00:01
And what about secondary hypertension?
When do you see that?
I think a secondary hypertension,
it's rare.
00:07
It's only up to 10% of
cases of hypertension.
00:10
It’s probably less than that.
00:11
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.
00:23
Thyroid disease is very easy to
test for and pretty common,
but oftentimes it will also be
associated with other symptoms
and a pulse if they're
hyperthyroid that's high.
00:33
So, therefore, you can ferret out
that they have thyroid disease
from other historical factors.
00:38
It’s rare when it’s just sitting there.
00:40
And the only symptom it's really
causing is high blood pressure.
00:44
Hyperaldosteronism can be a problem.
00:46
Conn syndrome.
00:47
So, look for electrolyte
abnormalities associated with that.
00:51
Renal artery stenosis is the most common
cause of secondary hypertension.
00:55
And if it’s middle-aged adults,
you're probably talking about
acquired renal artery stenosis
as opposed to congenital
renal artery stenosis.
01:03
This – watch what their GFR,
their glomerular filtration rate, is doing.
01:09
Watch their creatinine levels.
01:11
But it often needs
analysis with something like either a CT
or magnetic resonance angiography of the renal arteries.
01:20
And pheochromocytoma, we all worry about it.
01:22
It's actually incredibly rare.
01:24
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.
01:34
It's rare that it’s just –
oh, the blood pressure is elevated by itself.
01:40
What do you to evaluate patients once
they are diagnosed with hypertension?
Everybody gets a baseline
electrocardiogram,
looking for things like left ventricular
hypertrophy or prior cardiac damage,
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.
02:09
That's your baseline.
02:10
And these essentially should be repeated
at least when we talk about the electrolytes,
the urinalysis on an annual basis.
02:21
At least. At least on an annual basis.
02:24
Remember the lifestyle changes
are still at the foundation
for the treatment of hypertension.
02:30
And actually if you look at something like the
dietary approaches to stop hypertension,
that reduction on average with 11.5 over
5.5 points of mercury is really remarkable.
02:43
That's more powerful than most
anti-hypertensive agents.
02:46
And, obviously, patients can do a DASH.
02:49
That’s going to yield other good things in terms
of their cholesterol and their metabolism,
their body weight.
02:55
So, there are side benefits to that
diet that are really wonderful.
02:59
But that reduction in blood
pressure values is outstanding.
03:04
Weight loss certainly promotes a
lower blood pressure as well.
03:09
So, that's one of the benefits
of, say, bariatric surgery.
03:12
A lot of patients are cured of hypertension,
following the significant weight loss
they experience with bariatric surgery.
03:19
But even following a good diet
and exercise and losing 4 kilos
can result in a significant
reduction in blood pressure.
03:27
And exercise, as I
mentioned, in and of itself
can reduce blood pressure as well.
03:31
So, these are the keys.
03:33
And you can see that,
if you put all of these things together,
many patients wouldn't –
could avoid medical therapy
completely if they really embraced diet and exercise.
03:47
So, let’s return to our case.
She has actually come back to clinic now.
03:51
And a repeat blood pressure, unfortunately,
despite trying to do her lifestyle changes
in the past two weeks, is 150/94.
03:58
Her pulse is 86 bpm.
04:00
So, now, what do you want to do?
Do you want to allow six months for lifestyle
changes to have an affect 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.
04:16
That is recommended as a
first-line therapy by JNC 8.
04:20
So, here are the first-line treatments
after lifestyle for hypertension.
04:25
And JNC 8 left this fairly open.
04:28
And again, these are only recommendations,
but the recommendations are broad
and catch most patients, I think.
04:34
Thiazide diuretics are a great option for patients.
04:39
One thing, whenever I prescribe a diuretic,
is that I will ask them if they
have any urinary issues.
04:45
Many older adults have overactive
bladder or benign prostatic hypertrophy,
and therefore, already may be
struggling with genitourinary issues.
04:55
I don't want to exacerbate that by
giving them a thiazide diuretic.
04:59
I would choose something else for those patients.
05:02
The other thing is prescribing a thiazide alone –
watch closely for the potassium because
thiazide promotes hypokalemia.
05:10
Whereas ACE inhibitors and ARBs,
also considered a first-line agent,
can promote hyperkalemia.
05:16
So, therefore, a combination
of one of those agents
with a thiazide is helpful in terms
of maintaining normokalemia.
05:24
And calcium channel blockers have
their own range of side effects,
but one thing they don't do
much is affect electrolytes.
05:31
It’s also worth noting that atenolol
is not recommended by JNC 8.
05:34
It doesn't confer overall the same mortality
benefit for cardiovascular disease
that these other agents maintain.