Hypertension: How to Manage Challenging Cases

1. Hypertension: How to Manage Challenging Cases J. Emilio Exaire, MD. Assistant Professor of Medicine Cardiovascular Section, OUHSC

2. Hypertension

3. QUESTION 1 • In average, how many hypertensive patients are well controlled (e.g. BP<140/90) a. 90% b. 80% c. 70% d. 60% e. 48%

4. How big is the problem? • Only 48% are controlled; 37% if patients have renal failure • About 20%-30% have resistant HTN

9. Case 1 • 56 yr female • First diagnosis of HTN at age 19 • Bipolar disorder • On ACEI only with poor control

10. Case 1 considerations • Suspicious high for secondary HTN • Never had a renal duplex ultrasound • Step 1: consider adding more drugs • Step 2: order renal US

12. Re-evaluation • Still HTN • US showed possible bilateral renal artery stenosis

13. Question 2 • What is the most likely diagnosis? A. Fibromuscular dysplasia B. Medial fibroplasia C. Atherosclerotic renal artery disease D. Essential hypertension

14. Medial fibroplasia • Smooth highly stenotic lesions in children and adolescents. • Affects proximal, mid or distal portions of the renal artery. • Idiopathic intimal fibroplasia • Respond well to angioplasty.

19. Medial fibroplasia

21. After stenting

22. Learning Points • Always ask for the onset of hypertension • Look for secondary causes, even in adults

23. Case 2 • 33 year old female • 113 pounds • Severe hypertension of recent onset • Family history for HTN • Negative ultrasound • Positive CT scan for left adrenal mass • Not controlled on ACEI

24. Case 2

26. Question 3 • How often are adrenal masses non-functioning? • 80% • 50% • 20% • 10% • They always secret

27. Case 2 considerations • 80% of adrenal masses are non-functioning (“Incidentaloma”) • The test of choice is an upright plasma aldosterone–to–renin ratio (>30 and a plasma aldosterone concentration of greater than 18 ng/dL is suggestive of primary aldosteronism). • Normal suppression test

28. (Olmesartan/amlodipine)40/10 mg

29. Learning points • Onset of hypertension can be in the early 30’s • Although some tests are desirable to rule-out some secondary causes, sometimes, healthy, non-obese patients need only a combination therapy to achieve control.

30. Case 3 • 64 year female • DM, dyslipidemia, normal coronaries • Severe HTN. • Sleep apnea on CPAP. Compliant. • Taking HCTZ 25 mg, clonidine 0.2 prn, spironolactone 100 mg bid, carvedilol 50 mg bid, olmesartan/amlodipine 40/10 mg daily

31. Initial BP

33. Case 3 F/U • Added nisoldipine 20 mg • Normal kidney scan • Complaints of dizzy spells and syncope • Referred to Neurology

35. Case 3 • Normal CT and MRI • Possible neurocardiogenic syncope • Currently taking: Nisoldipine, carvedilol, olmesartan/amlodipine, spironolactone • Admitted to ER at Shawnee due to hyperkalemia and syncope

36. How often does the combination of ACEI/ARB + spironolactone result in hyperkalemia? • A. 10% • B. 5% • C <2% • D. 0% • E. 50%

37. Case 3 • Stopped Azor, spironolactone and carvedilol at the hospital • Only continued nisoldipine, HCTZ with erratic control. • Started: • Metoprolol 100 mg every day. • Aliskiren (Tekturna) 150 mg every day. • Felodipine 20 mg every day.

39. Case 3 • Reasonable control, less postural hypotension but tachycardic • Decided to increase betablockers, stop tekturna (risk of hyperkalemia) and start a clonidine patch, changed felodipine to olmesartan/amlodipine

40. Current medications • Clonidine patch 0.2 mg every week. • HCTZ 25 mg every day. • Metoprolol 100 mg b.i.d. • Olmesartan/Amlodipine 40/10 mg every day. Total 5 antihypertensives

41. 5 antihypertensives

42. 1 year after • The patient lost 50 pounds. She is down to 2 BP med’s and well controlled!

43. Learning points • Beware of side effects! • Hyperkalemia • Postural hypotension • Don’t be afraid to titrate up to maximal doses and add drugs or combination pills • Average 3 drugs per patient (4 if renal dysfunction). • Encourage the patients to lose weight!

44. Questions?