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  1. 1. MAY 31, 2008
  2. 2. SECONDARY HYPERTENSION <ul><ul><li>HYPERTENSION THAT RESULTS FROM AN UNDERLYING, IDENTIFIABLE, OFTEN CORRECTABLE CAUSE </li></ul></ul><ul><ul><li>5-10 % </li></ul></ul>
  3. 3. SECONDARY HYPERTENSION <ul><li>INCIDENCE < 5% </li></ul><ul><li>CLINICAL IMPORTANCE </li></ul><ul><li>UNLIKE ESSENTIAL HYPERTENSION – INCURABLE LIFE LONG DISORDER </li></ul><ul><li>SECONDARY HYPERTENSION – CURABLE BY REMOVING THE UNDERLYING CAUSE </li></ul><ul><li>CAUSES </li></ul><ul><li>RENAL PARENCHYMAL DISEASE E.G ACUTE NEPHRITIS, CHR. GN ETC. </li></ul><ul><li>RENOVASCULAR DISEASE E.G RAS, ATHEROSCLEROSIS ETC </li></ul><ul><li>CO-ARCTATION OF AORTA </li></ul><ul><li>ENDOCRINE CAUSES </li></ul>
  4. 4. RISK FACTORS FOR SECONDARY HYPERTENSION <ul><li>POOR RESPONSE TO THERAPY I.E. RESISTANT HYPERTENSION </li></ul><ul><li>WORSENING OF CONTROL IN PREVIOUSLY STABLE HYPERTENSIVE PATIENT </li></ul><ul><li>STAGE 3 HYPERTENSION ( SYSTOLIC BLOOD PRESSURE >180 mm Hg OR DIASTOLIC BLOOD PRESSURE >110 MM HG) </li></ul><ul><li>ONSET OF HYPERTENSION IN PERSON YOUNGER THAN 20 OR OLDER THAN 50 YRS </li></ul><ul><li>SIGNIFICANT HYPERTENSIVE TARGET ORGAN DAMAGE </li></ul><ul><li>LACK OF FAMILY HISTORY OF HYPERTENSION </li></ul><ul><li>FINDINGS ON HISTORY, PHYSICAL EXAMINATION OR LABORATORY TESTING THAT SUGGEST A SECONDARY CAUSE </li></ul>
  5. 5. ENDOCRINE HYPERTENSION <ul><li>ENDOCRINE HYPERTENSION IS AN UNCOMMON CAUSE OF RAISED BLOOD PRESSURE. </li></ul><ul><li>IT ACCOUNTS FOR LESS THAN 2% OF ALL CASES, BUT BECAUSE HYPERTENSION AFFECTS OVER 10% OF THE POPULATION, A SIGNIFICANT NUMBER OF PATIENTS HAVE AN UNDERLYING ENDOCRINE CAUSE TO EXPLAIN THEIR HIGH BLOOD PRESSURE. </li></ul>
  6. 6. ENDOCRINE HYPERTENSION <ul><li>RARE CAUSE OF HYPERTENSION </li></ul><ul><li>1 -2 % OF SECONDARY HTN </li></ul><ul><li>IN MAJORITY </li></ul><ul><li>1 . MINERALOCORTICOID EXCESS EG PRIMARY HYPERALDOSTERONISM </li></ul><ul><li>2. PHEOCROMOCYTOMA </li></ul><ul><li>3. GLUCOCORTICOID EXCESS EG CUSHINGS SYNDROME </li></ul><ul><li>OTHER CONDITIONS </li></ul><ul><li>ESTROGEN – INDUCED HYPERTENSION </li></ul><ul><li>PREGNANCY - INDUCED HYPERTENSION </li></ul><ul><li>HYPERPARATHYROIDISM </li></ul><ul><li>HYPOTHROIDISM </li></ul><ul><li>ACROMEGALY </li></ul><ul><li>CONGENTIAL ADRENAL HYPERPLASIA </li></ul><ul><li>LIDDLE SYDROME </li></ul><ul><li>RENIN SECRETING TUMORS </li></ul>
  7. 7. PHEOCROMOCYTOMA <ul><li>SYMPATHOCHROMAFFIN (SYMPATHOADRENAL) SYSTEM </li></ul><ul><li>PROTOTYPE NEUROENDOCRINE SYSTEM </li></ul><ul><li>TWO COMPONENTS </li></ul><ul><li>SYMPATHETIC NERVOUS SYSTEM (POST GANGLIONIC NEUROINES) </li></ul><ul><li>VAST MAJORITY RELEASE NOREPINEPHRINE (NORADRENALINE) </li></ul><ul><li>CROMAFFIN TISSUES INCLUDING ADRENAL MEDULAE – MAJOR SOURCE OF CIRCULATING EPINEPHRINE (ADRENALINE) </li></ul><ul><li>NOREPINEPHRINE + EPINEPHRINE + DOPAMINE = CATECHOLAMINES </li></ul>
  8. 8. <ul><li>“ PHEOCHROMOCYTOMAS ARE TUMORS THAT PRODUCE, STORE AND SECRETE CATECHOLAMINES.” </li></ul><ul><li>“ THE CLASSIC SYMPTOMS OF PHEOCHROMOCYTOMA INCLUDE HEADACHE, DIAPHORESIS, PALPITATIONS, AND PAROXYSMAL HYPERTENSION.” </li></ul>
  9. 9. CATHACHOLAMINE PRODUCTING TUMOURS CHROMAFFIN CELLS <ul><li>LABILE HYPERTENSION </li></ul><ul><li>PAROXYSMAL SYMPTOMS </li></ul><ul><li>RARE </li></ul><ul><li>0.1% OF HYPERTENSIVE PATIENTS </li></ul><ul><li>IMPORTANT TO DETECT BECAUSE </li></ul><ul><li>HTN CURABLE </li></ul><ul><li>UNTREATED – RISK OF LETHAL HTN </li></ul><ul><li>5-10% MALIGNANT </li></ul><ul><li>CLUE TO PRESENCE OF FAMILIAL & AUTOSOMAL SYNDOME </li></ul><ul><li>MEN-2A HYPERPARATHRODISM MEDULALLARY CA THYROID </li></ul><ul><li>2B MUCOSAL NEUROMAS, MEDULLARY CA THYROID </li></ul>
  10. 10. <ul><li>DIAGNOSIS </li></ul><ul><li>CLINICAL SUSPICION </li></ul><ul><li>BIOCHEMICAL CONFIRMATION </li></ul><ul><li>ANATOMICAL LOCALIZATION </li></ul><ul><li>CLINICAL </li></ul><ul><li>PAROXYSMM SYMPTOMS HEADACHE, DIAPHORESIS , PALPITATIONS </li></ul><ul><li>PPTED BY VARIETY OF STIMULI </li></ul><ul><li>POSITIONAL CHANGES </li></ul><ul><li>EMOTIONAL STRESS </li></ul><ul><li>ABDOMINAL PRESSURE </li></ul><ul><li>DIRECT PRESSURE ON TUMORS </li></ul><ul><li>MEDICATIONS </li></ul><ul><li>2. LABILE OR PAROXYSMAL HTN </li></ul><ul><li>3. F/H </li></ul><ul><li>METABOLIC FEATURES – SIGNS OF HYPERCATABOLISM </li></ul><ul><li> METABOLIC RATE </li></ul><ul><li>PROFUSE SWEATING </li></ul><ul><li>HYPERGLYCAEMIA (GLYCOSURIA) </li></ul><ul><li>WEIGT LOSS (INSPITE OF GOOD APPT) </li></ul><ul><li>ORTHOSTATIC HYPERTENSION + HYPERGLYCAEMIA + ERHROCYTOSIS </li></ul>
  11. 11. <ul><li>BIOCHEMICAL </li></ul><ul><li>24 HOUR URINE FOR CATHACHOLAMINE / VMA (PREFERABLE CATHACHRAMMES) </li></ul><ul><li>> 90% VALUES – TWICE NORMAL </li></ul><ul><li>AVOID HTNSIVES (CLONIDINE) </li></ul><ul><li>AVOID FALSE +VE </li></ul><ul><li>PLASMA CATECHOLAMINES </li></ul><ul><li>LOCALIZATION </li></ul><ul><li>90% ADRENAL MEDULLAE </li></ul><ul><li>99% ABDOMEN </li></ul><ul><li>REMAINDER – MEDIASTINUM </li></ul><ul><li>LOCALIZED CT </li></ul><ul><li>MRI </li></ul><ul><li>(IODOBENZYLGUANADINE SCINTIGRAPHY) </li></ul><ul><li>RULE OF 10% </li></ul><ul><li>MULTIPLE </li></ul><ul><li>BILATERAL </li></ul><ul><li>MALIGNANT </li></ul>
  12. 12. TYROSINE DIHYDROXY PHENYLALANINE (DOPA) CATHACHOLAMINES 3 – METHOXY 4 HYDROXY MANDELIC ACID VMA HYDROXYLATED DECARBOXYLATED DEGRADED
  13. 13. TREATMENT <ul><li>SURGICAL – EXPERIENCED SURGEONS </li></ul><ul><li>PRE OP CONTROL OF BP ( α – ADRENERGENIC) ANTAGONIST E.G. PHENOXY BENZAMINE, PRAZOSIN). </li></ul><ul><li>PREVENT CATASTROPHIC RISE IN BP DURING SURGICAL HANDLING OF TUMOR </li></ul><ul><li>SUCCESSFUL RESECTION. </li></ul><ul><li>PROMPT RESOLUTION OF HYPERTENSION </li></ul><ul><li>MOST GRATIFYING </li></ul>
  14. 14. HYPERALDOSTERISM PRIMARY SECONDARY <ul><li>BOTH RENIN & ALDOSTERONE </li></ul><ul><li>ECF VOLUME </li></ul><ul><li>(VOMITING / DIARREHA) </li></ul><ul><li> PERFUSION OF KIDNEYS </li></ul><ul><li>(CIRRHOSIS, HF, RAS) </li></ul><ul><li>OEDEMA </li></ul><ul><li>(SPIRONALATONE) </li></ul>EXCESS OF ALDOSTERONE ECF EXPANSION HTN MARKED SUPPRESSON OF RENIN SECRETION 2/3 ADENOMA < 2CM BILATERAL HYPERPLASIA
  15. 15. CLINICAL <ul><li>HYPERTENSION </li></ul><ul><li>HYPOKALAMIA </li></ul><ul><li> NA </li></ul><ul><li> ECF </li></ul><ul><li>VASCULAR RESISTANCE </li></ul><ul><li>MUSCULAR WEAKNESS </li></ul><ul><li>CRAMPS </li></ul><ul><li>POLYURIA </li></ul>
  16. 16. <ul><li>DIAGNOSIS </li></ul><ul><li>HYPERTENSION </li></ul><ul><li>SPONTANEOUS HYPOKALAMIA </li></ul><ul><li>URINARY POTASSIUM > 30 MMOL 24 HR </li></ul><ul><li> RENAL POTASSIUM WASTING </li></ul><ul><li>RENIN  </li></ul><ul><li>ALDOSTERONE  </li></ul><ul><li>SCREENING </li></ul><ul><li>PLASMA POTASSIUM (NOT ON DIURETICS) </li></ul><ul><li>PLASMA ALDOSTERONE / PLASMA ACTIVITY RATIO </li></ul><ul><li>< 30 NOT IRY </li></ul><ul><li>> 50 CERTAINLY IRY </li></ul><ul><li>ALDOSERONE SUPPRESSIN </li></ul><ul><li>2 LITER 0.9% SALINE I/V OVER 4 HOURS WITH PATIENT SUPINE NORMAL PLASMA ALDOSTERONE < 4MG/DL. </li></ul>
  17. 17. <ul><li>DD </li></ul><ul><li>INCIDENTAL ADRENAL NODULES </li></ul><ul><li>IRY DIAGNOSED BY ENDOCRINE </li></ul><ul><li>TESTING NOT RADIOLOGY </li></ul><ul><li>ADRENAL VENOUS ALDOSTERONE MEASUREMENTS </li></ul><ul><li>TREATMENT </li></ul><ul><li>RESECTION </li></ul>
  18. 18. GLUCORTICOID EXCESS HYPERCORTISOLISM CUSHING SYNDROME ACTH DEPENDENT PITUITARY DEPENDENT CUSHING DISEASE) 65% ECTOPIC ACTH PRODUCING 10% ACTH ADMINISTRATION NON -ACTH DEPENDENT ADRENAL 25% ADENOMA HYPERPLASIA CARCINOMA CORTICOSTEROID ADMINISTRATION
  19. 19. CUSHING’S SYNDROME <ul><li>HYPERCOTISOLISM </li></ul><ul><li>CUSHINGOID FACIES </li></ul><ul><li>CENTRAL OBESITY </li></ul><ul><li>PROXIMAL MUSCLE WEAKNESS </li></ul><ul><li>ECCHYMOSES </li></ul><ul><li>STRIAE </li></ul><ul><li>HYPERTENSION </li></ul><ul><li>GLUCOSE INTOLERANCE </li></ul>
  20. 20. DIAGNOSIS <ul><li>CIRCADIAN RHYTHM </li></ul><ul><li>24 HR URINARY COTRISOL </li></ul><ul><li>ACTH </li></ul><ul><li>LOW DOSE DEYAMETHASONE </li></ul><ul><li>HIGH DOSE DEXAMETHASONE TEST </li></ul>
  21. 21. IMAGING
  22. 22. SURGICAL
  23. 23. ENDOCRINE HYPERTENSION <ul><li>RARE CAUSE OF HYPERTENSION </li></ul><ul><li>1 -2 % OF SECONDARY HTN </li></ul><ul><li>IN MAJORITY </li></ul><ul><li>1 . MINERALOCORTICOID EXCESS EG PRIMARY HYPERALDOSTERONISM </li></ul><ul><li>2. PHEOCROMOCYTOMA </li></ul><ul><li>3. GLUCOCORTICOID EXCESS EG CUSHINGS SYNDROME </li></ul><ul><li>OTHER CONDITIONS </li></ul><ul><li>ESTROGEN – INDUCED HYPERTENSION </li></ul><ul><li>PREGNANCY - INDUCED HYPERTENSION </li></ul><ul><li>HYPERPARATHYROIDISM </li></ul><ul><li>HYPOTHROIDISM </li></ul><ul><li>ACROMEGALY </li></ul><ul><li>CONGENTIAL ADRENAL HYPERPLASIA </li></ul><ul><li>LIDDLE SYDROME </li></ul><ul><li>RENIN SECRETING TUMORS </li></ul>
  24. 24. <ul><li>CASE 1 </li></ul><ul><li>67 year old woman is referred to you by a psychiatrist to rule out an organic cause for “panic attacks” </li></ul><ul><li>She is somewhat anxious appearing and complains of severe “pounding” headaches, two to three times a week episodes of “breaking out in sweats,” palpitations, and nausea. </li></ul><ul><li>Her BP in clinic is 150/100. She says, “That must be a mistake, because at the psychiatrist’s office they checked me and I was much lower than that.” On exam, she is diaphoretic and her heart rate is tachycardic but regular. </li></ul>
  25. 25. CASE 2 <ul><ul><ul><li>19 MALE – ATTENDED OP </li></ul></ul></ul><ul><ul><ul><li>UNCONTROLLED BP 180 / 120 </li></ul></ul></ul><ul><ul><ul><li>INVESTIGATIONS DONE AT ABBOTABAD </li></ul></ul></ul><ul><ul><ul><li>HB 13.6 G </li></ul></ul></ul><ul><ul><ul><li>S.CREATININE 0.8 mEq </li></ul></ul></ul><ul><ul><ul><li>ECG </li></ul></ul></ul>MAK-AKU 2008
  26. 26. MAK-AKU 2008
  27. 27. INVESTIGATION DONE AT AKUH <ul><ul><ul><li>K+ 2.3 </li></ul></ul></ul><ul><ul><ul><li>2.6 </li></ul></ul></ul><ul><ul><ul><li>2.4 </li></ul></ul></ul><ul><ul><ul><li>RENIN 0.9 n/ml.hr ALDOSTERONE 60 n/dl </li></ul></ul></ul><ul><ul><ul><li>CT SCAN </li></ul></ul></ul><ul><ul><ul><li>OPERATED </li></ul></ul></ul>
  28. 29. THIS PATIENT HAS A BP 155/110
  29. 30. TAKE HOME MESSAGE <ul><li>EARLY, ABRUPT, RESISTANT, HYPERTENSION THINK ABOUT SECONDARY HYPERTENSION. </li></ul><ul><li>PAROXYSMAL HYPERTENSION, SWEATING, PALPITATIONS, HEADACHE PHEOCHROMOCYTOMA </li></ul><ul><li>MOST OF THE CAUSES ARE TREATABLE. </li></ul>
  30. 31. THANKYOU FOR YOUR ATTENTION MAK-AKU 2008

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