrology and Hypertension, Faculty of Health Sciences, Groote Schuur Hospital and University of Cape Town, South Africa 2 Private Practice, and Division of Family Medicine, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa 3 Department of Family Medicine, Dr George Mukhari Academic Hospital and Sefako Makgatho Health Sciences University, Pretoria, South Africa Corresponding author: P Mangena ([email protected]) Hypertension is the leading cause of death worldwide. Globally and locally there has been an increase in hypertension in children, adolescents and young adults <40 years of age. In South Africa, the first decade of the millennium saw a doubling of the prevalence rate among adolescents and young adults aged 15 ­ 24 years. This increase suggests that an explosion of cerebrovascular disease, cardiovascular disease and chronic kidney disease can be expected in the forthcoming decades. A large part of the increased prevalence can be attributed to lifestyle factors such as diet and physical inactivity, which lead to overweight and obesity. The majority (>90%) of young patients will have essential or primary hypertension, while only a minority (<10%) will have secondary hypertension. We do not recommend an extensive workup for all newly diagnosed young hypertensives, as has been the practice in the past. We propose a rational approach that comprises a history to identify risk factors, an examination that establishes the presence of target­organ damage and identifies clues suggesting secondary hypertension, and a limited set of basic investigations.
    [Show full text]
  • Secondary Hypertension: Discovering the Underlying Cause LESLEY CHARLES, MD; JEAN TRISCOTT, MD; and BONNIE DOBBS, Phd University of Alberta, Edmonton, Alberta, Canada
    This is a corrected version of the article that appeared in print. Secondary Hypertension: Discovering the Underlying Cause LESLEY CHARLES, MD; JEAN TRISCOTT, MD; and BONNIE DOBBS, PhD University of Alberta, Edmonton, Alberta, Canada Most patients with hypertension have no clear etiology and are classified as having primary hypertension. However, 5% to 10% of these patients may have secondary hypertension, which indicates an underlying and potentially revers- ible cause. The prevalence and potential etiologies of secondary hypertension vary by age. The most common causes in children are renal parenchymal disease and coarctation of the aorta. In adults 65 years and older, atherosclerotic renal artery stenosis, renal failure, and hypothyroidism are common causes. Secondary hypertension should be considered in the presence of suggestive symptoms and signs, such as severe or resistant hypertension, age of onset younger than 30 years (especially before puberty), malignant or accelerated hypertension, and an acute rise in blood pressure from previously stable readings. Additionally, renovascular hypertension should be considered in patients with an increase in serum creatinine of at least 50% occurring within one week of initiating angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy; severe hypertension and a unilateral smaller kidney or dif- ference in kidney size greater than 1.5 cm; or recurrent flash pulmonary edema. Other underlying causes of secondary hypertension include hyperaldosteronism, obstructive sleep apnea, pheochromocytoma, Cushing syndrome, thyroid disease, coarctation of the aorta, and use of certain medications. (Am Fam Physician. 2017;96(7):453-461. Copyright © 2017 American Academy of Family Physicians.) CME This clinical content ypertension is common, affect- hypertension, onset before 30 years of age conforms to AAFP criteria ing nearly 30% of U.S.
    [Show full text]
  • Polyarteritis Nodosa Complicated by Posterior Reversible Encephalopathy Syndrome: a Case Report
    http://www.revistanefrologia.com © 2014 Revista Nefrología. Órgano Oficial de la Sociedad Española de Nefrología caso clínico Polyarteritis nodosa complicated by posterior reversible encephalopathy syndrome: a case report Alper Alp1, Hakan Akdam1, Harun Akar1, Kutsi Koseoglu2, Ayca Ozkul3, Ibrahim Meteoglu4, Yavuz Yenicerioglu1 1 Department of Nephrology. Adnan Menderes University. School of Medicine. Aydin (Turkey); 2 Department of Radiology. Adnan Menderes University. School of Medicine. Aydin (Turkey); 3 Department of Neurology. Adnan Menderes University. School of Medicine. Aydin (Turkey); 4 Department of Pathology. Adnan Menderes University. School of Medicine. Aydin (Turkey) Nefrologia 2014;34(6):789-96 doi:10.3265/Nefrologia.pre2014.Sep.12510 Complicación de la poliarteritis nodosa por síndrome de ABSTRACT encefalopatía posterior reversible. Caso clínico RESUMEN Hypertension (HT) represents a major public health problem La hipertensión es uno de los principales problemas de salud pública, affecting many individuals worldwide. It is well known to be an que afecta a muchas personas en todo el mundo. Se sabe que es important risk factor for the development of cerebrovascular and un importante factor de riesgo para el desarrollo de enfermedades cardiovascular diseases. Classifying hypertension as ‘primary’ or cerebrovasculares y cardiovasculares. Su clasificación como “primaria” ‘secondary’ depends on the underlying mechanism. In 5 to 10% o “secundaria” depende del proceso subyacente. En el 5-10% de of hypertensive patients, HT develops ‘secondary’ to a separate los pacientes hipertensos, se trata de un problema “secundario” mechanism that has been encountered with increasing frequency a otro proceso de creciente frecuencia en los centros de atención in the tertiary refferral centers. The frequent causes of secondary terciaria.
    [Show full text]
  • High Blood Pressure: Secondary Hypertension
    High Blood Pressure: Secondary Hypertension What is secondary hypertension? Blood pressure is the force of the blood on the artery walls as the heart pumps blood through the body. High blood pressure caused by a disease or another known medical problem is called secondary hypertension. Most cases of secondary hypertension are caused by kidney or hormonal problems. Normal blood pressure ranges up to 120/80 ("120 over 80") but blood pressure can rise and fall with exercise, rest, or emotions. The pressures are measured in millimeters of mercury. The upper number (120) is the pressure when the heart pushes blood out to the rest of the body (systolic pressure). The bottom number (80) is the pressure when the heart rests between beats (diastolic pressure). • Healthy blood pressure is less than 120/80. • Pre-high blood pressure (prehypertension) is from 120/80 to 139/89. • Stage I high blood pressure ranges from 140/90 to 159/99. • Stage II high blood pressure is over 160/100. If repeated checks of your blood pressure show that it is higher than 140/90, you have hypertension. If you have prehypertension and other health problems, such as diabetes, you need treatment. How does it occur? Many medical conditions, diseases, and medicines can cause secondary hypertension, including: • narrowing of the arteries in the kidneys • narrowing of the aorta, a large blood vessel that supplies blood to the lower body • several types of kidney disease • excess secretion of a hormone called aldosterone from the adrenal gland • tumor of the adrenal gland • Cushing's syndrome, a disorder in which there is too much corticosteroid hormone in the blood • medicines such as estrogen and oral contraceptives • abuse of drugs such as amphetamines, alcohol, or diet pills • pregnancy.
    [Show full text]
  • Secondary Forms of Hypertension: Diagnosis and Management
    Secondary Forms of Hypertension: Diagnosis and Management Glenn Kershaw, M.D. Professor of Clinical Medicine University of Massachusetts Medical School Disclosures • No conflicts of interest Conditions Contributing to BP Elevation: Potentially Reversible Lifestyle-Nutritional Factors Classic Forms of Secondary Hypertension Obesity Prescription or Dietary salt Renovascular Disease Life stress Primary Aldosteronism OTC Drugs OSA Pheo Renal Parenchymal Disease Cushings Disease PHEO: Symptoms Cleveland Clinic 73/76 : 1 or more 55/76: at least 2 • Headache • Sweats • Palpitation Pheo: Screening • Spot urine: metanephrine/creatinine: mcg/mg = mg/24 hour • Plasma Metanephrine 100% sensitive (52/52) 100% negative predictive value (162/162) Cushing’s Syndrome: Screening Overnight Dexamethasone Suppression • Dexamethasone 1 mg hs • Plasma cortisol @ 8:00 AM • Normal suppression: cortisol < 5 mcg/dl • 10-20 % false positive RENOVASCULAR DISEASE RVH: Clinical Clues • Severe HTN… > 180/120 • Unexplained loss of GFR with antihypertensive therapy, especially : – ↑ creat > 30-50% 1-4 weeks following ACE-I or ARB • Severe HTN and – diffuse atherosclerosis + > 50 y/o – unexplained small kidney (<9cm) or asymmetry – Recurrent episodes (flash) pulmonary edema • Systolic-Diastolic bruit RAS + HTN STENT ? RAS + CKD STENT ? STARS: Decline GFR or Death RAS + HTN STENT RAS + CKD STENT Hypertensive patients with atherosclerotic renal artery disease, who have stable renal function and well managed blood pressure on medical therapy derive no proven benefit by revascularization
    [Show full text]
  • How Do I Investigate Suspected Secondary Hypertension?
    How do I investigate suspected secondary hypertension? Marie Freel RCP Update in Medicine 23 rd November 2016 World beaters…..! Michel Joffres et al. BMJ Open 2013;3:e003423 Hypertension often poorly controlled Scottish Health Survey 2009 Hypertension targets just got lower…… SPRINT investigators NEJM 2015 373:2103-2116 Secondary hypertension • 5-10% of ‘essential’ hypertension cases • Clinical ‘clues’ important • Age based approach essential Secondary hypertension according to age Age group % with underlying Most common cause cause Children (<12 years) 70-85% Renal parenchymal disease Coarctation of aorta Adolescents (12-18 years) 10-15% Renal parenchymal disease Coarctation of aorta Young adults (19-39 years) 5% Fibromuscular dysplasia Renal parenchymal disease Middle aged adults (40-65 8-12% Primary Aldosteronism years) Obstructive Sleep Apnoea Cushing’s syndrome Phaeochromocytoma Older adults 17% Atherosclerotic renovascular disease Renal failure hypothyroidism Secondary hypertension • 5-10% of ‘essential’ hypertension cases • Clinical ‘clues’ important • Age based approach essential • Consider if: – Severe or resistant hypertension – Child/adolescent – Worsening of previously stable hypertension – Malignant hypertension – No other risk factors identified and age <30 Secondary hypertension: investigations • Renal function and urinalysis • Renal imaging – Ultrasound – MRA renal arteries • Aldosterone to renin ratio (ARR) • 24h urine for catecholamines/metanephrines – Only if clinical suspicion Case 1: Just another case of hypertension…….?
    [Show full text]