secondary hypertension
DESCRIPTION
SECONDARY HYPERTENSION. DEFINITION. Essential, primary, or idiopathic hypertension is defined as high BP in which secondary causes or mendelian (monogenic) forms are not present High BP – repeatedly measured BP exceeding 140/90 mmHg, i.e. a systolic BP above 140 and/or diastolic BP above 90. - PowerPoint PPT PresentationTRANSCRIPT
SECONDARY HYPERTENSION
DEFINITION
• Essential, primary, or idiopathic hypertension is defined as high BP in which secondary causes or mendelian (monogenic) forms are not present
• High BP – repeatedly measured BP exceeding 140/90 mmHg, i.e. a systolic BP above 140 and/or diastolic BP above 90
Aetiology of Hypertension
• Primary – 90-95% of cases – also termed “essential” of “idiopathic”
• Secondary – about 5% of cases– Renal or renovascular disease– Endocrine disease
• Phaeochomocytoma• Cushings syndrome• Conn’s syndrome• Acromegaly and hypothyroidism
– Coarctation of the aorta– Iatrogenic
• Hormonal / oral contraceptive• NSAIDs
Aetiology of Hypertension
• Primary – 90-95% of cases – also termed “essential” of “idiopathic”
• Secondary – about 5% of cases– Renal parenchymal (2-5%)or renovascular disease– Endocrine disease
• Phaeochomocytoma• Cushing syndrome• Conn syndrome• Acromegaly and hypothyroidism
– Coarctation of the aorta– Iatrogenic
• Hormonal / oral contraceptive• NSAIDs
Renal parenchymal disease
• Acute and chronic glomerulonephritis
• Polycystic kidney disease
• Diabetic nephropathy
• Pyelonephritis
• Obstructive uropathy
• Neoplasms
• Renal trauma
• Radiation nephritis
Renal parenchymal disease
CIN – chronic interstitial nephritis; APKD – adult-onset polycystic kidney disease; MCN - minimal change nephropathy; MGN – membranous glomerulonephritis; DN – diabetic nephropathy; MPGN – membranoproliferative glomerulonephritis; FSGN – focal segmental glomerulonephritis
Candidate pathophysiologic mechanisms related to hypertension in parenchymal renal disease
Hypertension in parenchymal renal disease: major target organ manifestations
Hypertension in parenchymal renal disease
Hypertension in parenchymal renal disease:CONCLUSIONS
• Hypertension may result from renal disease that reduces functioning nephrons;
• Evidence shows a clear relationship between high blood pressure and end-stage renal disease;
• BP should be controlled to 130/85 mmHg (125/75 mmHg in patients with proteinuria in excess of 1g/24 h)
Aetiology of Hypertension• Primary – 90-95% of cases – also termed “essential” of
“idiopathic”
• Secondary – about 5% of cases– Renal parenchymal
or renovascular disease (0.3-3%)– Endocrine disease
• Phaeochomocytoma• Cushings syndrome• Conn’s syndrome• Acromegaly and hypothyroidism
– Coarctation of the aorta– Iatrogenic
• Hormonal / oral contraceptive• NSAIDs
RENAL ARTERY STENOSIS(RAS)
• Atherosclerotic RAS (>90% of cases): involves the ostium and the proximal portion of the main renal artery with plaque extending into the perirenal aorta
• Fibromuscular dysplasia (10% of cases): typically seen in young and middle-aged females. As opposed to atherosclerotic RAS, fibromuscular dysplasia typically affects the distal two thirds of the main renal artery
RENAL ARTERY STENOSIS:screening and diagnostic studies
Renal duplex sonography Magnetic resonance angiography Renal artery arteriography Captopril renography
RENAL ARTERY STENOSIS:renal duplex sonography
Stenoses over 60%:
• Peak systolic velocity (PSV) >150-180 cm/sec
• Renal-aortic ratio >3.5
Prognostic value:
• Resistance index (RI): RI=(1-EDV)/PSVx100;
if RI>80 no benefit after revascularization
RENAL ARTERY STENOSIS:MR angiography
Strong sides:
• Provides images of the renal arteries, 3D-reconstruction, plaque characterization and hemodynamic information
• Gadolinium (contrast agent): non-nephrotoxic
Weak sides: high cost and limited availability
RENAL ARTERY EVALUATION:MR angiography (3D-reconstruction)
RENAL ARTERY EVALUATION:contrast angiography (the “gold” standard)
Fibromuscular dysplasia: “string of beads” appearance
Atherosclerotic RAS with poststenotic dilatation
What is your diagnosis ?
RENAL ARTERY STENOSIS:treatment
• BP control
• Antiplatelet, lipid-lowering therapy, and beta-blockers, if appropriate
• No ACE-inhibitors in severe RAS !
RENAL ARTERY STENOSIS:treatment
Percutaneous or surgical revascularization, if:
● Resistant or poorly controlled hypertension and unilateral or bilateral renal artery stenosis
● Renal artery stenosis and recurrent flash pulmonary edema for which there is no readily explainable cause
● Chronic renal failure and bilateral renal artery stenosis or renal artery stenosis to a solitary functioning kidney
● Sonographic renal longitudinal length >7cm
Aetiology of Hypertension
• Primary – 90-95% of cases – also termed “essential” of “idiopathic”
• Secondary – about 5% of cases– Renal or renovascular disease– Endocrine disease
• Phaeochomocytoma (0.1-0.6 %)• Cushings syndrome• Conn’s syndrome• Acromegaly and hypothyroidism
– Coarctation of the aorta– Iatrogenic
• Hormonal / oral contraceptive• NSAIDs
PHEOCHROMOCYTOMA“frequently searched for, but rarely found”
• About 90 % of pheochromocytomas are located within the adrenal glands;
• 10% are bilateral;• 10% are malignant;
• 10% are extra-adrenal;
• Extra-adrenal pheochromocytomas develop in paraganglion chromaffin tissue of the sympathetic nervous system; of them, 40% are not diagnosed, 5% are multiple;
• overall, nearly 98% of pheochromocytomas are found in the abdomen
Frequency of signs and symptoms (%) of pheochromocytoma
PHEOCHROMOCYTOMA“the great mimic”
PHEOCHROMOCYTOMAdiagnostic techniques
Biochemical tests High pressure liquid chromatography:
• Plasma catecholamines: noradrenaline, adrenaline;
• Free plasma fractionated metanephrines: normetanephrine, metanephrine;
• Urinary catecholamines (24h)• Urinary fractionated metanephrines (24h)
Spectrophotometry:• Total metanephrines (24h urine);• Vanillylmandelic acid (24h urine)
PHEOCHROMOCYTOMA
Sensitivity and specifity of biochemical tests for diagnosis of pheochromocytoma
PHEOCHROMOCYTOMAimaging techniques
• Duplex sonography;
• Magnetic resonance imaging (MRI);
• Computed romography (CT);
• 123I – meta-iodo-benzyl-guanidine scanning (123I-MIBG)
PHEOCHROMOCYTOMA
Sonography :
• Sonographic appearances are those of a well-defined homogeneous hypoechoic mass in approximately 50 pet cent of patients.
• However the mass may be complex or even cystic (16 pet cent) and hyperechoic to the renal parenchyma (approximately 20 pet cent).
PHEOCHROMOCYTOMA
MRI (coronal and sagittal sections):
• Magnetic resonance (MR) imaging is equally sensitive to CT and lends itself to in vivo tissue characterization, which is not possible with CT;
• MR imaging is nearly 100% sensitive and around 70% specific.
• Preferred for the localisation of extra-adrenal tumours or tumours during pregnancy, in children, or in patients with allergies to contrast
PHEOCHROMOCYTOMA
CT:
• accurately detects tumors larger than 1.0 cm and has a localization precision of approximately 98%, although it is only 70% specific;
• since CT scanning and MRI have similar sensitivities (90–100%) and specificities (70–80%), MRI is the preferred procedure
PHEOCHROMOCYTOMA
123I-MIBG scanning:
• increased specificity (95–100%), as compared with CT or MRI;
• provides both anatomic and functional characterization;
• Relevant in patients with multiple, extra-adrenal, malignant (metastatic) tumors
PHEOCHROMOCYTOMA: laparoscopic removalPreoperative Management (10-14 days)
Purpose: to prevent catecholamine induced, serious, and potentially life-threatening complications during surgery, including hypertensive crises, cardiac arrhythmias, pulmonary oedema, and cardiac ischemia;
BP should be reduced to below 160/90 mm Hg for at least 24h;
orthostatic hypotension should be present, but blood pressure in the upright position should not fall below 80/45 mm Hg;
there should be no more than one ventricular extrasystole every 5 min;
and the electrocardiogram should show no S-T segment changes and T-wave inversions for 1 week;
PHEOCHROMOCYTOMA:Management
• Phenoxybenzamine, a long acting alpha-adrenergic blocker, is the mainstay of medical treatment to control BP. A total dose of 1 mg/kg is sufficient in most patients.
• An alpha-blocker Doxazosin in increasing doses from 1 to 16 mg once a day.
•A beta-adrenoceptor blocker (eg,propranolol 40 mg three times daily or atenolol 25–50 mg once daily) could be included after several days of alpha-adrenergic blockade.
• Adequate salt and fluid intake lowers the risk of orthostatic hypotension.
PHEOCHROMOCYTOMA:Management
•Should substantial rises in blood pressure still take place during surgery, these can be controlled by bolus or by continuous infusion of phentolamine, sodium nitroprusside, or a shortacting calcium antagonist (eg, nicardipine);
• Tachyarrhythmias can be treated by infusion of a shortacting -adrenoceptor blocker (eg, esmolol).
PHEOCHROMOCYTOMA
Sensitivity and specifity of biochemical tests for diagnosis of pheochromocytoma
Conn’s Syndrome (primary hyperaldosteronism)
• Should be considered in any hypertensive pt with muscle weakness, polydipsia, andor hypokalemia;
• 75% - adrenal adenoma;
• 25% - adrenal hyperplasia
• Rarely – adrenocortical cancer
Primary Hyperaldosteronism• Screening for hyperaldosteronism should include
plasma aldosterone and plasma renin activitymeasured in morning samples
• Plasma aldosterone:renin ratio: normally <20; diagnostic cut-off value >30;
• Aldosterone excretion rate during salt loading, captopril, or spironolactone test (the captopril test may be less useful in blacks because of the high prevalence of low plasma renin activity)
• Adrenal CT, MRI
Primary HyperaldosteronismShould be differentiated from
• Secondary hyperaldosteronism in patients with renal failure, CHF, essential hypertension
• Monogenic forms of hypertension (pseudohyperaldosteronism):
Liddle’s syndrome (autosomal-dominant disorder, characterized by low-renin, low-aldosterone, low-potassium volume-expanded hypertension)
Gordon’s syndrome (autosomal-dominant disorder, characterized by low-renin, low-aldosterone, high-potassium volume-expanded hypertension)
Primary Hyperaldosteronism
TREATMENT
1. Medical• Spironolactone, a competitive aldosterone antagonist• Amiloride, a potassium-sparing diuretic
• Glucocorticoids (in glucocorticoid-remediable form)
2. Surgical, if appropriate
Aetiology of Hypertension
• Primary – 90-95% of cases – also termed “essential” of “idiopathic”
• Secondary – about 5% of cases– Renal or renovascular disease– Endocrine disease
• Phaeochomocytoma
• Cushing’s syndrome (0.1-0.6%)Conn’s syndrome • Acromegaly and hypothyroidism
– Coarctation of the aorta– Iatrogenic
• Hormonal / oral contraceptive• NSAIDs
Cushing’s Syndrome
• Hypertension occurs in about 80% of patients;
• Urinary free cortisol
• If 24h UFC>100 µg/ml: measure plasma ACTH
Hypothyroidism
• Both hypertension (particularly diastolic) and hypotension are common;
Hyperthyroidism
• Accompanied by systolic hypertension, especially in the elderly;
Acromegaly
• 25-50% exhibit elevated blood pressure