Essential hypertension, if not treated appropriately is associated with;

Left ventricle hypertrophy (heart muscle growth) -Heart ultrasound gives the possibility to examine if there’s a diastolic relaxation disorder too. ECG is less sensitive in detecting hypertrophy -Heart failure (90% of all heart failure cases are preceded by hypertension) Eye bottom changes  -Fundus hypertonicus II-IV Kidney damage -Albuminuria, kidney failure Arteriosclerosis-Stroke (TIA, carotid disease, intracranial bleeding etc.) -Heart infarction

The prevalence av primary aldosteronism (PA) depends on how high the blood pressure is

JNC VI:

Grade I (140-159 / 90-99 mmHg) = 2%

Grade II (160-179/ 100-109 mmHg) = 8%

Grade III (>180 >110 mmHg) 0 13% (hypertension 2003, 42:161-165)

Investigation of suspected primary aldosteronism (PA)

Criteria: Reduced renin Often used test: Aldosterone / renin – ratio Aldosteron levels should be at least > 500 µmol/L (note! if there’s hypercalcemia it must be corrected, cause it prevents aldosterone release)

Medications can intervene with the ratio:

Beta blockers gives a false positive test because of the the fact that they lead to a renin reduction ACE- blockers, AII rec antagonists, Ca antagonists and diuretics increase renin. Alfa-blockers doesn’t affects the test.

Other tests for PA are:

24h urine collection CT adrenal glands (bilat hyperplasia, adenoma)

NaCl infusion test – inhibition of aldosterone release speaks against PA Before an operation

Differentiate between incidentaloma (frequency 2-10% in adults). Make sure that there’s lateralization (eg that more aldosterone is released from the side that’s gonna be operated) It’s done through vein catheterization with aldosterone measurements or by scintigraphy that shows activity from the tumor.

Renal artery stenosis

Investigate if:

  • It’s a younger woman (she could have fibromuscular hyperplasia)
  • Remarkably  good blood pressure response by ACE – inhibitors or Ang II rec antagonist
  • Strong creatinine  increase after getting ACE-inhibitors or Ang II rec antagonist medication

Other factor that should lead to renal artery stenosis suspect are:

  • murmurs over the renal arteries
  • concurrent claudicatio interm.
  • Hypocalcemia (sec. aldesteronism)

Bilat. renal artery stenosis can give rise to heart failure symptoms without hypertension. The treatment for renal artery is dilatation with PTRA.

Pheochromocytoma

Can give rise to a multitude of symptoms, but the classical ones are:

  • Headache
  • Palpitations
  • Sweating
  • Pallor
  • Hypertension- constant or in attacks

Prevalence: 0,1-0,6% in those patients who have hypertension (0,05% in post-mortem material) >10% are malign, bilat +/- originate from a non adrenal places.

Screening: Urine or plasma metnephrine (O-methylated NA and A, that are produced constantly by the tumors)

Localization:

  • CT
  • MIBG-scint

Treatment:Operation or pre-treatment with alpha-blockers

 Treatment of primary / essential hypertension

non pharmacological treatment is recommended for blood pressure over 90 mmHg diastolic

  • Weight loss
  • Increase exercise
  • Lesser salt intake (a high salt reduction leads to a significant blood pressure reduction)
  • Relaxation exercise

Unfortunately there are  little benefits of these interventions, except for the salt reduction.

Pharmacological treatment of hypertension

Most of the medicine gives a reduction by 12/8 mmHg in comparison with placebo. First choice medications right now ( typical side effects are in parenthesis)

Thiazide diuretics

Natriuretic (though not very much in the clinical setting), vasodilatation. (hypokalemia, may give negative metabolic effects but gives a good effect on morbidity and mortality, hypercalcaemia; counteract osteoporosis)

Calcium blockers: Amlodipin

Vasodilatation through reduction of intracellular (in smooth muscle cells) calcium. Good if the patient has cold hands. (leg edema, headache, flushing, verapamil shouldn’t be combine with beta blockers  due to bradycardia risk)

ACE-inhibitors: Enalapril

Reduces the production of ang II, increases bradykinine. Good as medical treatment for unilateral renal artery stenosis, not in bilateral stenosis. (dry cough, angio-edema)

Angiotensin Receptor Antagonist (ARB, Sub type 1)

Reduces the effect of ang II on the ang II receptor sub type 1. Renin increases, aldosterone decreases. Good as medical treatment for unilateral renal artery stenosis, not in bilateral stenosis. It’s not a first choice treatment

Beta Blockers

(Probably worse effect on hard point evidence) inhibits symphaticus effect on beta 1 receptors, which decreases the cardiac output. It’s a good choice with concurrent migraine, tachycardia or angina pectoris. It doesn’t lowers the central blood pressure as good as other anti-hypertensive medications.

(cold hands and feets, asthma, bad dreams, bradycardia, “heavy legs”)

Other medications; not first choice

Alfa-blockers

Vasodilatation through reduced symphaticus effect on the alfa-1 receptor

(nasal obstruction, orthostatism, should not be given as mono-therapy. It has no good end point documentation in comparison with thiazide diuretics  according to the ALLHAT study.

Spironolactone

Aldosterone antagonist. Good when there’s hypokalemia. It’s a first choice treatment in primary aldosteronism.

(Gynecomastia, impotence, hyperkalemia) There’s no hard-end points documentation in hypertension, but there is in heart failure.

Epierenone

a new and more selective aldosterone antagonist. No hard-end points documentation in hypertension but there is in heart failure. It’s expensive, but will soon loose it’s patent.

Alliskiren

Renin inhibitor with very few side effects. No hard-end point results. Expensive.

Furosemide / Loop diuretics

This is not a hypertension medication, it lacks data on blood pressure reducing effect. It’s still important in reduced renal function. There’re no hard end point documentation.

 Treatment effects with pharmacological anti hypertensive treatment

These results are in patients with moderate hypertension. The effects are better in more serious hypertension.

Stroke reduction with approximately 30-40%

Heart disease reduction with approximately 15-30%

 Treatment suggestion / Stair

1. Ace inhibitors (enalapril 20-40 mg) alternative ARB if there’s side effects.

2. Thiazide diuretics (12-25 mg hydroklorthiazide x 1)

3. Calcium inhibitors (amlodipin 5-10 mg x 1)

4. Beta blockers (atenolol 50-100 mg x1)

 

Note! number 1 can be combined with number 2-4.

 

 

 

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