A Toolkit for Health Care Professionals Unmet Needs in Hypertension 17 Assess Medication/Substance Use Multiple classes of medications and nonprescription substances can increase BP and contribute to RH. When diagnosing RH, it is essential to assess for and, if possible, mitigate medications or other substances that may be a factor of elevated BP. See page 8 for a full list of substances and common drugs that can elevate BP. Recognize Secondary Hypertension About 10% of adults with hypertension have a specific, remediable cause related to an existing health condition. All new patients with hypertension should be screened for secondary hypertension with a history, exam and labs prior to initiating treatment.1-5.4 Secondary Forms of Hypertension Once secondary hypertension is properly diagnosed and treated, patients can attain marked improvements in BP control and CVD risk. The following conditions are often associated with secondary hypertension. Primary aldosteronism is a group of disorders characterized by excessive or inappropriate secretion of aldosterone. This includes hypertension caused by volume expansion and sympathetic nervous system activation, metabolic alkalosis, advanced cardiovascular disease, renal disease and, in severe cases of potassium excretion, hypokalemia. Other adverse effects include left ventricular hypertrophy (LVH), diastolic dysfunction and heart failure, large artery stiffness, oxidative stress, widespread tissue inflammation and fibrosis and increased resistance vessel remodeling.5-Primary Aldosteronism Primary aldosteronism occurs in about 20% of patients with confirmed RH. This high prevalence means all patients with RH should be screened for primary aldosteronism. Patients who test positive are usually referred to an endocrinologist or hypertension specialist for further evaluation and management.5-Primary Aldosteronism Renal parenchymal disease, usually referred to as CKD, is both a cause and a complication of poorly controlled hypertension. CKD prevalence will increase as the population ages, leading to an increase in RH. Patients with CKD and RH are at higher risk for CVD events and renal events, including end-stage kidney disease, compared to patients with CKD without RH declines.5-Renal Parenchymal Disease It is recommended that all patients with RH be screened for CKD, as well as other potential forms of secondary hypertension including renal artery stenosis, primary aldosteronism or other endocrine causes. Most people with CKD eventually require antihypertensive medications, but achievement of BP goals declines with higher CKD stages despite increasing use of BP medications. Because reduced salt intake may improve efficacy of hypertensive medications, special attention should be focused on dietary sodium reductions. Effective control generally requires a diuretic in the mix with evolution to more potent thiazide-type agents at higher doses or loop diuretics as renal function declines.5-Renal Parenchymal Disease Renal artery stenosis can exacerbate or worsen hypertension. It is among the most common causes of RH and may affect up to 24% of older people. Atherosclerotic disease is the usual culprit, but fibromuscular dysplasia, renal artery dissection or infarction, Takayasu arteritis, radiation fibrosis, endovascular stent grafts and other uncommon blockages can cause renovascular hypertension. Current practice focuses on optimizing antihypertensive drug therapy, most often using RAS blockade such as ACE inhibitors or ARBs.5-Renal Artery Stenosis Pheochromocytoma and paraganglioma, which are two types of chromaffin cell tumors, can be elevated in up to 4% of patients with RH. Symptoms include paroxysmal hypertension, which may be accompanied by headache, palpitations, pallor and piloerection or “cold sweat.” Clinicians should consider the diagnosis in anyone referred for RH. The screening test of choice is measurement of circulating catecholamine metabolites.5-Pheochromocytoma/ Paraganglioma
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