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The BP-lowering response to specific antihypertensive drugs may offer important clues to the presence and type of secondary hypertension; for example, patients with early renovascular hypertension RVHT often have an impressive BP-lowering response to an angiotensin-converting enzyme ACE inhibitor or angiotension receptor blocker ARB and those with bilateral adrenal hyperplasia as a cause of primary aldosteronism respond well to spironolactone, but not vice versa.

The initial evaluation for secondary hypertension is shown in Table 41—2 and will be discussed in detail in the chapter. The choice of tests and the order in which they are obtained depend not only on the pretest probability of the disease, but also on safety, availability, local expertise with the test, and its cost. Recognition of important clinical clues for RVHT is paramount in the clinical diagnosis of this condition. Forgot Password? What is MyAccess?

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Overview and Screening

Case Files Collection. Clinical Sports Medicine Collection. Davis AT Collection. Davis PT Collection. Early recognition, precise localization and attentive management of a benign pheochromocytoma in most instances leads to a complete cure.

Secondary Hypertension: Discovering the Underlying Cause

Although a pheochromocytoma can appear at any age, it presents most commonly during the fourth and fifth decades of life. Symptoms, including the pattern of BP elevation, do not correlate with tumor volume per se. There is not a specific BP pattern that could be held as the sine qua non for a pheochromocytoma. The BP patterns that can develop with a pheochromocytoma include 1 a sustained hypertensive state without BP spikes; 2 a persistent hypertensive state with intermittent hypertensive spikes potentially reaching crisis levels; and 3 a normotensive state with brief, sudden, and striking BP elevations.

Although such symptoms are not pathognomonic of pheochromocytoma, they differ sufficiently from nonendocrine hypertensive crises to warrant a workup for pheochromocytoma. Hypertensive crises are truly random with this disease. A wide spectrum of diseases can masquerade as a pheochromocytoma and therein obscure its diagnosis. In the case of pseudopheochromocytoma, pheochromocytoma has been excluded and there exists an augmented BP response to changes in the sympathoneural release of norepinephrine. Patients with signs and symptoms consistent with a pheochromocytoma should be evaluated on a priority basis.

Biochemical evidence of excessive catecholamine production is a necessary step for the diagnosis of pheochromocytoma Figure. Traditional biochemical tests include measurements of urinary and plasma catecholamines, urinary metanephrines normetanephrine and metanephrine , and urinary vanillylmandelic acid; each of these tests has its advantages and disadvantages. Clinical suspicion is triggered by paroxysmal hypertension, family history of pheochromocytoma or associated conditions, or incidentally discovered adrenal mass.

High suspicion with normal urinary catecholamines warrants rechecking in conjunction with a spell. Low suspicion with elevated urinary catecholamines dictates an imaging study and, if urinary catecholamines are normal, investigation for other causes of spells. Adapted with permission from Young. Accumulating evidence, however, suggests that measurements of plasma free metanephrines or urinary fractionated metanephrines normetanephrine and metanephrine separately are the most sensitive tests for diagnosis and are the most suitable for reliable exclusion of pheochromocytoma.

Major diagnostic difficulties exist for patients with a clinical picture compatible with pheochromocytoma but in whom catecholamine levels fall in a range less than 2 to 3 times the upper reference limits. This test is based on the principle that increases in catecholamines are customarily mediated through sympathetic nervous system activation. In the case of pheochromocytoma, the excess in catecholamines sidesteps the normal storage and release mechanisms; thus, clonidine would not be expected to suppress catecholamine release.

Abdominal computed tomography CT or magnetic resonance imaging MRI preferred imaging mode can be performed as a means to tumor localization in patients with clinical and biochemical features compatible with a pheochromocytoma. Surgical treatment is the only effective therapeutic approach for pheochromocytoma, be it benign or malignant. Primary aldosteronism is a common cause of resistant hypertension in black and white patients.

Primary aldosteronism should be considered as a diagnostic possibility in any patient with spontaneous hypokalemia, moderately severe hypokalemia induced by usual doses of diuretics, or refractory hypertension. Considerable dispute exists as to the true prevalence of primary aldosteronism.

Children and Adolescents (Birth to 18 Years of Age)

Patients with primary aldosteronism frequently develop left ventricular hypertrophy as well as heart failure with and without preserved systolic function. Treatment of primary aldosteronism is also characterized by partial reversibility of renal dysfunction and frequent return to normoalbuminuria from microalbuminuria.

Hypertension - Clinical Presentation

Several rare syndromes produce an endocrine form of hypertension that can simulate various aspects of primary hyperaldosteronism. These hypertensive syndromes are typified by hypokalemia, metabolic alkalosis, and suppression of both plasma renin and aldosterone levels. These entities include the syndrome of apparent mineralocorticoid excess, Liddle's syndrome, and licorice ingestion. Until relatively recently, the diagnosis of primary aldosteronism was mainly considered when hypertension and hypokalemia coexisted.


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Unfortunately, many cases of primary aldosteronism do not meet all such criteria. Although this computation is viewed as the screening test of choice for primary aldosteronism, there are drawbacks with its use.


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  • The various types of primary aldosteronism need to be distinguished because the best management practices can differ. Unilateral adrenal adenomas are best treated surgically, either by an open or preferably a laparoscopic procedure. In most but not all instances, adenoma removal alleviates or substantially improves the hypertension.

    Older age, longer duration of hypertension, and the presence of other conditions associated with hypertension obesity, sleep abnormalities, etc predict a less favorable response to surgical intervention. Medical therapy is indicated in patients with bilateral adrenal hyperplasia or adenomas and in those patients with adenomas in whom there exists a high operative risk.

    Medical therapy with the aldosterone receptor antagonist spironolactone is generally effective in reversing the biochemical abnormalities of primary aldosteronism, but additional antihypertensive medication may be required for full BP control. The dosage of spironolactone may be limited by symptoms of gynecomastia and impotence. Endogenous Cushing's syndrome is an infrequent cause of hypertension in that it affects fewer than 0.

    The peak incidence of Cushing's syndrome, whether due to an adrenal or pituitary adenoma, occurs from age 25 to Validity of plasma aldosterone-to-renin activity ratio in African American and white subjects with resistant hypertension. The kidney, hypertension, and obesity. Effect of longer-term modest salt reduction on blood pressure. The Cochrane Database of Systemic Reviews. Review of salt restriction and the response to antihypertensive drugs: satellite symposium on calcium antagonists. Dietary sodium restriction as adjunctive treatment of hypertension. Increased sodium intake correlates with greater use of antihypertensive agents by subjects with chronic kidney disease.

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    A randomized, double-blind, placebo-controlled trial of ibuprofen compared with acetaminophen. Effect of indomethacin on blood pressure lowering by captopril and losartan in hypertensive patients. Am J Cardiol. Effects of celecoxib on ambulatory blood pressure in hypertensive patients on ACE inhibitors. Modafinil elicits sympathomedullary activation. Link Google Scholar 40 Ernst E. The risk-benefit profile of commonly used herbal therapies: ginkgo, St.

    Herbs and alternative therapies in the hypertension clinic. Licorice-induced hypertension and syndromes of apparent mineralocorticoid excess. Endocrinol Metab Clin North Am. Pontefract cakes can be bad for you: refractory hypertension and liquorice excess. Nephrol Dial Transplant. The occurrence of sleep-disordered breathing among middle-aged adults.