What about secondary hypertension?
When do you see that?
I think a secondary hypertension, it’s rare.
It’s only up to 10% of cases of hypertension.
It’s probably less than that.
But especially in a middle-aged adult,
when they come in with a very high blood pressure,
and particularly a blood pressure that’s not well controlled on initial therapy,
you can consider some differential diagnosis.
Thyroid disease is very easy to test for and pretty common,
but often times it will also be associated with other symptoms,
and a pulse, if they’re hyperthyroid, that’s high.
So, therefore you can ferret out
that they have thyroid disease from other historical factors.
It’s rare when it’s just sitting there and the only symptom
it’s really, you know, causing his high blood pressure.
醛甾酮过多症 或者说原醛症 也是病因之一
Hyperaldosteronism can be a problem, Conn’s syndrome.
So look for electrolyte abnormalities associated with that.
Renal artery stenosis is the most common cause of secondary hypertension.
And if it’s middle-aged adults,
you are probably talking about acquired renal artery stenosis,
as opposed to congenital renal artery stenosis.
This in a watch what their GFR, their glomerular filtration rate, is doing.
Watch their creatinine levels.
But it often needs analysis with something like
either a CT or magnetic resonance angiography of the renal arteries.
And pheochromocytoma, we all worry about it.
It’s actually incredibly rare.
And again, these patients usually have other symptoms,
tremor, sweating, and weight loss,
that can give away the fact
that they have this excess of catecholamines.
It’s rare that just,
oh, the blood pressure is elevated by itself.
What do you do to evaluate patients
once they’re diagnosed with hypertension?
Everybody gets a baseline electrocardiogram,
looking for things like left ventricular hypertrophy or prior cardiac damage.
A glucose level or an HbA1c,
something to screen for diabetes,
something to screen for hyperlipidemia.
A check of their electrolytes along with their kidney function as well as a hemoglobin level.
And urinalysis or a microalbumin/creatinine ratio
to check for the possibility of proteinuria and early kidney disease.
That’s your baseline.
And these essentially should be repeated at least
when we talk about the electrolytes, the urinalysis on an annual basis.
And at least. At least on an annual basis.
Remember the lifestyle changes are still
at the foundation for the treatment of hypertension.
And actually if you look at something like the Dietary Approaches to Stop Hypertension,
that reduction on average with 11.5 or 5.5 points of mercury
is really remarkable.
That’s more powerful than most antihypertensive agents.
And, obviously, patients can do a DASH.
That’s gonna yield other good things
比如胆固醇水平 新陈代谢水平 体重等等
in terms of their cholesterol and their metabolism, their body weight,
so there are side benefits to that diet that are really wonderful,
but that reduction in blood pressure values is outstanding.
Weight loss certainly promotes a lower blood pressure as well,
so that’s one of the benefits of, say, bariatric surgery.
A lot of patients are cured of hypertension,
following the significant weight loss they experience with bariatric surgery.
But even following a good diet and exercise and losing 4 kilos
can result in significant reduction in blood pressure.
And exercise, as I mentioned, in and of itself,
can reduce blood pressure as well,
so these are the keys.
And you can see that if you put all of these things together,
many patients wouldn’t, you know, could avoid medical therapy completely
if they really embraced diet and exercise.
So let’s return to our case.
She’s actually come back to clinic now.
And a repeat blood pressure, unfortunately,
despite trying to do her lifestyle changes in the past 2 weeks,
Her pulse is 86 beats per minute.
So now what do you wanna do?
Do you want to allow 6 months for lifestyle changes
to have an effect since she started them?
Do you want to start a thiazide diuretic,
start an alpha adrenergic blocker or start a beta blocker?
Which one would you choose?
I would go with a thiazide diuretic.
That is recommended as a first-line therapy by JNC 8.
So here are the first-line treatments after lifestyle for hypertension.
And JNC 8 left this fairly open.
And again, these are only recommendations,
but the recommendations are broad
and catch most patients I think.
Thiazide diuretics are great option for patients.
One thing whenever I prescribe a diuretic is that
I will ask them if they have any urinary issues.
Many older adults have overactive bladder or benign prostatic hypertrophy,
and therefore already maybe struggling with genitourinary issues.
I don’t want to exacerbate that by giving them a thiazide diuretic.
I would choose something else for those patients.
The other thing is prescribing a thiazide alone,
watch closely for the potassium,
because thiazide promotes hypokalemia.
Whereas ACE inhibitors and ARBs
also considered a first-line agent can promote hyperkalemia.
So therefore, a combination of one of those agents with a thiazide
is helpful in terms of maintaining normokalemia.
And calcium channel blockers have their own range of side effects,
but one thing they don’t do much is affect electrolytes.
It’s also worth noting
that atenolol is not recommended by JNC8.
It doesn’t confer overall the same mortality benefit for cardiovascular disease
that these other agents maintain.