00:00
Let’s go on to
another case.
00:03
A 38-year-old man is evaluated
for resistant hypertension.
00:07
He was diagnosed with
hypertension at age 35
and reported that his blood pressure
has never been well-controlled.
00:15
He is compliant with
all his medications.
00:18
He denies headaches,
chest pain, palpitations,
shortness of breath, or
symptoms of panic attack.
00:25
He has no history of
cardiovascular disease,
does not smoke,
and does not drink alcohol.
00:30
Medications are lisinopril,
amlodipine, hydrochlorothiazide,
metoprolol, and potassium
chloride supplementation.
00:39
On physical exam,
his blood pressure is 155/92.
00:43
His pulse rate is 65 beats per minute.
His BMI is 25.
00:48
Examination of the heart is
significant for the presence
of a fourth heart sound
but no murmurs.
00:55
The remainder of the
exam is unremarkable.
00:59
Lab studies are significant for a
serum creatinine level of 1 mg/dL,
a fasting plasma glucose
level of 82 mg/dL,
and a serum potassium
level of 3.2.
01:12
What is the next most appropriate
diagnostic step?
Here we have a young man
with resistant hypertension
on three different blood
pressure lowering meds.
01:24
Essentially, the definition of
resistant hypertension
is taking three or more blood
pressure lowering meds
of which one
is a diuretic.
01:33
He also has a
low potassium.
01:36
This should trigger
the suspicion
for primary aldosterone
in this patient.
01:40
First of all, the younger onset
of his high blood pressure
and the degree to which his
blood pressure is elevated
despite all the
medications
is enough to make you
suspect the condition.
01:54
The conclusion here is that the most
appropriate step to perform
is to measure the plasma aldosterone
to plasma renin activity ratio.
02:03
If this is positive, confirmation
testing with IV salt-loading,
fludrocortisone suppression testing,
or captopril testing
should be
considered.
02:13
This patient has resistant hypertension
defined as a blood pressure
that remains
above goal
despite concurrent use of multiple
antihypertensive agents.
02:21
He has significant
hypokalemia
in the presence of treatment
with an ACE inhibitor
and potassium
supplementation
which raises the possibility of
primary hyperaldosteronism.
02:34
Adrenal imaging is
indicated to determine
if hyperaldosteronism is due to
a bilateral or unilateral cause.
02:41
Mineralocorticoid receptor antagonists
such as spironolactone
are indicated for the patients
with bilateral causes
of primary hyperaldosteronism and
those with a unilateral cause
who refuse or are not
candidates for surgery.