secondary hypertension: adrenal and nervous systems Ανδρέας Πιτταράς...
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Secondary Hypertension: Adrenal and Nervous Systems
Ανδρέας ΠιτταράςΑνδρέας Πιτταράς ΚαρδιολόγοςΚαρδιολόγος
Clinical Hypertension Specialist ESHClinical Hypertension Specialist ESHΥπερτασικό ιατρείο Τζάνειο νοσοκομείοΥπερτασικό ιατρείο Τζάνειο νοσοκομείο
Υπερηχοκαρδιογραφικό εργαστήριο ΝΜΥΑ ΙΚΑΥπερηχοκαρδιογραφικό εργαστήριο ΝΜΥΑ ΙΚΑ
Clinical clues to the presence of primary aldosteronism
•Spontaneous hypokalemia
•Diuretic-induced hypokalemia
•Difficulty in maintaining a normal serum potassium while
on diuretics despite concomitant use of potassium-sparing
agents or KCl supplementation
•Refractory hypertension
•Family history of primary aldosteronism
Primary aldosteronism can occur at all ages
Biochemical confirmation of adenoma versus hyperplasia
MEASUREMENTS ADENOMA BILATERAL HYPERPLASIA
Serum potassium, mEq/L
3.0 3.0
Plasma 18-OHB, ng/dL
100 100
Plasma aldosterone response to ambulation
Decrease Increase
Urinary 18-hydroxycortisol
Increase Normal
Diagnostic accuracy of imaging techniques in
adrenocortical disorders
TRUE POSITIVES, % DISORDER PATIENTS, n NP-59 CT
Cushing's syndrom 28 93 90
Primary aldosteronis 58 88 91
Nonfunctional tumors 13 100 89
Diagnostic accuracy of iodocholesterol NP-59 scanning
Efficacy of long-term medical management of aldosterone-producing adenomas
ELECTROLYTE LEVELS AT DIAGNOSIS
ELECTROLYTE LEVELS AT LAST FOLLOW-UP
PATIENTAGE ySEXFOLLOW-UP, yBLOOD PRESSURE AT PRESENTATION*, mm HgMOST RECENT BLOOD PRESSURE*, mm HgSODIUMPOTASSIUMCHLORIDECARBON DIOXIDESODIUMPOTASSIUMCHLORIDECARBON DIOXIDE165M5170/94120/801453.1105301405.211028269M12164/65157/861413.298351413.910430363M11178/96130/951412.9100281444.010726443F8180/104124/821403.098311374.110525539F5184/132128/801413.9102291403.710628676M9174/100116/741432.9104291394.710323768M6180/105195/761403.198321424.210928869M5190/95130/701442.9103291404.110421959M7180/116145/991442.4102351394.3104301055M8180/110140/741453.0102301424.6104301159M6165/102112/681423.0106301424.8108301250M6177/117115/801443.1102311434.5104271344M6160/110130/821413.0106291404.3103291454F8160/98142/601443.4106291424.7108251552F13150/104104/761423.3105241374.4106251652F5168/102128/911432.7102321413.6106321754F17180/110101/711433.0105331394.4101301859M8176/116158/781422.6106291384.6101271944F9190/122122/781422.698321373.698262061F14160/110144/721452.9103351403.7113292168F5166/108111/781432.6103301464.5108262266M11178/108150/921413.0101311423.8102262373M10178/100107/661433.899311434.8105242456M15200/125128/851413.2102321394.610226*Blood pressure values are the average of at least three measurements. Levels are measured in millimoles per liter.
Important facts about pheochromocytomas•About 30% of pheochromocytomas reported in the
literature are found either at autopsy or at surgery for an
unrelated problem
•35% to 76% of pheochromocytomas discovered at autopsy
are clinically unsuspected during life
•The average age of diagnosis in those whose disease was
discovered before death was 48.5 y, while the average in
those diagnosed at autopsy was 65.8 y
•Death was usually attributed to cardiovascular
complications
-Adrenergic hyperresponsivenessAcute state of anxietyAngina pectorisAcute infectionsAutonomic epilepsyHyperthyroidismIdiopathic orthostatic hypotensionCerebellopontine angle tumorsAcute hypoglycemiaAcute drug withdrawal (Clonidine - Adrenergic blockade -Methyldopa Alcohol) Vasodilator therapy (Hydralazine, Minoxidil)Factitious administration of sympathomimetic agentsTyramine ingestion in patients on monoamine oxidase inhibitorsMenopausal syndrome with migraine headaches
Differential diagnosis of pheochromocytoma
Priorities for detection of pheochromocytoma
•Patients with the triad of episodic headaches, tachycardia,
and diaphoresis (with or without associated hypertension)
•Family history of pheochromocytoma
• Incidental suprarenal masses
•Patients with a multiple endocrine adenomatosis syndrome,
neurofibromatosis, or von Hippel-Lindau disease
•Adverse cardiovascular responses to anesthesia, to any
surgical procedure, or to certain drugs (eg, guanethidine,
tricyclics, thyrotropin-releasing hormone, naloxone, or
antidopaminergic agents)
Perioperative hemodynamic variables OPEN, n=20 LAPAROSCOPIC, n=14 P VALUE
Mean preoperative blood pressure*, mm Hg 140 18/78 10 144 13/74 14 0.50
Highest blood pressure*, mm Hg 191 33/98 25 194 19/106 19 0.50
Hypertension 0.5 (0 5) 1.0 (0 3) 0.41
SBP 200 mm Hg 0 (0 4) 0 (0 2) 0.70
Lowest blood pressure*, mm Hg 88 14/50 13 98 19/57 8 0.05
Hypotension 2.0 (0 6) 0 (0 2) 0.005
Highest heart rate, bpm 104 15 101 24 0.78
Heart rate 110 bpm 0 (0 3) 0 (0 3) 0.36
Lowest heart rate, bpm 61 11 60 9 0.81
Heart rate 50 bpm 0 (0 1) 0 (0 5) 0.81
Patients requiring treatment for hypertension‡, n 17.0 13.0 0.63
Patients requiring treatment for hypotension , n 9.0 1.0 0.02*Systolic and diastolic blood pressure presented as the standard deviation; P value based on the test. Median number of episodes for one patient, with the range in parentheses; P value based on the
Jackson-Whitney U test.‡Includes patients who intraoperatively received at least one of the following treatments: nitroglycerin,
sodium nitroprusside, -blocker, / -blocker, or a calcium channel antagonist. Includes patients who intraoperatively received at least one of the following treatments: phenylephrine,
dopamine, or epinephrine.