1. Presenter: Abdulrhman M. AlOmair Group: 4 Tutor: Dr. Ayub Ali Resistant Hypertension 6.1

2. CASE SUMMARY 43-year-old woman Visits her GP Complains from abdomina l pain, constipation, nocturia and general malaise She had high BP for which she has been prescribed ACE inhibitor with Hydrochlorothiazide

3. CASE SUMMARY P\E shows she had diffuse pressure pain in the abdomen and reduced peristalsis BP is 148/112 mmHg HR is 85 min -1, her BMI is 32 Reduced Plasma Reni n Activity and Elevated Aldosterone level

4. NORMAL VALUES Blood testPatient resultNormal valueinterpretation Ca ⁺⁺ 2.3 mmol/l2.2 – 2.6 mmol/lnormal Cl ⁻ 100 mmol/l97 – 107 mmol/lnormal Na ⁺ 146 mmol/l135 -145 mmol/lSlightly Increased( hypernatremia) K ⁺ 3.2 mmol/l3.6 – 5 mmol/lDecreased (Hypokalemia) Glucose5.3 mmol/l4 - 5.5mmol/lnormal

5. LEARNING OBJECTIVES  what is resistant hypertension and what can cause it?  What is the main problem in our case?  Why the antihypertensive medications didn’t work with the patient?  Causes of patient’s abdominal pain, reduced peristalsis and constipation?  What are the effects of reduced plasma ren in activity and increased aldosterone?  Diagnosis  Treatment

6. Resistant Hypertension  Resistant Hypertension: is high blood pressure that remains uncontrolled despite treatment wit h at least three antihypertensive agents.  Causes: Drug-induced hypertension, primary hyperaldosteronism, and chronic k idney disease.

7. THE MAIN COMPLAINT The patients has abdominal p ain, constipation, nocturia an d generalized malaise. The patient’s hypertension is not improving my medications.

8. CAUSES OF PATIENT’S SYMPTOMS Sign and symptomCause Abdominal pain and constipationhypokalemia > muscle weakness and cramps > less peristalsis > constipation Nocturiacertain drugs, including diuretics hy drochlorothiazide Generalized malaiseHypokalemia Acid-base imbalance Hypertensionhigh aldosterone > increased sodium > increased volume > increased BP

9. REASON FOR UNEFFECIENT MEDICATONS Because these anti-hypertensive drugs ( Hydrochlorothiazide and ACE inhibitor) which treat the hypertension, doesn't treat the main cause of hypertension in our case

10. Effects of reduced PRA and increased aldosterone  renin–angiotensin–aldosterone system (RAAS): is a hormone system that regulates blood pressure and water (fluid) balance.

11. CONT..  renin–angiotensin–aldosterone system (RAAS):  Main stimulus: low blood pressure  Effects: Increases blood pressure and extra-c ellular volume toward normal by increasing so dium and water reabsorption.  Effects in this case: Reduced by the drugs an d by the increase in blood pressure.

12. CONT..  Aldosterone:  Main stimulus: - Increased angiotensin II in ECF - Decreased when Na+ concentration increase in ECF  Effects: Increased Na+ reabsorption and K+ excretion leading to increase in blood pressure.  Effects in this case: Elevated and can cause high blood p ressure and low potassium levels.

13. QUIZ  Increased in Aldosterone concentration in the plasma, called: A. Hyperthyroidism B. Hyperaldosteronism C. Hypercalcemia

14. Hyperaldosteronism PrimarySecondary  The problem with adrenal gland itself.  Most cases caused by a b enign adrenal tumor  Low renin  Conn’s syndrome  No abnormalities with the adrenal cortex itself  Cirrhosis  heart failure  liver disease  Elevated renin  Cushing syndrome

15. Conn’s syndrome (primary hyperaldosteronism)  It is an endocrine disorder, characterized by excessive s ecretion of the aldosterone from the adrenal glands.  This excessive aldosterone is produced by one or more benign adrenal tumors ( adenoma ).

16. Diagnosis  What are other tests we can do it to reach the final diagnosis?  PAC:PRA ratio: A high ratio of PAC to PRA suggests primary hyperaldosteronism  Captopril Suppression Test: This test measures the body's response t o captopril.

17. Diagnosis  24-hour Urinary Excretion of Aldosterone Test: Patients eat a high-salt diet for five days, and th en undergo urine Tests during a 24-hour period.  Saline Suppression Test: the patient receives a salt solution through an IV.  (CT) scan or (MRI) scan

18. Treatment  1- Surgical removal of the gland: called (adrenalectomy) it may resolve high bl ood pressure and potassium deficiency, and r eturn aldosterone levels to normal.  2- Aldosterone antagonist drugs: to block the action of aldosterone suc h as; (spironolactone).  3- Life style and diet changes

19. Complication  Problems related to Hypertension: Heart attack Heart failure Left ventricular hypertrophy Stroke kidney failure  Problems related to low potassium levels: Weakness Cardiac arrhythmias Muscle cramps Excess thirst or urination

20. QUIZ Q) What is the syndrome that the patient has? A- Cushing syndrome B- Conn’s syndrome C- Down’s syndrome Q) Decreasing of potassium below the normal levels, called: A- Hypotension B- Hypoxia C- Hypokalemia

21. SUMMARY Adrenal Adenoma (Conn’s syndrome or Primary hyperaldosteronism ) Elevated Aldosteron e (Hyperaldosteronis m) Hypernatremia, Hypokalemia and hypertension Constipation, abdominal pain, malaise and Nocturia Diagnosis & treatment

22. REFERENCES

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