Transcript ΔΕΥΤΕΡΟΠΑΘΗΣ ΥΠΕΡΤΑΣΗ

Secondary Hypertension: Adrenal and
Nervous Systems
Ανδρέας Πιτταράς
Καρδιολόγος
Clinical Hypertension Specialist ESH
Υπερτασικό ιατρείο Τζάνειο νοσοκομείο
Υπερηχοκαρδιογραφικό εργαστήριο ΝΜΥΑ ΙΚΑ
Adrenocortical Causes of Hypertension
The adrenal cortex can cause hypertension
Pathways of adrenal steroidogenesis
Algorithmic approach to mineralocorticoid-induced
hypertension
Hypertensive Syndromes Secondary to
Hypersecretion of Deoxycorticosterone
Abnormalities of steroid production
Findings on physical examination
17 -hydroxylase deficiency syndrome
Physical characteristics
Hypertensive Syndromes Secondary to
Cortisol Excess
Causes of Cushing's syndrome
Abdominal striae caused by excess cortisol
production
Ectopic adrenocorticotropic hormone excess
Inferior petrosal sinus sampling for ACTH
Inferior petrosal sinuses before and after oCRH
OHSD deficiency syndromes
Hypertensive Syndromes Secondary to
Hypersecretion of Aldosterone
Primary aldosteronism
Primary aldosteronism can occur at all ages
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
Serum potassium concentrations in primary aldosteronism
Stimulated plasma renin activity in primary aldosteronism
Aldosterone excretion rate
Plasma aldosterone concentration
Sensitivity and specificity of screening tests
Biochemical confirmation of adenoma versus hyperplasia
MEASUREMENTS
ADENOMA BILATERAL HYPERPLASIA
Serum potassium, mEq/L
3.0
3.0
100
100
Plasma 18-OHB, ng/dL
Plasma aldosterone response to ambulation
Decrease
Increase
Urinary 18-hydroxycortisol
Increase
Normal
CT scan of normal adrenal glands
CT scan of a right adrenal tumor
Venography of a left adrenal tumor
Diagnostic accuracy of iodocholesterol NP-59 scanning
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
Hemodynamic features of primary aldosteronism
Diuretic therapy in patients with primary
aldosteronism
Relationship between plasma volume and arterial BP
Calcium antagonists as alternatives to diuretics
Surgery is indicated in patients with solitary adenomas
Influence of the severity of hypertension on BP response
after surgery
Efficacy of long-term medical management of aldosteroneproducing adenomas
ELECTROLYTE LEVELS AT DIAGNOSIS
ELECTROLYTE LEVELS AT LAST FOLLOW-UP
PATIENT
AGE y
SEX
FOLLOW-UP, y
BLOOD PRESSURE AT PRESENTATION*, mm Hg
MOST RECENT BLOOD PRESSURE*, mm Hg
SODIUM
POTASSIUM
CHLORIDE
CARBON DIOXIDE
SODIUM
POTASSIUM
CHLORIDE
Comparison of eplerenone and spironolactone
Glucocorticoid-remediable aldosteronism
Pheochromocytoma
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
Pathologic features of pheochromocytoma
Differential diagnosis of pheochromocytoma
-Adrenergic hyperresponsiveness
Acute state of anxiety
Angina pectoris
Acute infections
Autonomic epilepsy
Hyperthyroidism
Idiopathic orthostatic hypotension
Cerebellopontine angle tumors
Acute hypoglycemia
Acute drug withdrawal (Clonidine - Adrenergic blockade
-Methyldopa Alcohol)
Vasodilator therapy (Hydralazine, Minoxidil)
Factitious administration of sympathomimetic agents
Tyramine ingestion in patients on monoamine oxidase
inhibitors
Menopausal syndrome with migraine headaches
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)
Supine resting plasma catecholamines
Relationship between BP and plasma catecholamines
Effect of clonidine on BP
Clonidine suppression test in pheochromocytoma
Glucagon stimulation test for pheochromocytoma
Urinary normetanephrine values
Comparison of indexes of catecholamine production
Sensitivity and specificity of tests for pheochromocytoma
Three modalities used to localize pheochromocytomas
Three modalities used to localize pheochromocytomas
Three modalities used to localize pheochromocytomas
Three modalities used to localize pheochromocytomas
Diagnostic strategies in pheochromocytoma
Medical management of pheochromocytoma
Perioperative hemodynamic variables
OPEN, n=20
Mean preoperative blood pressure*, mm Hg
140 18/78 10
Highest blood pressure*, mm Hg
Hypertension
SBP 200 mm Hg
Lowest blood pressure*, mm Hg
LAPAROSCOPIC, n=14
P VALUE
144 13/74 14
0.50
194 19/106 19
0.50
0.5 (0 5)
1.0 (0 3)
0.41
0 (0 4)
0 (0 2)
0.70
98 19/57 8
0.05
191 33/98 25
88 14/50 13
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
1.0
0.02
*Systolic
9.0
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.
Blood pressure response to calcium antagonists
References