Title: Diagnosis of Secondary Hypertension
1Diagnosis of Secondary Hypertension
- Morris Brown
- University of Cambridge
2Apparent Prevalence of Secondary Hypertension
3Apparent Prevalence of Secondary Hypertension
4http//www.hyp.ac.uk/bhs/images/abcd_bhsis_version
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5Measure plasma renin
6Measure plasma renin
High (gt400 mU/L)
Low (lt10 mU/L)
Renal Artery Stenosis
Conns Syndrome
7Measure plasma renin
High (gt100 mU/L)
Low (lt20 mU/L)
8Causes of secondary hypertension
9Causes of secondary hypertension
- Reversible
- Renal
- Endocrine
- Vascular
- Iatrogenic/toxic
- Irreversible
- Renal
- Monogenic syndromes
10Causes of secondary hypertension
- Reversible
- Renal
- Endocrine
- Vascular
- Iatrogenic/toxic
- Irreversible
- Renal
- Monogenic syndromes
- Renal artery stenosis
- Small pyelonephritic kidney
- Large hydronephrotic kidney
- Renin secreting tumor
11Causes of secondary hypertension
- Reversible
- Renal
- Endocrine
- Vascular
- Iatrogenic/toxic
- Irreversible
- Renal
- Monogenic syndromes
- Adrenal
- Conns
- Phaeochromocytoma
12Causes of secondary hypertension
- Reversible
- Renal
- Endocrine
- Vascular
- Iatrogenic/toxic
- Irreversible
- Renal
- Monogenic syndromes
- Co-arctation
- Vasculitis
- Takayasu
- Polyarteritis
- Scleroderma
13Causes of secondary hypertension
- Reversible
- Renal
- Endocrine
- Vascular
- Iatrogenic/toxic
- Irreversible
- Renal
- Monogenic syndromes
- Drugs
- Glucocorticoids
- NSAIDs
- Decongestants
- Liquorice
- Alcohol
14Causes of secondary hypertension
- Reversible
- Renal
- Endocrine
- Vascular
- Iatrogenic/toxic
- Irreversible
- Renal
- Monogenic syndromes
- Chronic Renal Failure
- Polycystic kidneys
15Poiseuilles Law and Hypertension
BP Peripheral Resistance x Cardiac Output
16Poiseuilles Law and Hypertension
BP Peripheral Resistance x Cardiac Output
Renin
Aldosterone
Angiotensin II (AII)
BP
N
A
Na
or
drenaline
Volume
Vasoconstriction
17Two types of hypertension type 1 (high-renin)
arteries
Angiotensinogen
AI
AII
Renin
adrenal glands
Aldosterone
kidneys
18Two types of hypertension type 2 (low-renin)
arteries
Angiotensinogen
AI
AII
Renin
adrenal glands
Aldosterone
kidneys
Na
Na
19Two types of drugs for hypertension 1Brown MJ.
Matching the right drug to the right patient.
Heart 200186113-120.
arteries
Angiotensinogen
AI
AII
Renin
adrenal glands
Aldosterone
kidneys
20Two types of drugs for hypertension 2Brown MJ.
Matching the right drug to the right patient.
Heart 200186113-120.
arteries
Angiotensinogen
AI
AII
Renin
adrenal glands
Aldosterone
kidneys
21Two types of drugs for hypertensionBrown MJ.
Matching the right drug to the right patient.
Heart 200186113-120.
arteries
Angiotensinogen
AI
AII
Renin
adrenal glands
Aldosterone
kidneys
22Principal pathways and disorders altering sodium
reabsorption in the nephron
Monogenic Syndromes of Hypertension are due to
molecular variants of the Na channels inhibited
by the diuretics
23Principal pathways and disorders altering sodium
reabsorption in the nephron
Monogenic Syndromes of Hypertension are due to
molecular variants of the Na channels inhibited
by the diuretics
24Principal pathways and disorders altering sodium
reabsorption in the nephron
Monogenic Syndromes of Hypertension are due to
molecular variants of the Na channels inhibited
by the diuretics
25Monogenic and secondary syndromes of
hypertension individual response to treatment
26Monogenic and secondary syndromes of
hypertension individual response to treatment
27Monogenic and secondary syndromes of
hypertension individual response to treatment
28Investigations for secondary hypertension
- Screening (i.e. all patients)
- Plasma electrolytes
- Plasma renin
- 24-h urine VMA (or other index of catecholamine
secretion)
29Investigations for secondary hypertension
- Screening (i.e. all patients)
- Plasma electrolytes
- Plasma renin
- 24-h urine VMA (or other index of catecholamine
secretion) - Specialised
- Renal
- Vascular
- MAG3 Scan
- Angiography (MR/CT) MRI/CT Scan
- (Renal vein sampling)
30MAG3 Renogram
Pre-Captopril
31MAG3 Renogram
Pre-Captopril
32MAG3 Renogram
333-D CT- and conventional angiogram 23 year old
accelerated hypertension
34Renal Vein Sampling for ReninRenin (Random)
9-56 mU/L
IVC Suprarenal 307
Aorta 287
LRV 522
RRV 259
IVC Infrarenal 242
35MR angiogram
22 year old man BP 160/120 mmHg on atenolol
lisinopril Creatinine 110 umol/L Renin 23mU/l
(9-56) on Atenolol 578mU/l on Candesartan
36MR angiogram suprarenal aortic stenosis
37 year old woman BP 210/52 mm Hg on 5
drugs Diffuse bruit front back Plasma renin
257 mU/L (5 x ULN) - repeated
off B 4672
182/57
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38Renin-secreting tumour
WATANABE et al. Juxtaglomerular cell tumor.
International Journal of Urology 9 (12) 704-706
39Polycystic kidneys
Polycystic kidneys
40Investigations for secondary hypertension
- Screening (i.e. all patients)
- Plasma electrolytes
- Plasma renin
- 24-h urine VMA (or other index of catecholamine
secretion) - Specialised
- Adrenal
- Conns tumour
- Plasma aldosterone
- MRI/CT Scan
- Adrenal vein sampling
41Coronal MRI Scan of Conns Tumour
42CT Scan of Conns Tumour
43CT Scan of Conns Tumour
Untreated
Amlodipine
Spironolactone
Adrenalectomy
Brown Hopper. Calcium-channel blockade can mask
the diagnosis of Conns syndrome. Postgrad Med J
199975235-6.
44Selective adrenal vein sampling
45Selective adrenal vein sampling
46Influence of AB drugs on plasma renin
47Influence of AB drugs on plasma renin
48Investigations for secondary hypertension
- Screening (i.e. all patients)
- Plasma electrolytes
- Plasma renin
- 24-h urine VMA (or other index of catecholamine
secretion) - Specialised
- Adrenal
- Phaeochromocytoma
- Plasma catecholamines
- MRI/CT Scan
- MIBG Scan
- Selective venous sampling
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50Adrenal phaeochromocytomaCT and 123I-mIBG scans
51More phaeos
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