Udayan Bhatt, MD MPH OSU Nephrology Hypertension Cases Udayan Bhatt, MD MPH OSU Nephrology

Learning Objectives Identify the epidemiology of hypertension - both primary and secondary form. Identify clinical indicators of possible secondary hypertension. Define the common classes of medications used to treat hypertension and their common side effects.

Case 1 A 41-year-old Caucasian female with an 8-year history of hypertension which had previously been somewhat difficult to control has been referred to you clinic. She is on several classes of antihypertensive drugs, including amlodipine 10mg daily and metoprolol tartarate 25mg twice daily. She has no other past medical history. She does not have a family history of hypertension. At her visit, her blood pressure was 150/94 mmHg. She has no abdominal bruit. Her labs are significant for hypokalemia (3.0 mEq/l) with an elevated urine potassium. She was also noted to have a serum bicarbonate of 29meEq/L and a pH confirming mild metabolic alkalsosis. What would you expect the renin and aldosterone to be? A. High renin and high aldosterone B. High renin and low aldosterone C. Low renin and high aldosterone D. Low renin and low aldosterone

Actions of aldosterone in the kidney HCO3- H+ Aldosterone (net effect) H+ Na+ K+ Tubule lumen

Case 1 A 41-year-old Caucasian female with an 8-year history of hypertension which had previously been somewhat difficult to control has been referred to you clinic. She is on several classes of antihypertensive drugs, including amlodipine 10mg daily and metoprolol tartarate 25mg twice daily. She has no other past medical history. She does not have a family history of hypertension. At her visit, her blood pressure was 150/94 mmHg. She has no abdominal bruit. Her labs are significant for hypokalemia (3.0 mEq/l) with an elevated urine potassium. She was also noted to have a serum bicarbonate of 29meEq/L and a pH confirming mild metabolic alkalsosis. If surgery would not be possible, which of the following drugs could be utilized? A. ACE inhibitors B. ARBs C. Spironolactone D. All of the above

Case 2 A 24 year-old Caucasian female with a 5-year history of hypertension has been referred to you clinic. She is on lisinopril 10mg daily, HCTZ 25mg daily, and labetolol 200mg twice daily. She has no other past medical history. She has a family history of hypertension occurring in an elderly relative, heart disease and diabetes. At her visit, her blood pressure was 140/94 mmHg. She has a systolic/diastolic abdominal bruit. The rest of her exam is unremarkable. Is this a typical presentation for essential hypertension? A. Yes B. No

Case 2 A 24 year-old Caucasian female with a 5-year history of hypertension has been referred to you clinic. She is on lisinopril 10mg daily, HCTZ 25mg daily, and labetolol 200mg twice daily. She has no other past medical history. She has a family history of hypertension occurring in an elderly relative, heart disease and diabetes. At her visit, her blood pressure was 140/94 mmHg. She has a systolic/diastolic abdominal bruit. The rest of her exam is unremarkable. What would be an appropriate diagnostic test for hypertension? A. Renal arteriogram B. 24 hour urine for aldosterone C. Kidney biopsy D. 24 hour urine for catecholamines

Case 2 A 24 year-old Caucasian female with a 5-year history of hypertension has been referred to you clinic. She is on lisinopril 10mg daily, HCTZ 25mg daily, and labetolol 200mg twice daily. She has no other past medical history. She has a family history of hypertension occurring in an elderly relative, heart disease and diabetes. At her visit, her blood pressure was 140/94 mmHg. She has a systolic/diastolic abdominal bruit. The rest of her exam is unremarkable. What concerns would you have about her blood pressure regimen? A. She is not on hydralazine B. She is not on a diuretic C. She is of child bearing age on an ACEI D. None

Case 3 A 78 year-old male presents to your clinic with episodic, significant elevations in blood pressure. He has been hospitalized twice in the last year for hypertensive emergency. He was diagnosed with hypertension 3 years ago. He is on multiple blood pressure medications. He also has a past medical history of prostate hypertrophy, coronary artery disease, and COPD. On exam, he has a blood pressure of 158/94. Is this a typical presentation of essential hypertension? A. Yes B. No

Case 3 A 78 year-old male presents to your clinic with episodic, significant elevations in blood pressure. He has been hospitalized twice in the last year for hypertensive emergency. He was diagnosed with hypertension 3 years ago. He is on multiple blood pressure medications. He also has a past medical history of prostate hypertrophy, coronary artery disease, and COPD. On exam, he has a blood pressure of 158/94. What physical exam findings may also be seen in this patient? A. Bruits B. Poor pulses C. Spider angiomata D. Both A and B

Case 4 A 28 year-old male presents to your clinic with sustained hypertension. You learn that he was first told his blood pressure was elevated during high school and Division I football physicals. He is on multiple blood pressure medications. He has no other past medical history. On exam, he has a blood pressure of 164/94. He is 6’8” and over 300lbs. The remainder of his exam is normal. Is this a typical presentation of essential hypertension? A. Yes B. No

Case 4 A 28 year-old male presents to your clinic with sustained hypertension. You learn that he was first told his blood pressure was elevated during high school and Division I football physicals. He is on multiple blood pressure medications. He has no other past medical history. On exam, he has a blood pressure of 164/94. He is 6’8” and over 300lbs. The remainder of his exam is normal. On further questioning, his brother mentions that he frequently falls asleep in the middle of playing video games. Which diagnostic test would be the most helpful? A. Renal arteriogram B. 24 hour urine for aldosterone C. Sleep study D. 24 hour urine for catecholamines

Matching Toxicities Agents Highly teratogenic Hydralazine Drug induced lupus Terazosin Cyanide toxicity Clonidine Rare cases of cardiac tamponade Furosemide First dose effect Hydrochlorothiazide (HCTZ) Withdrawal syndrome frequent Amiloride Diuretic used to treat hypercalcemia Methyldopa Diuretic that can cause hypercalcemia Minoxidil Cough Sodium nitroprusside Used with other diuretics to control hypokalemia ACE Inhibitor Useful in pregnancy associated hypertension Metoprolol Beware of depression

Matching Toxicities Agents Highly teratogenic Hydralazine Drug induced lupus Terazosin Cyanide toxicity Clonidine Rare cases of cardiac tamponade Furosemide First dose effect Hydrochlorothiazide (HCTZ) Withdrawal syndrome frequent Amiloride Diuretic used to treat hypercalcemia Methyldopa Diuretic that can cause hypercalcemia Minoxidil Cough Sodium nitroprusside Used with other diuretics to control hypokalemia ACE Inhibitor Useful in pregnancy associated hypertension Metoprolol Beware of depression

Matching Toxicities Agents Highly teratogenic Hydralazine Drug induced lupus Terazosin Cyanide toxicity Clonidine Rare cases of cardiac tamponade Furosemide First dose effect Hydrochlorothiazide (HCTZ) Withdrawal syndrome frequent Amiloride Diuretic used to treat hypercalcemia Methyldopa Diuretic that can cause hypercalcemia Minoxidil Cough Sodium nitroprusside Used with other diuretics to control hypokalemia ACE Inhibitor Useful in pregnancy associated hypertension Metoprolol Beware of depression

Matching Toxicities Agents Highly teratogenic Hydralazine Drug induced lupus Terazosin Cyanide toxicity Clonidine Rare cases of cardiac tamponade Furosemide First dose effect Hydrochlorothiazide (HCTZ) Withdrawal syndrome frequent Amiloride Diuretic used to treat hypercalcemia Methyldopa Diuretic that can cause hypercalcemia Minoxidil Cough Sodium nitroprusside Used with other diuretics to control hypokalemia ACE Inhibitor Useful in pregnancy associated hypertension Metoprolol Beware of depression

Matching Toxicities Agents Highly teratogenic Hydralazine Drug induced lupus Terazosin Cyanide toxicity Clonidine Rare cases of cardiac tamponade Furosemide First dose effect Hydrochlorothiazide (HCTZ) Withdrawal syndrome frequent Amiloride Diuretic used to treat hypercalcemia Methyldopa Diuretic that can cause hypercalcemia Minoxidil Cough Sodium nitroprusside Used with other diuretics to control hypokalemia ACE Inhibitor Useful in pregnancy associated hypertension Metoprolol Beware of depression

Matching Toxicities Agents Highly teratogenic Hydralazine Drug induced lupus Terazosin Cyanide toxicity Clonidine Rare cases of cardiac tamponade Furosemide First dose effect Hydrochlorothiazide (HCTZ) Withdrawal syndrome frequent Amiloride Diuretic used to treat hypercalcemia Methyldopa Diuretic that can cause hypercalcemia Minoxidil Cough Sodium nitroprusside Used with other diuretics to control hypokalemia ACE Inhibitor Useful in pregnancy associated hypertension Metoprolol Beware of depression

Matching Toxicities Agents Highly teratogenic Hydralazine Drug induced lupus Terazosin Cyanide toxicity Clonidine Rare cases of cardiac tamponade Furosemide First dose effect Hydrochlorothiazide (HCTZ) Withdrawal syndrome frequent Amiloride Diuretic used to treat hypercalcemia Methyldopa Diuretic that can cause hypercalcemia Minoxidil Cough Sodium nitroprusside Used with other diuretics to control hypokalemia ACE Inhibitor Useful in pregnancy associated hypertension Metoprolol Beware of depression

Matching Toxicities Agents Highly teratogenic Hydralazine Drug induced lupus Terazosin Cyanide toxicity Clonidine Rare cases of cardiac tamponade Furosemide First dose effect Hydrochlorothiazide (HCTZ) Withdrawal syndrome frequent Amiloride Diuretic used to treat hypercalcemia Methyldopa Diuretic that can cause hypercalcemia Minoxidil Cough Sodium nitroprusside Used with other diuretics to control hypokalemia ACE Inhibitor Useful in pregnancy associated hypertension Metoprolol Beware of depression

Matching Toxicities Agents Highly teratogenic Hydralazine Drug induced lupus Terazosin Cyanide toxicity Clonidine Rare cases of cardiac tamponade Furosemide First dose effect Hydrochlorothiazide (HCTZ) Withdrawal syndrome frequent Amiloride Diuretic used to treat hypercalcemia Methyldopa Diuretic that can cause hypercalcemia Minoxidil Cough Sodium nitroprusside Used with other diuretics to control hypokalemia ACE Inhibitor Useful in pregnancy associated hypertension Metoprolol Beware of depression

Matching Toxicities Agents Highly teratogenic Hydralazine Drug induced lupus Terazosin Cyanide toxicity Clonidine Rare cases of cardiac tamponade Furosemide First dose effect Hydrochlorothiazide (HCTZ) Withdrawal syndrome frequent Amiloride Diuretic used to treat hypercalcemia Methyldopa Diuretic that can cause hypercalcemia Minoxidil Cough Sodium nitroprusside Used with other diuretics to control hypokalemia ACE Inhibitor Useful in pregnancy associated hypertension Metoprolol Beware of depression

Matching Toxicities Agents Highly teratogenic Hydralazine Drug induced lupus Terazosin Cyanide toxicity Clonidine Rare cases of cardiac tamponade Furosemide First dose effect Hydrochlorothiazide (HCTZ) Withdrawal syndrome frequent Amiloride Diuretic used to treat hypercalcemia Methyldopa Diuretic that can cause hypercalcemia Minoxidil Cough Sodium nitroprusside Used with other diuretics to control hypokalemia ACE Inhibitor Useful in pregnancy associated hypertension Metoprolol Beware of depression

Matching Toxicities Agents Highly teratogenic Hydralazine Drug induced lupus Terazosin Cyanide toxicity Clonidine Rare cases of cardiac tamponade Furosemide First dose effect Hydrochlorothiazide (HCTZ) Withdrawal syndrome frequent Amiloride Diuretic used to treat hypercalcemia Methyldopa Diuretic that can cause hypercalcemia Minoxidil Cough Sodium nitroprusside Used with other diuretics to control hypokalemia ACE Inhibitor Useful in pregnancy associated hypertension Metoprolol Beware of depression

Secondary Hypertension Etiology Summary Renal Chronic kidney disease Adrenal Hyperaldosteronism Pheochromocytoma Cushing’s Syndrome Thyroid/Parathyroid Hypothyroidism Hyperparathyroidism Vascular Renovascular disease Coarctation of the aorta Other Medications (NSAIDs, OCP, stimulants, etc.) Sleep apnea

Thank You Please feel free to contact me with questions Udayan.bhatt@osumc.edu 614-293-4997