1) This document discusses the diagnosis and management of primary aldosteronism according to the 2016 Endocrine Society guideline.
2) It outlines the three phase diagnostic workup including screening tests, confirmatory tests, and differentiation of unilateral vs bilateral disease.
3) Recent studies have challenged some recommendations and confirmed others, prompting an update on current approaches to medical management of primary aldosteronism.
The ATHENA trial evaluated the drug dronedarone for reducing cardiovascular hospitalization and death in patients with atrial fibrillation. It found that dronedarone reduced the primary composite endpoint of all-cause mortality and cardiovascular hospitalization by 24% compared to placebo. It also decreased cardiovascular death by 30% and the risk of arrhythmia-related death by 45%. However, dronedarone was associated with higher rates of gastrointestinal side effects, skin disorders, and increased creatinine levels.
The ATHENA trial evaluated the drug dronedarone for reducing cardiovascular hospitalization and death in patients with atrial fibrillation. It found that dronedarone reduced the primary composite endpoint of all-cause mortality and cardiovascular hospitalization by 24% compared to placebo. It also decreased cardiovascular death by 30% and the risk of arrhythmia-related death by 45%. However, dronedarone was associated with higher rates of gastrointestinal side effects, skin disorders, and increased creatinine levels.
DAPT trial evaluated whether 30 months of dual antiplatelet therapy (DAPT) was superior to 12 months in patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stent placement. The trial found that prolonged DAPT reduced stent thrombosis and major adverse cardiac and cerebrovascular events compared to aspirin alone, but increased bleeding risk. An analysis of the trial developed the DAPT score to predict ischemic and bleeding risks and help determine optimal DAPT duration for individual patients. Newer PRECISE-DAPT and other scores further refine risk stratification to personalize DAPT duration based on balancing ischemic benefit versus bleeding risk.
2019 ESC guidelines on pulmonary embolismSaitej Reddy
The document provides an overview of the updates in the 2019 guidelines for pulmonary embolism (PE) diagnosis and treatment. Key changes include adjusted D-dimer cut-off values based on age and probability; revised algorithms for diagnosing high-risk PE and assessing severity; recommending non-vitamin K antagonist oral anticoagulants as first-line treatment for eligible patients; classifying recurrence risk factors and extending treatment duration indications; and proposing a comprehensive post-PE patient follow-up algorithm. The guidelines aim to improve PE risk stratification, optimize acute care, determine chronic anticoagulation regimens, and ensure long-term management and surveillance for complications.
Acute pulmonary embolism is a form of venous thromboembolism that occurs when a blood clot breaks off and lodges in the pulmonary arteries of the lungs. The clinical presentation of PE can be variable and non-specific, making diagnosis challenging. It is important to efficiently evaluate patients suspected of having a PE to diagnose and treat it quickly in order to reduce morbidity and mortality. Treatment involves hemodynamic and respiratory support, initial anticoagulation with drugs like heparin, and potentially reperfusion therapies for more severe cases including thrombolysis or embolectomy.
Hematologic drugs are used to treat various blood disorders like thrombosis, bleeding, and anemia. The document discusses several classes of drugs including anticoagulants, antiplatelets, thrombolytics, agents to treat bleeding, antihyperlipidemics, and antianemics. Specific drugs within each class like heparin, warfarin, aspirin, streptokinase, iron, and erythropoietin are explained in terms of their mechanisms of action, indications, adverse effects and nursing considerations.
1) Chronic thromboembolic pulmonary hypertension (CTEPH) is a form of pulmonary hypertension that results from chronic obstruction of the pulmonary arteries by thromboembolic material.
2) CTEPH can be treated through pulmonary endarterectomy (PEA) surgery to remove the obstructive material, which provides long-term benefits. For inoperable cases or persistent PH after PEA, medical therapies targeting the prostacyclin, endothelin, and nitric oxide pathways may provide clinical improvements.
3) The document reviews the definition, epidemiology, risk factors, diagnosis, management options including PEA surgery outcomes, and evidence for medical therapies of CTEPH.
The ATHENA trial evaluated the drug dronedarone for reducing cardiovascular hospitalization and death in patients with atrial fibrillation. It found that dronedarone reduced the primary composite endpoint of all-cause mortality and cardiovascular hospitalization by 24% compared to placebo. It also decreased cardiovascular death by 30% and the risk of arrhythmia-related death by 45%. However, dronedarone was associated with higher rates of gastrointestinal side effects, skin disorders, and increased creatinine levels.
The ATHENA trial evaluated the drug dronedarone for reducing cardiovascular hospitalization and death in patients with atrial fibrillation. It found that dronedarone reduced the primary composite endpoint of all-cause mortality and cardiovascular hospitalization by 24% compared to placebo. It also decreased cardiovascular death by 30% and the risk of arrhythmia-related death by 45%. However, dronedarone was associated with higher rates of gastrointestinal side effects, skin disorders, and increased creatinine levels.
DAPT trial evaluated whether 30 months of dual antiplatelet therapy (DAPT) was superior to 12 months in patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stent placement. The trial found that prolonged DAPT reduced stent thrombosis and major adverse cardiac and cerebrovascular events compared to aspirin alone, but increased bleeding risk. An analysis of the trial developed the DAPT score to predict ischemic and bleeding risks and help determine optimal DAPT duration for individual patients. Newer PRECISE-DAPT and other scores further refine risk stratification to personalize DAPT duration based on balancing ischemic benefit versus bleeding risk.
2019 ESC guidelines on pulmonary embolismSaitej Reddy
The document provides an overview of the updates in the 2019 guidelines for pulmonary embolism (PE) diagnosis and treatment. Key changes include adjusted D-dimer cut-off values based on age and probability; revised algorithms for diagnosing high-risk PE and assessing severity; recommending non-vitamin K antagonist oral anticoagulants as first-line treatment for eligible patients; classifying recurrence risk factors and extending treatment duration indications; and proposing a comprehensive post-PE patient follow-up algorithm. The guidelines aim to improve PE risk stratification, optimize acute care, determine chronic anticoagulation regimens, and ensure long-term management and surveillance for complications.
Acute pulmonary embolism is a form of venous thromboembolism that occurs when a blood clot breaks off and lodges in the pulmonary arteries of the lungs. The clinical presentation of PE can be variable and non-specific, making diagnosis challenging. It is important to efficiently evaluate patients suspected of having a PE to diagnose and treat it quickly in order to reduce morbidity and mortality. Treatment involves hemodynamic and respiratory support, initial anticoagulation with drugs like heparin, and potentially reperfusion therapies for more severe cases including thrombolysis or embolectomy.
Hematologic drugs are used to treat various blood disorders like thrombosis, bleeding, and anemia. The document discusses several classes of drugs including anticoagulants, antiplatelets, thrombolytics, agents to treat bleeding, antihyperlipidemics, and antianemics. Specific drugs within each class like heparin, warfarin, aspirin, streptokinase, iron, and erythropoietin are explained in terms of their mechanisms of action, indications, adverse effects and nursing considerations.
1) Chronic thromboembolic pulmonary hypertension (CTEPH) is a form of pulmonary hypertension that results from chronic obstruction of the pulmonary arteries by thromboembolic material.
2) CTEPH can be treated through pulmonary endarterectomy (PEA) surgery to remove the obstructive material, which provides long-term benefits. For inoperable cases or persistent PH after PEA, medical therapies targeting the prostacyclin, endothelin, and nitric oxide pathways may provide clinical improvements.
3) The document reviews the definition, epidemiology, risk factors, diagnosis, management options including PEA surgery outcomes, and evidence for medical therapies of CTEPH.
2019 ESC guidelines for pulmonary embolism Dina Mostafa
The document summarizes the key points of the 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism (PE). Some of the main updates in the new guidelines include: using age-adjusted D-dimer cut-offs rather than fixed values; revising the risk stratification algorithm to emphasize multidisciplinary care and early risk assessment; strengthening recommendations for rescue thrombolysis and interventional treatments for unstable patients; and recommending direct oral anticoagulants over warfarin as first-line treatments. The guidelines also provide a dedicated diagnostic algorithm for PE in pregnancy and recommend follow-up care after PE to monitor for long-term sequelae.
Acs0538 Disorders Of The Adrenal Glandsmedbookonline
This document summarizes the evaluation and management of disorders of the adrenal glands, focusing on primary hyperaldosteronism. It describes the clinical presentation of primary hyperaldosteronism and the initial biochemical evaluation. It outlines the diagnostic algorithm, including confirmation with suppression testing and distinguishing between subtypes. It discusses distinguishing aldosterone-producing adenomas from idiopathic hyperaldosteronism and evaluating indeterminate cases with adrenal vein sampling or imaging. Surgical treatment with laparoscopic adrenalectomy is recommended for unilateral macroadenomas, while bilateral disease is usually treated medically.
This study assessed the safety and efficacy of octreotide in treating post-cardiac surgery chylothorax in pediatric patients over 12 years. The study found that octreotide resolved chylothorax in 62% of patients, with complete resolution in 28% and partial resolution in 34%. Octreotide failed to resolve chylothorax in 38% who required thoracic duct ligation. Common minor side effects included transient hyperglycemia, abdominal distension, and tachycardia, but no patients discontinued octreotide due to side effects. The study concludes that octreotide shows promising benefits for treating post-cardiac surgery chylothorax with an acceptable safety profile.
This document summarizes a literature review on thromboprophylaxis in intensive care unit (ICU) patients. It was published on September 21, 2018 after being reviewed from September 7-9, 2018. The review discusses the epidemiology and risk factors of thromboembolism in ICU patients. It also examines the challenges of diagnosing deep vein thrombosis and pulmonary embolism in critically ill patients. Finally, it analyzes the existing evidence on pharmacological thromboprophylaxis using heparins as well as mechanical thromboprophylaxis for high-bleeding risk ICU patients.
The ALPHEUS trial compared ticagrelor to clopidogrel in reducing periprocedural myocardial injury in 1900 stable coronary patients undergoing high-risk elective PCI. Patients received a loading dose of either ticagrelor 180mg or clopidogrel 300-600mg before PCI, followed by 30 days of maintenance therapy. The primary outcome of periprocedural MI or major myocardial injury within 48 hours did not differ between groups. No differences were found in secondary outcomes including death or MI at 30 days. Ticagrelor did not increase major bleeding but was associated with more minor bleeding and dyspnea. The study concluded that higher platelet inhibition from ticagrelor did not translate to reduced per
1) The ATLANTIC study compared the efficacy and safety of pre-hospital initiation of ticagrelor versus in-hospital initiation in STEMI patients undergoing primary PCI. The study found no significant differences between the groups in measures of coronary reperfusion or clinical outcomes up to 30 days.
2) Rates of ST-segment resolution, TIMI flow grade 3, and a composite of these measures were similar between the groups both before and after PCI. Clinical event rates for death, MI, revascularization were also not significantly different.
3) There was a non-significant reduction in early stent thrombosis (within 24 hours of PCI) with pre-hospital ticagrelor, but no significant differences
High risk pulmonary embolism , Dr David JimenezFundacion EPIC
Presentación de "High risk pulmonary embolism" por el Dr David Jimenez del Hospital Ramón y Cajal, en el I Curso IVP, Intervencionismo Vascular Pulmonar, organizado por EpicLearning (Fundación EPIC) el 23 de marzo de 2021.
This document summarizes key information about giant pheochromocytomas. It discusses the anatomy, presentation, diagnosis and management of these rare tumors. Giant pheochromocytomas are defined as greater than 7 cm in size. While most are benign, malignancy cannot be ruled out without evidence of metastasis. The document compares laparoscopic and open surgical approaches for removing giant pheochromocytomas, finding laparoscopic surgery to be feasible and superior with fewer complications. Long term postoperative surveillance with biochemical testing and imaging is important due to the risk of recurrence or metastasis.
Management of pulmonary embolism in emergency departmentdrbarai
An short overview of the diagnostic approach and treatment options for Pulmonary Embolism which is a Medical Emergency. In the USA alone about 600,000 people are diagnosed with Pulmonary Embolism every year. However, this is just the tip of the iceberg as many more people have sudden head due to this notorious condition. This Power Point presentation will give you some idea based on my experience in the Emergency Departments in 3 continents of the world.
This document summarizes a presentation on diagnosing pulmonary embolism (PE) in the emergency department. It discusses guidelines for PE diagnosis and reasons clinicians may not follow guidelines. It also looks at using D-dimer tests and Wells criteria to evaluate patients and focuses on managing younger patients, pregnant patients, and diagnosing subsegmental PE.
This document summarizes a presentation given by Prof Kyaw Soe Win on arterial health in hypertension. The presentation covered:
- Cardiovascular diseases are now major causes of mortality, with hypertension as a common risk factor.
- Lifestyle changes like urbanization have led to increased stress and sedentary lifestyles, contributing to rising hypertension rates globally.
- Treating hypertension can significantly reduce cardiovascular outcomes. More intensive control of blood pressure through 24-hour coverage can further reduce risks.
- Choosing antihypertensive drugs that improve arterial health in addition to blood pressure control may maximize cardiovascular protection. Perindopril was highlighted as having properties that protect the endothelium.
This document summarizes pulmonary embolism (PE), including its causes, symptoms, diagnosis, and treatment. PE occurs when blood clots or other substances block arteries in the lungs, and is usually caused by deep vein thrombosis. Common symptoms include chest pain, difficulty breathing, and cough. Diagnosis involves tests like plasma D-dimer levels, ECGs, lung scans, and pulmonary angiography. Treatment focuses on anticoagulation therapy, and sometimes thrombolytic therapy or inferior vena cava filters for severe cases. Prognosis is generally good with proper diagnosis and treatment.
This document discusses pulmonary hypertension (PH) in patients with rheumatic diseases. It provides recommendations on diagnosing and classifying PH based on guidelines from the European Society of Cardiology and European Respiratory Society. PH is often detected through echocardiogram screening in asymptomatic patients with connective tissue diseases like scleroderma. Right heart catheterization is necessary to confirm a diagnosis of PH. While drug treatments for PH have shown benefits in clinical trials, their effectiveness may be more limited in patients with PH associated with connective tissue diseases compared to those with idiopathic PH. Strict diagnosis and classification of PH type is important to determine appropriate treatment management in rheumatic disease patients.
Pulmonary thromboembolism Management and prophylaxisMd Shahid Iqubal
1. Risk stratification of PE involves clinical assessment, evaluation of right ventricular size and function, and analysis of cardiac biomarkers.
2. Management of normotensive PE with normal RV involves anticoagulation alone while hypotensive PE requires primary therapy like thrombolysis or embolectomy.
3. Anticoagulation options include parenteral anticoagulants bridging to warfarin or novel oral anticoagulants like Rivaroxaban. LMWH is preferred in pregnant women. The duration of anticoagulation depends on whether the PE was provoked or unprovoked.
A pulmonary embolism occurs when a blood clot or other material occludes the pulmonary artery or its branches. This most commonly results from a deep vein thrombosis in the lower leg that embolizes to the lung. When a PE occurs, it causes ventilation-perfusion mismatching in the lungs. Diagnosis is difficult due to nonspecific symptoms but evaluation involves a Wells criteria assessment, D-dimer testing, echocardiogram, and CT pulmonary angiogram. Treatment consists of anticoagulation with low molecular weight heparin or novel oral anticoagulants. Fibrinolytic therapy may be used in massive PEs. Prevention focuses on prophylaxis in high risk hospitalized patients.
This document defines pulmonary embolism and describes its causes, risk factors, symptoms, diagnostic tests, and treatment options. Pulmonary embolism is caused by blockage of the pulmonary arteries, most commonly by blood clots originating in the deep veins of the lower extremities. It can be diagnosed based on risk factors, symptoms of dyspnea and chest pain, and tests including D-dimer, CT scans, ventilation/perfusion scans and pulmonary angiography. Treatment involves blood thinners, thrombolytic drugs, or occasionally surgery to restore blood flow in severe cases.
Patient with chronic PE treatment options - dr Szymon Darochapiodof
This document discusses treatment options for a 52-year-old female patient with chronic thromboembolic pulmonary hypertension (CTEPH) who is not eligible for pulmonary endarterectomy surgery. It provides background on CTEPH, describes the patient's condition and past treatment history, and reviews the potential for balloon pulmonary angioplasty (BPA) as an alternative treatment approach. BPA involves using a balloon catheter to break up clots and scar tissue in the lungs and has shown promising results in some CTEPH patients who cannot undergo surgery. The document also shares early experience with BPA from another medical center and reviews its safety profile.
This document provides a summary of articles across various medical specialties discussed in the April 2015 edition of the UTSW Journal Watch. In the Hepatology section, an article is summarized that finds corticosteroids may be safely used in patients with severe alcoholic hepatitis who present with an upper GI bleed after bleeding is controlled. In Pulmonary/Critical Care, a summary is provided of a trial finding no difference in mortality between early goal-directed therapy and usual care for treating septic shock. The study suggests protocols for goals of care are less important than early antibiotics and fluids. In Nephrology, a meta-analysis summary indicates preoperative use of renin-angiotensin system inhibitors may be linked to
This document provides a critical evaluation of laboratory tests used in the diagnosis and assessment of acute pancreatitis. It discusses the advantages and limitations of commonly used tests like serum amylase and lipase. While amylase remains an important initial test due to its availability and sensitivity, it lacks specificity. Lipase has greater sensitivity in alcoholic pancreatitis and late presentations, but can also be nonspecifically elevated. No single test can accurately diagnose, assess severity, or determine the etiology of acute pancreatitis. Multiple tests and factors like time of testing must be considered.
2019 ESC guidelines for pulmonary embolism Dina Mostafa
The document summarizes the key points of the 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism (PE). Some of the main updates in the new guidelines include: using age-adjusted D-dimer cut-offs rather than fixed values; revising the risk stratification algorithm to emphasize multidisciplinary care and early risk assessment; strengthening recommendations for rescue thrombolysis and interventional treatments for unstable patients; and recommending direct oral anticoagulants over warfarin as first-line treatments. The guidelines also provide a dedicated diagnostic algorithm for PE in pregnancy and recommend follow-up care after PE to monitor for long-term sequelae.
Acs0538 Disorders Of The Adrenal Glandsmedbookonline
This document summarizes the evaluation and management of disorders of the adrenal glands, focusing on primary hyperaldosteronism. It describes the clinical presentation of primary hyperaldosteronism and the initial biochemical evaluation. It outlines the diagnostic algorithm, including confirmation with suppression testing and distinguishing between subtypes. It discusses distinguishing aldosterone-producing adenomas from idiopathic hyperaldosteronism and evaluating indeterminate cases with adrenal vein sampling or imaging. Surgical treatment with laparoscopic adrenalectomy is recommended for unilateral macroadenomas, while bilateral disease is usually treated medically.
This study assessed the safety and efficacy of octreotide in treating post-cardiac surgery chylothorax in pediatric patients over 12 years. The study found that octreotide resolved chylothorax in 62% of patients, with complete resolution in 28% and partial resolution in 34%. Octreotide failed to resolve chylothorax in 38% who required thoracic duct ligation. Common minor side effects included transient hyperglycemia, abdominal distension, and tachycardia, but no patients discontinued octreotide due to side effects. The study concludes that octreotide shows promising benefits for treating post-cardiac surgery chylothorax with an acceptable safety profile.
This document summarizes a literature review on thromboprophylaxis in intensive care unit (ICU) patients. It was published on September 21, 2018 after being reviewed from September 7-9, 2018. The review discusses the epidemiology and risk factors of thromboembolism in ICU patients. It also examines the challenges of diagnosing deep vein thrombosis and pulmonary embolism in critically ill patients. Finally, it analyzes the existing evidence on pharmacological thromboprophylaxis using heparins as well as mechanical thromboprophylaxis for high-bleeding risk ICU patients.
The ALPHEUS trial compared ticagrelor to clopidogrel in reducing periprocedural myocardial injury in 1900 stable coronary patients undergoing high-risk elective PCI. Patients received a loading dose of either ticagrelor 180mg or clopidogrel 300-600mg before PCI, followed by 30 days of maintenance therapy. The primary outcome of periprocedural MI or major myocardial injury within 48 hours did not differ between groups. No differences were found in secondary outcomes including death or MI at 30 days. Ticagrelor did not increase major bleeding but was associated with more minor bleeding and dyspnea. The study concluded that higher platelet inhibition from ticagrelor did not translate to reduced per
1) The ATLANTIC study compared the efficacy and safety of pre-hospital initiation of ticagrelor versus in-hospital initiation in STEMI patients undergoing primary PCI. The study found no significant differences between the groups in measures of coronary reperfusion or clinical outcomes up to 30 days.
2) Rates of ST-segment resolution, TIMI flow grade 3, and a composite of these measures were similar between the groups both before and after PCI. Clinical event rates for death, MI, revascularization were also not significantly different.
3) There was a non-significant reduction in early stent thrombosis (within 24 hours of PCI) with pre-hospital ticagrelor, but no significant differences
High risk pulmonary embolism , Dr David JimenezFundacion EPIC
Presentación de "High risk pulmonary embolism" por el Dr David Jimenez del Hospital Ramón y Cajal, en el I Curso IVP, Intervencionismo Vascular Pulmonar, organizado por EpicLearning (Fundación EPIC) el 23 de marzo de 2021.
This document summarizes key information about giant pheochromocytomas. It discusses the anatomy, presentation, diagnosis and management of these rare tumors. Giant pheochromocytomas are defined as greater than 7 cm in size. While most are benign, malignancy cannot be ruled out without evidence of metastasis. The document compares laparoscopic and open surgical approaches for removing giant pheochromocytomas, finding laparoscopic surgery to be feasible and superior with fewer complications. Long term postoperative surveillance with biochemical testing and imaging is important due to the risk of recurrence or metastasis.
Management of pulmonary embolism in emergency departmentdrbarai
An short overview of the diagnostic approach and treatment options for Pulmonary Embolism which is a Medical Emergency. In the USA alone about 600,000 people are diagnosed with Pulmonary Embolism every year. However, this is just the tip of the iceberg as many more people have sudden head due to this notorious condition. This Power Point presentation will give you some idea based on my experience in the Emergency Departments in 3 continents of the world.
This document summarizes a presentation on diagnosing pulmonary embolism (PE) in the emergency department. It discusses guidelines for PE diagnosis and reasons clinicians may not follow guidelines. It also looks at using D-dimer tests and Wells criteria to evaluate patients and focuses on managing younger patients, pregnant patients, and diagnosing subsegmental PE.
This document summarizes a presentation given by Prof Kyaw Soe Win on arterial health in hypertension. The presentation covered:
- Cardiovascular diseases are now major causes of mortality, with hypertension as a common risk factor.
- Lifestyle changes like urbanization have led to increased stress and sedentary lifestyles, contributing to rising hypertension rates globally.
- Treating hypertension can significantly reduce cardiovascular outcomes. More intensive control of blood pressure through 24-hour coverage can further reduce risks.
- Choosing antihypertensive drugs that improve arterial health in addition to blood pressure control may maximize cardiovascular protection. Perindopril was highlighted as having properties that protect the endothelium.
This document summarizes pulmonary embolism (PE), including its causes, symptoms, diagnosis, and treatment. PE occurs when blood clots or other substances block arteries in the lungs, and is usually caused by deep vein thrombosis. Common symptoms include chest pain, difficulty breathing, and cough. Diagnosis involves tests like plasma D-dimer levels, ECGs, lung scans, and pulmonary angiography. Treatment focuses on anticoagulation therapy, and sometimes thrombolytic therapy or inferior vena cava filters for severe cases. Prognosis is generally good with proper diagnosis and treatment.
This document discusses pulmonary hypertension (PH) in patients with rheumatic diseases. It provides recommendations on diagnosing and classifying PH based on guidelines from the European Society of Cardiology and European Respiratory Society. PH is often detected through echocardiogram screening in asymptomatic patients with connective tissue diseases like scleroderma. Right heart catheterization is necessary to confirm a diagnosis of PH. While drug treatments for PH have shown benefits in clinical trials, their effectiveness may be more limited in patients with PH associated with connective tissue diseases compared to those with idiopathic PH. Strict diagnosis and classification of PH type is important to determine appropriate treatment management in rheumatic disease patients.
Pulmonary thromboembolism Management and prophylaxisMd Shahid Iqubal
1. Risk stratification of PE involves clinical assessment, evaluation of right ventricular size and function, and analysis of cardiac biomarkers.
2. Management of normotensive PE with normal RV involves anticoagulation alone while hypotensive PE requires primary therapy like thrombolysis or embolectomy.
3. Anticoagulation options include parenteral anticoagulants bridging to warfarin or novel oral anticoagulants like Rivaroxaban. LMWH is preferred in pregnant women. The duration of anticoagulation depends on whether the PE was provoked or unprovoked.
A pulmonary embolism occurs when a blood clot or other material occludes the pulmonary artery or its branches. This most commonly results from a deep vein thrombosis in the lower leg that embolizes to the lung. When a PE occurs, it causes ventilation-perfusion mismatching in the lungs. Diagnosis is difficult due to nonspecific symptoms but evaluation involves a Wells criteria assessment, D-dimer testing, echocardiogram, and CT pulmonary angiogram. Treatment consists of anticoagulation with low molecular weight heparin or novel oral anticoagulants. Fibrinolytic therapy may be used in massive PEs. Prevention focuses on prophylaxis in high risk hospitalized patients.
This document defines pulmonary embolism and describes its causes, risk factors, symptoms, diagnostic tests, and treatment options. Pulmonary embolism is caused by blockage of the pulmonary arteries, most commonly by blood clots originating in the deep veins of the lower extremities. It can be diagnosed based on risk factors, symptoms of dyspnea and chest pain, and tests including D-dimer, CT scans, ventilation/perfusion scans and pulmonary angiography. Treatment involves blood thinners, thrombolytic drugs, or occasionally surgery to restore blood flow in severe cases.
Patient with chronic PE treatment options - dr Szymon Darochapiodof
This document discusses treatment options for a 52-year-old female patient with chronic thromboembolic pulmonary hypertension (CTEPH) who is not eligible for pulmonary endarterectomy surgery. It provides background on CTEPH, describes the patient's condition and past treatment history, and reviews the potential for balloon pulmonary angioplasty (BPA) as an alternative treatment approach. BPA involves using a balloon catheter to break up clots and scar tissue in the lungs and has shown promising results in some CTEPH patients who cannot undergo surgery. The document also shares early experience with BPA from another medical center and reviews its safety profile.
This document provides a summary of articles across various medical specialties discussed in the April 2015 edition of the UTSW Journal Watch. In the Hepatology section, an article is summarized that finds corticosteroids may be safely used in patients with severe alcoholic hepatitis who present with an upper GI bleed after bleeding is controlled. In Pulmonary/Critical Care, a summary is provided of a trial finding no difference in mortality between early goal-directed therapy and usual care for treating septic shock. The study suggests protocols for goals of care are less important than early antibiotics and fluids. In Nephrology, a meta-analysis summary indicates preoperative use of renin-angiotensin system inhibitors may be linked to
This document provides a critical evaluation of laboratory tests used in the diagnosis and assessment of acute pancreatitis. It discusses the advantages and limitations of commonly used tests like serum amylase and lipase. While amylase remains an important initial test due to its availability and sensitivity, it lacks specificity. Lipase has greater sensitivity in alcoholic pancreatitis and late presentations, but can also be nonspecifically elevated. No single test can accurately diagnose, assess severity, or determine the etiology of acute pancreatitis. Multiple tests and factors like time of testing must be considered.
This document provides clinical practice guidelines for the detection, diagnosis, and treatment of patients with primary aldosteronism from The Endocrine Society. It recommends:
1) Screening higher risk groups of hypertensive patients for primary aldosteronism, including those with resistant or severe hypertension, spontaneous hypokalemia, an adrenal incidentaloma, or a family history of early hypertension.
2) Using the aldosterone-renin ratio to detect cases of primary aldosteronism in at-risk patients.
3) Confirming suspected cases of primary aldosteronism with further testing before proceeding to subtype classification.
4) Performing adrenal CT scanning
Resistant hypertension is defined as blood pressure that remains above goal despite concurrent use of three antihypertensive agents of different classes, one of which should be a diuretic. It has a prevalence of 0.5-24.7% depending on the population. Causes include nonadherence, lifestyle factors like obesity and sleep apnea, secondary causes like primary aldosteronism and renal artery stenosis, and drug interactions. Evaluation involves assessing medication adherence, lifestyle behaviors, screening for secondary causes with tests like the aldosterone-renin ratio, and imaging of the kidneys and arteries. Management consists of optimizing lifestyle modifications, adjusting medications like adding mineralocorticoid receptor antagonists, and treating any identified
The document discusses updates to guidelines for defining and diagnosing pulmonary hypertension from the 5th World Symposium on Pulmonary Hypertension held in 2013. Key points include: maintaining the general definition of PH as a mPAP over 25 mm Hg, collecting more data on borderline PH cases with mPAP between 21-24 mm Hg, and not reintroducing exercise-induced PH criteria due to a lack of suitable definition. Recommendations are also provided on measuring and interpreting pulmonary vascular resistance and pulmonary artery wedge pressure during right heart catheterization.
1. Pulmonary embolism is an obstruction of the pulmonary artery or its branches by a thrombus originating in the venous system or right side of the heart.
2. The annual incidence of PE ranges from 23-69 cases per 100,000 population in India. Globally, the incidence of venous thromboembolism remains relatively constant at 117 cases per 100,000 person-years.
3. Diagnosis involves using criteria like Wells criteria and PERC rule to determine pre-test probability, D-dimer testing, and imaging like CT pulmonary angiography or lung scan if needed based on risk level and test results. Management involves anticoagulation with heparin or low molecular weight he
This document summarizes the presentation, evaluation, and management of acute upper gastrointestinal bleeding (UGIB). It discusses risk stratification tools like the Blatchford and Rockall scores used to predict patient risk and need for intervention. It recommends early endoscopy within 24 hours for high risk patients to determine the source of bleeding and administer endoscopic therapy if needed. For high risk patients with lesions like active bleeding, endoscopic therapy with methods like injection and thermal therapy is recommended to decrease rebleeding risk. Proton pump inhibitors are recommended as adjunct medical therapy for 72 hours to promote clot stability and healing. Surgery is now reserved for uncontrolled bleeding after failed endoscopic therapy while angiography may be considered if endoscopy fails
This ppt is prepared from content of braunwald, and some latest international journals. In account it make more clear concept about pulmonary hypertension.
it also contain latest ESC 2022 guidelines of pulmonary hypertension.
Pulmonary hypertension is defined as a mean pulmonary artery pressure greater than 25 mmHg. It is classified based on whether the elevation in pressure is pre-capillary or post-capillary. The pathogenesis involves various changes in the pulmonary vasculature that lead to increased pulmonary vascular resistance. Diagnosis involves symptoms, physical exam findings, imaging like echocardiogram, and right heart catheterization. Treatment aims to improve hemodynamics and symptoms through pulmonary vasodilators and diuretics. Anesthetic management of pulmonary hypertension patients requires optimizing preload, afterload, and contractility while avoiding triggers of pulmonary hypertension. Close monitoring is important both intraoperatively and postoperatively.
This document discusses pulmonary embolism (PE), including its definition, epidemiology, risk factors, pathophysiology, clinical features, diagnosis, and management. Some key points:
- PE is an obstruction of the pulmonary artery or its branches by a thrombus originating in the venous system or right heart. It is a common cause of preventable death in hospitalized patients.
- The annual incidence of PE ranges from 23-69 cases per 100,000 people in India. Worldwide, the incidence of venous thromboembolism (which includes PE and DVT) is 117 cases per 100,000 person-years.
- Risk factors for PE include hereditary clotting disorders, immobil
This document summarizes a clinical trial evaluating the safety and effectiveness of catheter-based renal denervation for treating uncontrolled hypertension. The trial was a prospective, randomized, single-blind study comparing renal denervation to a sham control procedure in over 500 patients. The trial met its primary safety endpoint but did not meet its primary efficacy endpoint of a reduction in systolic blood pressure of at least 5 mmHg. In response, the manufacturer suspended enrollment in other renal denervation hypertension trials pending further review, but will continue post-market surveillance and studies of non-hypertension indications based on the procedure's demonstrated safety profile.
The document discusses the management of upper gastrointestinal bleeding (UGIB) in the emergency room. It recommends initial resuscitation including IV access and fluid resuscitation. Patients should be risk stratified using scoring systems like Rockall or Blatchford to determine need for endoscopy. Early endoscopy within 24 hours is recommended to identify risk level and manage high risk lesions. Post-endoscopy, high-dose PPIs should be given and H. pylori testing and treatment initiated if positive to prevent rebleeding.
This document provides an overview of the key changes and recommendations in the 2019 guidelines for pulmonary embolism (PE). Some of the major updates include: revised criteria for diagnosing PE using D-dimer tests and imaging; a new definition of high-risk PE and assessment of severity; and preference for non-vitamin K antagonist oral anticoagulants as first-line treatment in eligible patients. The guidelines also provide new algorithms for diagnosing and managing PE in pregnancy and long-term follow-up care after PE.
This document summarizes the topics discussed at a journal club meeting led by Dr. Praveen Nagula. It includes discussions on valvular heart disease patterns in India, guidelines for ambulatory blood pressure monitoring, baroreflex activation therapy, electrocardiogram challenges, and the PREVAIL trial. It also reviews the incidence and characteristics of various valvular lesions seen on echocardiography at a large cardiac center in India, highlighting rheumatic heart disease as a major cause. Guidelines for the clinical use and interpretation of ambulatory blood pressure monitoring are summarized.
The document summarizes extracorporeal photopheresis (ECP) for the treatment of graft-versus-host disease (GVHD). ECP involves separating a patient's white blood cells from red blood cells, treating the white cells with a photosensitizing agent and ultraviolet light, and returning the treated cells to the patient. A case series of 27 pediatric patients found that ECP induced complete or partial remission in 11 of 21 acute GVHD patients and 3 of 6 chronic GVHD patients, with a median time to response of two to four cycles. Adverse events were mild. ECP may provide an effective treatment option for GVHD patients who fail standard steroid therapies.
This document discusses several studies related to atrial fibrillation and anticoagulation therapy:
1. A study of over 13,000 AF patients found higher baseline BNP levels were associated with increased risk of AF progression and major adverse cardiovascular events.
2. A direct comparison of dabigatran, rivaroxaban, and apixaban found apixaban and rivaroxaban had comparable safety and effectiveness to dabigatran in real-world practice, though major bleeding occurred more frequently with apixaban and rivaroxaban.
3. A study of NOAC safety in obese patients undergoing electrical cardioversion found no incidents of stroke, suggesting NOACs may be safe
1) The EAST-AFNET trial compared an early rhythm control strategy to usual care for patients with recent-onset atrial fibrillation.
2) The early rhythm control strategy involved early use of antiarrhythmic drugs or ablation to maintain sinus rhythm, while usual care followed guidelines.
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This document provides a review of treatment-resistant hypertension for cardiologists. It defines treatment-resistant hypertension and discusses the importance of 24-hour ambulatory blood pressure monitoring to confirm true resistant cases and rule out white coat hypertension. It emphasizes that secondary hypertension is common in resistant cases and that screening for causes like obstructive sleep apnea, renal disease, and primary aldosteronism is important. The review provides guidance on evaluating patients for resistant hypertension and managing treatment.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
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2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
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There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
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Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
2. EuropeanJournalofEndocrinology
179:1 R20Review T A Williams and M Reincke Management of primary
aldosteronism
www.eje-online.org
the population with hypertension has greatly increased
the diagnosis of PA (2). It is now widely accepted that
this syndrome is the most common form of endocrine
hypertension. PA is specifically treated by unilateral
adrenalectomy (preferably by laparoscopic surgery) or
pharmacologically with a mineralocorticoid receptor
(MR) antagonist that competitively inhibits the binding
of aldosterone to the MR (3).
Patients with PA have an increased risk of
cardiovascular and cerebrovascular events and target
organ damage (heart and kidney) relative to patients with
essential hypertension and a matched cardiovascular risk
profile (4, 5, 6, 7) or compared with the general population
with hypertension (8). Patients with PA also display an
increased prevalence of metabolic syndrome and diabetes
(4, 9, 10, 11), osteoporotic fractures (12) and symptoms
of depression with a reduced quality of life (13, 14). Some
of these comorbidities may be associated with cortisol
co-secretion (15). All available evidence indicates that
an early diagnosis and appropriate clinical management
(surgical or medical) is mandatory to minimize the
increased risks associated with PA (5, 16, 17, 18).
The diagnostic management of PA comprises
three phases: screening tests, case confirmation and
differentiation of unilateral from bilateral forms of PA for
therapeutic decision making and appropriate treatment
(Fig. 1).
Diagnosis: screening
Measurement of plasma aldosterone concentrations
(PACs) and plasma renin activity (PRA) or the direct
renin concentration (DRC) to assess the ARR is the most
reliable currently available method of screening for PA.
The Endocrine Society (ES) Clinical Practice Guideline
recommends screening patients with an increased
likelihood of PA (Table 1) (3). It has been suggested that
all patients with hypertension should be screened for
PA (19), based on the findings of the prospective PATO
study (8), which reported a 5.9% prevalence of PA in
1672 unselected patients with hypertension in primary
care (8). However, evidence that a systematic screening
approach (compared with selective screening) results in
a reduction of morbidity, mortality and cardiovascular
disease of patients with hypertension to an extent that
would justify the increased costs and burden on health
systems is lacking.
To screen for PA by the ARR, it is recommended
that medications interfering with the renin-angiotensin
system, and specifically those that may stimulate renin
secretion, should be withdrawn (this applies throughout
the diagnostic workup for PA because other tests and
procedures also rely on measurements of steroids under
conditions of suppressed renin). Antihypertensive
medication that interferes with the ARR includes diuretics
(including spironolactone) and should be withdrawn for
4 weeks. Other drugs that should be withdrawn, but for
a lesser period of 2 weeks prior to testing, are β-blockers,
clonidine, methyldopa, non-steroidal anti-inflammatory
drugs, ACE inhibitors, angiotensin receptor blockers and
dihydropyridine calcium blockers (3, 20). However, in
many instances, interpretation of the ARR is confidently
possible without changing interfering medications. Non-
dihydropyridine long-acting calcium channel blockers
(verapamil or diltiazem), the vasodilator hydralazine
Figure 1
Flow chart for the diagnostic workup of primary
aldosteronism. *Please refer to Table 1 for patients with
hypertension to be screened for PA ADX, adrenalectomy; CT,
computer-assisted tomography; MR, mineralocorticoid
receptor; PA, primary aldosteronism.
3. EuropeanJournalofEndocrinology
179:1 R21Review T A Williams and M Reincke Management of primary
aldosteronism
www.eje-online.org
and α1-adrenergic receptor blockers have limited or
no effects on the ARR compared to the above and are
suggested to control hypertension in those patients with
elevated blood pressure requiring medical treatment (3,
20). As a caveat, severe deleterious side effects have been
reported by adjustment of antihypertensive therapy in
accordance with the ES guideline during screening for
PA (21). In our center, more than 90% of patients receive
adjusted medication according to the ES guideline
during screening, and serious adverse events have been
reduced to a minimum after appropriate exclusion of
high-risk patients.
Before performing the ARR screening test, patients
should avoid a low salt diet and have a minimum intake
of 5 g NaCl/day. Hypokalemia, if present, should be
corrected. To allow activation of the renin-angiotensin
system, blood samples are withdrawn in the morning
when patients have been out of bed for ≥2 h. The
assay characteristics and the use of different available
commercial assays for the measurement of PAC, PRA or
DRC can highly influence the ARR (22). The method
dependence of aldosterone and renin measurements
has contributed to the lack of a standardized cut-off
value for ARR screening and the wide variability in
upper reference limits used across centers. The Japan
ES Guidelines recommend a specific cut-off for the ARR
(ARR > 200 with PAC in pg/mL and PRA in ng/mL/h and
indicate that the risk of PA increases with PAC > 120–
150 pg/mL) with a specific commercially available
assay (23). Radioimmunoassays are widely employed
for the measurement of plasma PAC, PRA or DRC but
assays using chemiluminescence have been shown to
be reliable alternatives (24, 25, 26) using simultaneous
assays for PAC and DRC (24).
An elevated ARR can result if the PRA (or DRC) is
very low even if the PAC is low-normal and inconsistent
with PA. Some centers do not proceed with the diagnostic
workup of PA of such patients and require a minimum
PAC in addition to an elevated ARR for a positive screening
test. At least, baseline PAC should be higher than the
normal range of confirmatory tests, as discussed later (20).
Diagnosis: confirmatory testing
Confirmatory testing is considered mandatory by the ES
guideline for a definitive diagnosis of PA. An exception is
in evident cases of PA with spontaneous hypokalemia and
a PAC > 20 ng/dL (550 pmol/L) with PRA (or DRC) below
assay detection limits (3). Confirmation or exclusion of
the diagnosis of PA is performed by ≥1 confirmatory tests
as recommended by the ES guideline (3).
Confirmatory tests demonstrate the inappropriate
production of aldosterone in response to exogenously
administered agents that normally completely suppress or
inhibit circulating angiotensin II levels (the endogenous
positive regulator of aldosterone production). The
test thereby confirms that aldosterone production is
autonomous of the renin-angiotensin system.
Potassium is a key regulator of aldosterone production
and hypokalemia (if present) should be corrected with
slow-release KCl tablets prior to confirmatory testing
because failure to do so may produce a false-negative
result. Since sodium chloride infusion during confirmatory
testing may further deteriorate plasma potassium levels we
administer KCl tablets even in patients with low-normal
potassium levels. Stress-induced increases of ACTH –
indicated by an increase in plasma cortisol concentration
– can interfere with aldosterone suppression and produce
a false-positive test result. Consequently, cortisol levels
should be monitored during confirmatory testing, and the
aldosterone response interpreted with caution if increased
cortisol levels indicate inappropriate stress at the end of
the test.
The most commonly employed suppression tests
use saline loading (either by intravenous infusion or
orally), fludrocortisone (FST) or a captopril challenge
(Table 2). Confirmatory testing based on saline loading
are widely in use because they are straight forward and
reliable and have low costs but saline loading by infusion
(2 L i.v. infusion of 0.9% NaCl over 4 h) or oral sodium
intake (6 g/day for 3 days, aldosterone measured in a 24 h
urine collection over days 3–4) carry the risk of acute
volume overload especially in those predisposed by left
Table 1 Screening for primary aldosteronism.
Risk groups recommended to be screened for primary
aldosteronism according to ES guideline
Patients with sustained blood pressure above
150/100 mmHg, grade 2 and grade 3 hypertension
Patients with resistant hypertension (blood pressure not
controlled by three conventional drugs including a
diuretic) or controlled BP (140/90 mmHg) on four or
more antihypertensive drugs
Patients with hypertension and spontaneous or diuretic
induced hypokalemia
Patients with hypertension and an adrenal incidentaloma
Patients with hypertension and sleep apnea
Patients with hypertension and a family history of
early-onset hypertension or cerebrovascular accident at a
young age (40 years)
All first-degree relatives of patients with PA
Includes data from Funder et al. (3) and Stowasser Gordon (20).
4. EuropeanJournalofEndocrinology
179:1 R22Review T A Williams and M Reincke Management of primary
aldosteronism
www.eje-online.org
ventricular or renal dysfunction. The saline infusion
test has a sensitivity of 83% using a cut-off of 6.8 ng/
dL (188 pmol/L) (27) and 88% using a cut-off of 5.0 ng/
dL (139 pmol/L) (28). A recent study suggested that up
to 29% of patients with PA with suppressed aldosterone
below 5.0 ng/dL (139 pmol/L) were patients with unilateral
aldosteronism and candidates for surgery (29). The authors
suggest that patients with an elevated ARR and elevated
basal aldosterone concentrations may directly undergo
AVS without a suppression test, a strategy also proposed
in the recently published guideline for patients with
hypokalemia (3). The sensitivity of the saline infusion
test is reportedly increased by performing the test in
the seated position (29, 30, 31). The captopril challenge
test (25–50 mg orally administered captopril after sitting
or standing for 1 h) is likewise easily performed and
circumvents potential fluid overload in patients who are
at risk due to compromised renal or cardiac function. The
FST requires the consumption of fludrocortisone with
sodium and potassium supplementation and up to 5-day
hospitalization to ensure control of blood pressure and
plasma potassium concentrations that must be closely
monitored throughout the test because of the risk of
hypokalemia. Proponents of the FST highlight the safety
of the test in expert hands with a superior sensitivity
compared with other methods (a detailed protocol
is described in Stowasser Gordon (20)). The test is
nonetheless unfeasible in most countries because of cost
limitations imposed by the requirement for several days
of hospitalization.
Diagnosis: subtype differentiation
Subtype diagnosis begins with the exclusion of patients
with a rare form of PA caused by an aldosterone-
producing carcinoma using an imaging technique such
as CT scanning or magnetic resonance imaging (MRI).
The value of CT scanning and MRI have been questioned
since they might not faithfully distinguish the source of
aldosterone excess, and micro-APAs (≤10 mm in diameter)
are often undetectable by current imaging methods (32,
33). In addition, the proportion of patients with adrenal
incidentalomas increases with age leading to false-positive
imaging findings and reduced specificity. Therefore, the
ES guideline issued a strong recommendation to perform
AVS in every patient who is a candidate for surgery to
reliably differentiate unilateral from bilateral PA.
Blood samples are obtained for steroid measurements
from the right and left adrenal veins to determine if the
overproduction of aldosterone originates from a unilateral
or bilateral source (Fig. 2). Some experts recommend AVS
in all patients with confirmed PA (34), others consider
predictors of unilateral disease and patient preference
(35, 36). According to the ES guideline, young patients
(35 years) with imaging findings of a unilateral adenoma
(10 mm and a normal appearing contralateral adrenal)
can bypass AVS if they display a marked phenotype (for
example, PAC 30 ng/dL (831 pmol/L) and spontaneous
hypokalemia at baseline) (3). Although selecting patients
to bypass AVS and proceed to surgery on the basis of
young age, imaging results and PA phenotype has been
reported to lack specificity (37), data from a multicentric
study in Japan reported that factors based on young age
and specific imaging and biochemical characteristics
as recommended by the ES guideline could accurately
predict unilateral disease (38).
In preparation for AVS, antihypertensive medication
that interferes with the renin-angiotensin system,
specifically by stimulating renin secretion, should be
withdrawn. Loop and thiazide diuretics, amiloride and
MR antagonists should be interrupted 4 weeks before
AVS and substituted for antihypertensive medication
with less (or minimal) effects on renin secretion such as
α1-adrenergic receptor blockers and non-dihydropyridine
long-acting calcium channel blockers (verapamil or
Table 2 Confirmatory testing for primary aldosteronism.
Confirmatory test Diagnostic cut-off values
Saline infusion test (SIT) PAC 5–10 ng/dL (140–280 pmol/L)
Oral salt loading test (SLT) uAldo 12 µg/24 h (33 nmol/day)* or 14 µg/24 h (39 nmol/24 h)†
Fludrocortisone suppression test (FST) Upright PAC 6 ng/dL (170 pmol/L) on day 4 at 10:00 h with PRA 1 ng/mL/h and plasma
cortisol less than the value at 07:00 h‡
Captopril challenge test (CCT) Decrease in PAC ≤ 30% (or ARR 200 pg/mL/ng/mL/h)**
Protocols describing confirmatory testing in detail are described in Stowasser and Gordon (20). Includes data from Funder et al. (3).
*At the Mayo clinic; †
At the Cleveland clinic; ‡
To exclude any confounding effect of ACTH; **Decrease in PAC ≤ 30% as defined by the ES Guideline (3)
and ARR 200 pg/mL/ng/mL/h by the Japan ES Guidelines (23).
PAC, plasma aldosterone concentration; PRA, plasma renin activity; uAldo, urinary aldosterone.
5. EuropeanJournalofEndocrinology
179:1 R23Review T A Williams and M Reincke Management of primary
aldosteronism
www.eje-online.org
diltiazem). If PRA or concentration is suppressed,
AVS can be performed irrespective of the time of drug
withdrawal (39) and, in exceptional cases, MR antagonist
therapy can be continued during AVS if renin remains
suppressed (40).
The success of AVS, determined by the correct
cannulation of the adrenal veins, is measured by the
selectivity index (SI), which is calculated as the ratio of
cortisol in the adrenal vein and in a peripheral vein. The
cannulation of the adrenal veins is particularly challenging
on the right side because of anatomical differences
between the right and left adrenal veins (Fig. 2). Success
rates differ greatly but can be improved by a rapid cortisol
assay to ascertain when resampling is necessary if the AVS
was unsuccessful (41, 42). The use of such an assay has
increased the proportion of successful AVS from 55% to
85% in the experience of one referral center largely due to
an increased successful cannulation of the right adrenal
vein (43). The lateralization of aldosterone production
is usually calculated by the lateralization index (LI)
although the LI is sometimes considered together with a
requirement for contralateral suppression of aldosterone
production to define lateralization (Tables 3 and 4). There
is no standardized cut-off for the SI, or indeed for any of the
indices used in AVS. Although there have been attempts
to standardize AVS protocols (39, 44), the reference limits
remain arbitrary to some extent and the interpretation of
AVS results vary widely across centers (Table 4).
AVS is performed in the morning when ACTH-
stimulated aldosterone production is maximal following
at least 1-h recumbency to avoid the effects of postural
changes on the stimulation of the renin-angiotensin
system. An AVS procedure with an exogenously
administered synthetic derivative of ACTH (ACTH 1–24,
called cosyntropin) is used by some for various reasons
that include increasing technical success rates, stimulating
the production of aldosterone from APAs and minimizing
variations in cortisol and aldosterone production caused
by stress-induced ACTH release during non-simultaneous
AVS. Although some concerns have been raised on the
possible stimulation of aldosterone production from the
contralateral adrenal gland (non-dominant gland) in
unilateral PA, AVS with ACTH infusion can improve the
technical success rate of AVS (45, 46) and can perform as
well as unstimulated protocols with ACTH administered
as a bolus (usually 0.25 mg (10 IU)) or continuous
infusion (initiated 30 min before the procedure (50 µg/h))
performing equally well (47). The effects of ACTH
stimulation were illustrated by a study in which a bolus of
250 µg of ACTH increased bilateral selectivity from 67%
in the basal state to 92% post stimulation. At the same
time, discordance between basal and post-ACTH values
was observed in 28% of patients, which were mostly
Figure 2
Differentiation of unilateral from bilateral forms of primary
aldosteronism by adrenal venous sampling. Adrenal venous
sampling is performed according to a defined standardized
protocol in patients with confirmed PA after withdrawal of
interfering medication (see text for details). Adrenal veins are
sequentially catheterized via the femoral veins and blood is
sampled from the inferior vena cava and from the right and left
adrenal veins. The success of catheterization of each adrenal
vein is indicated by the selectivity index (Tables 3 and 4) that can
be determined by a rapid-onset cortisol assay (41, 42, 43).
Plasma aldosterone and cortisol concentrations are measured in
all blood samples. Adrenal venous plasma aldosterone
concentrations are corrected for any dilution by blood from the
inferior phrenic vein (on the left side) or from the inferior vena
cava (on the right side) by dividing by the respective plasma
cortisol concentrations (aldosterone-to-cortisol ratios). The
measurements of aldosterone and cortisol are used to derive the
lateralization index and the contralateral ratio (Table 3).
6. EuropeanJournalofEndocrinology
179:1 R24Review T A Williams and M Reincke Management of primary
aldosteronism
www.eje-online.org
lateralized cases under basal conditions that became
bilateral post-ACTH. Therefore, ACTH stimulation may
reduce the proportion of lateralized PA. We observed
no significant differences in the post-surgical clinical
outcomes of patients with unilateral PA diagnosed by AVS
with an unstimulated protocol (n = 331) relative to patients
diagnosed with an ACTH infusion protocol (n = 374) (48).
In our center, we generally perform bilateral simultaneous
AVS without ACTH stimulation. ACTH stimulation is
restricted to specific situations: for example, if patients are
at risk of an allergic reaction to the anesthetic, if AVS is
performed in the afternoon and if patients receive chronic
low-dose synthetic glucocorticoid treatment (i.e. 5 mg
prednisolone/day).
The recently published SPARTACUS trial studied in a
randomized fashion whether CT imaging based subtype
determination was equivalent to AVS-based decision
making (49). The primary outcome of the study was the
intensity of antihypertensive medication measured as
defined daily drug dose (DDD) 1 year after initiation of
specific treatment. Outcomes were essentially similar: the
median DDDs of 92 patients receiving CT-based treatment
(in 46 adrenalectomy and in 46 MRA treatment) was
3.0 vs 3.0 in those receiving AVS-based treatment (46
adrenalectomies and 46 treated by MRA, P = 0.53). In
the surgical groups, target blood pressure was reached
in 39 (42%) patients and 41 (45%) of the operated
patients, respectively (P = 0.82). Additional secondary
endpoints, such as health-related quality of life or
biochemical remission (80% vs 89%, P = 0.25), were not
different. Details of the study and perceived weaknesses
in its design and methodology have been discussed in
an unprecedented and ongoing flood of commentaries
(50, 51, 52, 53) splitting the community into those who
were for or against AVS. The emotions arising from the
study are in part due to the trial highlighting that a
sophisticated procedure such as AVS is not 100% accurate,
having a failure rate of approximately 5% (48), and that
CT-based management might be better than previously
thought. As a consequence of this debate, centers that
used AVS for therapeutic decision making will continue to
do so but will likely exempt young patients with imaging-
positive adenomas. Centers without access to AVS will
base their decision making with increased confidence on
CT imaging, acknowledging that this strategy might have
a failure rate of up to 20% (49).
Treatment
The underlying cause of PA determines the appropriate
treatment, surgical or medical management. For patients
Table 3 Definition and interpretation of adrenal venous sampling criteria.
AVS index Definition and interpretation
Selectivity index (SI) (Cortisol)AV/(Cortisol)PV
Indicates successful AVS with correct cannulation of adrenal veins
Lateralization index (LI) ((Aldosterone)/(Cortisol))IpsilateralAV/((Aldosterone)/(Cortisol))ContralateralAV
Measures lateralization of aldosterone production
Contralateral ratio (CLR) ((Aldosterone)/(Cortisol))ContralateralAV/((Aldosterone)/(Cortisol))PV
Inhibition of aldosterone production from the non-dominant adrenal gland (contralateral
suppression, CLR ≤ 1)
ACTH, adrenocorticotropic hormone; AV, adrenal vein; AVS, adrenal venous sampling; PA, primary aldosteronism; PV, peripheral vein (often the inferior
vena cava); the ipsilateral AV is the adrenal vein from the adrenal with excess aldosterone production and the contralateral AV is the adrenal vein from
the adrenal on the opposite side.
Table 4 Different protocols and interpretation of adrenal venous sampling.
Referral center Unstimulated or ACTH infusion Successful AVS Diagnosis of unilateral PA
Munich, Paris Unstimulated SI ≥ 2 LI ≥ 4
Torino Unstimulated + continuous ACTH infusion SI ≥ 3 LI ≥ 4 or LI ≥ 3 and CLR ≤ 1
Brisbane Unstimulated SI ≥ 3 LI ≥ 2.5 and CLR ≤ 1
Rochester Continuous ACTH infusion SI ≥ 5 LI ≥ 4
Sendai Bolus ACTH infusion SI ≥ 5 LI ≥ 2.6
Yokohama City Bolus + continuous ACTH infusion (Cortisol)AV 200 µg/dL* (PAC)ipsilateralAV 1400 ng/dL*
Includes data from Williams et al. (48).
*In accordance with the Japan ES Guidelines (23).
ACTH, adrenocorticotropic hormone; AVS, adrenal venous sampling; LI, lateralization index; PA, primary aldosteronism; PAC, plasma aldosterone
concentration; SI, selectivity index.
7. EuropeanJournalofEndocrinology
179:1 R25Review T A Williams and M Reincke Management of primary
aldosteronism
www.eje-online.org
with unilateral PA, adrenalectomy offers the possibility
of blood pressure remission or clinical improvement
and the resolution of excess aldosterone production. In
an international cohort study, unilateral adrenalectomy
normalized blood pressure in 37% of 705 patients with PA
and substantially improved the clinical outcome (blood
pressure and antihypertensive medication response) in
a further 47% (48). A successful biochemical outcome
(correction of hypokalemia – if present pre-surgery – and
normalization of the ARR) was achieved in 94% of 699
patients (48).
Patients with bilateral PA are most effectively
treated medically with an MR antagonist, usually
spironolactone (54). Other patients included in this
category are those with unilateral PA who opt for medical
rather than surgical management or those who are unfit
for surgery. Cases of spontaneous complete biochemical
remission have been reported in patients with bilateral
PA after long-term treatment with MR antagonists in
(2 of 37 patients treated with spironolactone (5.4%)
at 10.8 and 12.9 years following diagnosis (55)) and in
patients following long-term treatment with potassium
canrenoate (56).
Spironolactone is a competitive inhibitor of
aldosterone for its receptor, the MR. It is non-selective
and displays both antagonist activity to the androgen
receptor and agonist activity to the progesterone receptor.
The non-selective action of spironolactone can cause
the associated adverse effects including gynecomastia,
erectile dysfunction and menstrual irregularities. The
incidence of gynecomastia increases from 6.9% at a dose
of 50 mg/day to 52% at 150 mg/day (57). Eplerenone
is a selective MR antagonist that has no adverse effects
but displays lower efficacy and high cost compared with
spironolactone (58, 59). In Japan, eplerenone is approved
for the treatment of hypertension, in the United States
and in Europe, for the treatment of congestive heart
failure after a myocardial infarction.
A longitudinal study that included 602 patients
with PA (treated with a MR antagonist) compared with
41 853 age-matched patients with essential hypertension
treated conventionally demonstrated a significantly
higher rates of cardiovascular events independent of
blood pressure control in the PA group (60). Patients
with PA also had higher adjusted risks for incident
mortality, diabetes and atrial fibrillation. The excess
risk for cardiovascular events and mortality was limited
to patients with PA whose renin activity remained
suppressed (1 μg/L per h) on MR antagonists. The study
suggests that titrating the increase in PRA as a response
to MR antagonist therapy instead of blood pressure
control would be a more effective therapeutic approach
to avoid the excess cardiovascular risk associated
with PA (60). The PAPY study analyzed long-term
cardiovascular outcomes and mortality in 1125 patients
screened for PA and treated according to biochemical
results: unilateral adrenalectomy (4.8%) in patients with
APA, MR antagonist treatment (6.4%) in patients with
BAH and standard medical treatment in the remaining
88.8% with essential hypertension. After a median of
11.2 years, overall survival was similar in patients treated
for PA and for essential hypertension. MR antagonist
treatment but not adrenalectomy was associated with a
higher risk of atrial fibrillation (61). In summary, both
studies raise the question of uptitrating the dose of MR
antagonists to block the MR more effectively and reduce
long-term complications.
Genetic forms of PA
A number of somatic mutations have been identified in ion
channels and transporters that drive the aldosterone excess
in patients with APAs (62, 63). No clinical application has
been firmly established although a potential future use
may lie in steroid profiling to circumvent AVS in patients
with bilateral disease by selection of those patients with
a high probability of having an APA (64) or by selecting
patients with an APA carrying KCNJS mutations using
macrolide antibiotics as selective inhibitors (65).
Germline variants have also been identified that
cause rare familial forms of PA (62, 63). The invasive
procedure of AVS is unnecessary in patients with familial
hyperaldosteronism types I and III (FH type I and FH
type III) (66, 67) because the former is effectively treated
with glucocorticoids (such as dexamethasone) and the
latter is treated by bilateral adrenalectomy or with MR
antagonists. Therefore, in accordance with the ES Society
Guideline (3), genetic testing is recommended in patients
with a diagnosis of early-onset PA (20 years old) or with
a family history of PA or stroke at a young age (40 years)
for the presence of the hybrid CYP11B1/CYP11B2 gene
that causes FH type I (66) and in very young patients with
a diagnosis of PA (for example, 20 years) for germline
mutations in the KCNJ5 gene that cause FH type III (68).
Genetic testing of patients in these target groups offers
the possibility of an early diagnosis of asymptomatic
relatives and provides timely treatment when appropriate.
AVS should be performed in patients with familial
hyperaldosteronism types II and IV (69, 70, 71) because
8. EuropeanJournalofEndocrinology
179:1 R26Review T A Williams and M Reincke Management of primary
aldosteronism
www.eje-online.org
these patients have been treated successfully by unilateral
adrenalectomy as well as with MR antagonists (62).
Germline heterozygous mutations in the voltage-
gated chloride channel CIC-2, encoded by the CLCN2
gene, have been identified in families with FH-II and in
patients with sporadic childhood-onset PA (72, 73). CIC-2
is expressed in adrenal glomerulosa cells, and the mutated
channels show gain of function with increased chloride
conductance at resting potentials resulting in increased
expression of aldosterone synthase and aldosterone
secretion. These findings establish CLCN2 mutations as a
cause of early-onset PA.
Conclusions
Since the publication of the ES guideline on PA in 2016,
several high-quality reports have advanced our knowledge
of the genetics, diagnosis, subtype differentiation and
treatment of PA. In general, these data confirm the
diagnostic and therapeutic algorithm of the guideline. An
exception is the SPARTACUS study but an independent
trial which takes into account the criticisms of the many
commentaries will resolve the issue of the validity of the
results. In addition, novel functional imaging methods
of PA, such as CXCR4 PET-CT imaging (74), could offer
an alternative to ease the subtyping of PA. In summary,
accumulating evidence highlights the importance of an
early diagnosis and indicates that specific treatments can
minimize or reverse the adverse effects of aldosterone
excess. However, simplified procedures are required to
enable timely, cost-effective and patient-friendly screening
and diagnosis for PA.
Declaration of interest
The authors declare that there is no conflict of interest that could be
perceived as prejudicing the impartiality of this review.
Funding
This work was supported by the European Research Council (ERC)
under the European Union’s Horizon 2020 research and innovation
programme (grant agreement No (694913) to M R) and by the Deutsche
Forschungsgemeinschaft (DFG) (within the CRC/Transregio 205/1 ‘The
Adrenal: Central Relay in Health and Disease’ to M R and T A W; and grant
RE 752/20-1 to M R) and the Else Kröner-Fresenius Stiftung in support
of the German Conns Registry-Else-Kröner Hyperaldosteronism Registry
(2013_A182 and 2015_A171 to M R).
Acknowledgements
The excellent artwork of Francesca Williams is gratefully acknowledged.
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Received 26 November 2017
Revised version received 26 March 2018
Accepted 18 April 2018