Secondary Hypertension: Adrenal and Nervous Systems Ανδρέας Πιτταράς Καρδιολόγος Καρδιολόγος Clinical Hypertension Specialist ESH Υπερτασικό

Secondary Hypertension: Adrenal and Nervous Systems

Ανδρέας ΠιτταράςΑνδρέας Πιτταράς ΚαρδιολόγοςΚαρδιολόγος

Clinical Hypertension Specialist ESHClinical Hypertension Specialist ESHΥπερτασικό ιατρείο Τζάνειο νοσοκομείοΥπερτασικό ιατρείο Τζάνειο νοσοκομείο

Υπερηχοκαρδιογραφικό εργαστήριο ΝΜΥΑ ΙΚΑΥπερηχοκαρδιογραφικό εργαστήριο ΝΜΥΑ ΙΚΑ

Adrenocortical Causes of Hypertension

The adrenal cortex can cause hypertension

Pathways of adrenal steroidogenesis

Algorithmic approach to mineralocorticoid-induced hypertension

Hypertensive Syndromes Secondary to Hypersecretion of Deoxycorticosterone

Abnormalities of steroid production

Findings on physical examination

17 -hydroxylase deficiency syndrome

Physical characteristics

Hypertensive Syndromes Secondary to Cortisol Excess

Causes of Cushing's syndrome

Abdominal striae caused by excess cortisol production

Ectopic adrenocorticotropic hormone excess

Inferior petrosal sinus sampling for ACTH

Inferior petrosal sinuses before and after oCRH

OHSD deficiency syndromes

Hypertensive Syndromes Secondary to Hypersecretion of Aldosterone

Primary aldosteronism

Clinical clues to the presence of primary aldosteronism

•Spontaneous hypokalemia

•Diuretic-induced hypokalemia

•Difficulty in maintaining a normal serum potassium while

on diuretics despite concomitant use of potassium-sparing

agents or KCl supplementation

•Refractory hypertension

•Family history of primary aldosteronism

Primary aldosteronism can occur at all ages

Serum potassium concentrations in primary aldosteronism

Stimulated plasma renin activity in primary aldosteronism

Aldosterone excretion rate

Plasma aldosterone concentration

Sensitivity and specificity of screening tests

Biochemical confirmation of adenoma versus hyperplasia

MEASUREMENTS ADENOMA BILATERAL HYPERPLASIA

Serum potassium, mEq/L

3.0 3.0

Plasma 18-OHB, ng/dL

100 100

Plasma aldosterone response to ambulation

Decrease Increase

Urinary 18-hydroxycortisol

Increase Normal

CT scan of normal adrenal glands

CT scan of a right adrenal tumor

Venography of a left adrenal tumor

Diagnostic accuracy of imaging techniques in

adrenocortical disorders

TRUE POSITIVES, % DISORDER PATIENTS, n NP-59 CT

Cushing's syndrom 28 93 90

Primary aldosteronis 58 88 91

Nonfunctional tumors 13 100 89

Diagnostic accuracy of iodocholesterol NP-59 scanning

Hemodynamic features of primary aldosteronism

Diuretic therapy in patients with primary aldosteronism

Relationship between plasma volume and arterial BP

Calcium antagonists as alternatives to diuretics

Surgery is indicated in patients with solitary adenomas

Influence of the severity of hypertension on BP response after surgery

Efficacy of long-term medical management of aldosterone-producing adenomas

ELECTROLYTE LEVELS AT DIAGNOSIS

ELECTROLYTE LEVELS AT LAST FOLLOW-UP

PATIENTAGE ySEXFOLLOW-UP, yBLOOD PRESSURE AT PRESENTATION*, mm HgMOST RECENT BLOOD PRESSURE*, mm HgSODIUMPOTASSIUMCHLORIDECARBON DIOXIDESODIUMPOTASSIUMCHLORIDECARBON DIOXIDE165M5170/94120/801453.1105301405.211028269M12164/65157/861413.298351413.910430363M11178/96130/951412.9100281444.010726443F8180/104124/821403.098311374.110525539F5184/132128/801413.9102291403.710628676M9174/100116/741432.9104291394.710323768M6180/105195/761403.198321424.210928869M5190/95130/701442.9103291404.110421959M7180/116145/991442.4102351394.3104301055M8180/110140/741453.0102301424.6104301159M6165/102112/681423.0106301424.8108301250M6177/117115/801443.1102311434.5104271344M6160/110130/821413.0106291404.3103291454F8160/98142/601443.4106291424.7108251552F13150/104104/761423.3105241374.4106251652F5168/102128/911432.7102321413.6106321754F17180/110101/711433.0105331394.4101301859M8176/116158/781422.6106291384.6101271944F9190/122122/781422.698321373.698262061F14160/110144/721452.9103351403.7113292168F5166/108111/781432.6103301464.5108262266M11178/108150/921413.0101311423.8102262373M10178/100107/661433.899311434.8105242456M15200/125128/851413.2102321394.610226*Blood pressure values are the average of at least three measurements. Levels are measured in millimoles per liter.

Comparison of eplerenone and spironolactone

Glucocorticoid-remediable aldosteronism

Pheochromocytoma

Important facts about pheochromocytomas•About 30% of pheochromocytomas reported in the

literature are found either at autopsy or at surgery for an

unrelated problem

•35% to 76% of pheochromocytomas discovered at autopsy

are clinically unsuspected during life

•The average age of diagnosis in those whose disease was

discovered before death was 48.5 y, while the average in

those diagnosed at autopsy was 65.8 y

•Death was usually attributed to cardiovascular

complications

Pathologic features of pheochromocytoma

-Adrenergic hyperresponsivenessAcute state of anxietyAngina pectorisAcute infectionsAutonomic epilepsyHyperthyroidismIdiopathic orthostatic hypotensionCerebellopontine angle tumorsAcute hypoglycemiaAcute drug withdrawal (Clonidine - Adrenergic blockade     -Methyldopa Alcohol) Vasodilator therapy (Hydralazine, Minoxidil)Factitious administration of sympathomimetic agentsTyramine ingestion in patients on monoamine oxidase inhibitorsMenopausal syndrome with migraine headaches

Differential diagnosis of pheochromocytoma

Priorities for detection of pheochromocytoma

•Patients with the triad of episodic headaches, tachycardia,

and diaphoresis (with or without associated hypertension)

•Family history of pheochromocytoma

• Incidental suprarenal masses

•Patients with a multiple endocrine adenomatosis syndrome,

neurofibromatosis, or von Hippel-Lindau disease

•Adverse cardiovascular responses to anesthesia, to any

surgical procedure, or to certain drugs (eg, guanethidine,

tricyclics, thyrotropin-releasing hormone, naloxone, or

antidopaminergic agents)

Supine resting plasma catecholamines

Relationship between BP and plasma catecholamines

Effect of clonidine on BP

Clonidine suppression test in pheochromocytoma

Glucagon stimulation test for pheochromocytoma

Urinary normetanephrine values

Comparison of indexes of catecholamine production

Sensitivity and specificity of tests for pheochromocytoma

Three modalities used to localize pheochromocytomas

Three modalities used to localize pheochromocytomas

Three modalities used to localize pheochromocytomas

Three modalities used to localize pheochromocytomas

Diagnostic strategies in pheochromocytoma

Medical management of pheochromocytoma

Perioperative hemodynamic variables OPEN, n=20 LAPAROSCOPIC, n=14 P VALUE

Mean preoperative blood pressure*, mm Hg 140 18/78 10 144 13/74 14 0.50

Highest blood pressure*, mm Hg 191 33/98 25 194 19/106 19 0.50

Hypertension 0.5 (0 5) 1.0 (0 3) 0.41

SBP 200 mm Hg 0 (0 4) 0 (0 2) 0.70

Lowest blood pressure*, mm Hg 88 14/50 13 98 19/57 8 0.05

Hypotension 2.0 (0 6) 0 (0 2) 0.005

Highest heart rate, bpm 104 15 101 24 0.78

Heart rate 110 bpm 0 (0 3) 0 (0 3) 0.36

Lowest heart rate, bpm 61 11 60 9 0.81

Heart rate 50 bpm 0 (0 1) 0 (0 5) 0.81

Patients requiring treatment for hypertension‡, n 17.0 13.0 0.63

Patients requiring treatment for hypotension , n 9.0 1.0 0.02*Systolic and diastolic blood pressure presented as the standard deviation; P value based on the test. Median number of episodes for one patient, with the range in parentheses; P value based on the

Jackson-Whitney U test.‡Includes patients who intraoperatively received at least one of the following treatments: nitroglycerin,

sodium nitroprusside, -blocker, / -blocker, or a calcium channel antagonist. Includes patients who intraoperatively received at least one of the following treatments: phenylephrine,

dopamine, or epinephrine.

Blood pressure response to calcium antagonists

References