Resistant Hypertension for Nurse Practitioners Part 2
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Show notes:
In Part 2 of our Resistant Hypertension videos, I’m looking at hyperaldosteronism, or high aldosterone levels, as a cause for treatment-resistant hypertension — and an under-recognized one at that.
So what is high aldosterone? Where does it come from? When do you check for it? What causes it? If a patient has high aldosterone, what do you do next?
Let’s dig in!
Note that assessing for this may be out of your practice comfort zone — and that’s totally fine! But it’s still important to know what hyperaldosteronism means for your patients.
Diagnosing Resistant Hypertension in Primary Care
In this video, I touch on:
✅ What distinguishes primary and secondary aldosteronism - and why it matters
✅ Symptoms to keep an eye on when looking at the different ideologies for high aldosterone
✅ And how to navigate that always-tricky dance of testing and referral as a nurse practitioner
Managing Diabetes, Hypertension & CKD Review Course
If you'd like support learning about how to manage these three chronic conditions, including medication management, most recent guidelines, when to refer and examples of real-life patient cases, join us for the Managing Diabetes, Hypertension & CKD Review Course. Check it out here!
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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
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company for nurse practitioners in primary care.
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In this week's video, I want to continue the conversation about resistant hypertension
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evaluation.
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And before I jump in, I just want to share that I have a brand new course coming up this
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It's the top three most common chronic conditions in primary care.
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So diabetes, hypertension, and CKD in terms of the medication management, as well
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as assessment and diagnostic workups for and management of monitoring and management
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of CKD.
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information coming out.
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So getting back into resistant hypertension now, I made a video, resistant
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hypertension part one.
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So definitely go watch that before you watch this one or in any order, I guess.
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But in that video, I talked about the steps to working up resistant
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hypertension, which just as a refresher is a patient who is on three or more
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hypertensive medications, including a diuretic that are optimized doses and
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they're still not at goal for their blood pressure.
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So in part one, I talked about all the different steps for evaluation and
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workup.
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And then this video, I'm delving a little bit more into a subset of
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investigation, which is high aldosterone.
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So hyper aldosteronism is an under recognized cause of resistant
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hypertension in primary care.
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And it is a place that I certainly have learned about more recently.
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And I want to not that I learned about more recently, but I'm doing a little bit
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more in my practice, getting comfortable with taking the step of evaluation,
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because it is under recognized.
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So and the rationale for well, first of all, you can just learn about this
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and not adopt these practices if you don't want to based on your personal
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comfort level of practice.
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However, this is important to know about as an etiology and can help you
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determine with a couple of simple blood tests who to refer to for help with
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resistant hypertension patient.
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So three referrals, three specialists can help us with resistant hypertension.
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So one is cardiology.
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Two is endocrine.
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If it's if it's thought to be an adrenal
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aldosterone related cause.
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And then the third one is renal because they can help for patients
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who have CKD with resistant hypertension.
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Those are the people you want to talk to.
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So doing this blood test can help us determine
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who is the best person to refer to if the patient's blood pressure
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is still not within goal, even though they're on all those meds. Right.
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OK, so at first, let's start with some basics. Quick refresher.
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So what are the adrenal glands? Right.
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Those are those endocrine glands that are on top of the kidneys
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and they release a number of hormones, aldosterone, of course,
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glucocorticoids, sex hormones and epinephrine.
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I have my notes here.
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That's why I'm taking a peek at my screen.
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So and then what is aldosterone?
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So aldosterone works in the kidneys and it helps with sodium
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reabsorption as well as potassium.
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And it's part of the renin and angiotensin system.
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That wonderful thing that you learned about in patho.
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Maybe you loved it, maybe you didn't.
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So why do we care about it?
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So if it's too high, it's going to cause resistant hypertension.
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What are the causes of that?
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So one of the causes, there's primary and secondary
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hyper aldosteronism.
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The first one, the most common one is idiopathic, meaning like we have no idea.
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We have normally looking, normally looking
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and normally sized adrenal glands on top of our kidneys.
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But for some reason that we don't understand,
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they're producing more aldosterone than they should.
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The next most common ones have to do with adrenal adenomas,
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little growths on top of the adrenal glands that are secreting
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aldosterone.
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And then also we can have things like pheochromocytoma,
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which is another type of growth and has its own specific symptoms
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as well as hypertension.
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I'm not going to get into that in this video,
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because I think that's a little bit information overload.
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But just keep in mind, pheochromocytoma is a potential option
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for high blood pressure, but it comes with a constellation of other symptoms.
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And then the other main causes for high aldosterone is it can be secondary,
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meaning it's not directly coming from the adrenal glands,
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but something is stimulating the adrenal glands to make more aldosterone.
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And the main causes for that are a carcinoma of some kind.
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Ovarian and renal are the most common causes.
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So those two can stimulate the adrenal glands to make more aldosterone
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or actually perhaps make more themselves.
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And actually, don't quote me on that.
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But having a tumor can cause that release of aldosterone.
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So when would you want to think about high aldosterone
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checking for this in a patient?
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So the reason I would check this is if somebody had resistant hypertension,
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I did the other workup that was available
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and we still couldn't figure it out before I sent them to a specialist,
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because that would help us determine who the best person is. Right.
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And so the other constellation of symptoms that can go along
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with high aldosterone are low potassium
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unrelated to any other medications that they take,
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unrelated to any other reason.
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They just happen to have low potassium and high blood pressure.
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And then the third one is metabolic alkalosis, signs of that,
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which you can see on the BMP a little bit.
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It's getting a little fancy, but
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that's that's the classic triad.
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But in the real world, most people do not have low potassium.
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So don't let that be a barrier for you.
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Let it be included in your resistant hypertension workup
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if you feel comfortable ordering and interpreting those labs.
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And again, if you don't, definitely seek out either continuing education
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or your colleagues or and or supervisor.
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So I guess just to throw in a couple of other symptoms,
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if you are thinking about a few chromocytoma, they have hypertension
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may or may not be resistant.
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They can have sweating, headaches.
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They can also have hyperglycemia or this like hypermetabolic state.
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But if you have like sweating and hypertension,
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you might think about a few chromocytoma included in your differential
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diagnosis, but again, treading lightly, getting support
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because that's a little bit of a zebra diagnosis that we're bringing in there.
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So not like jumping to that.
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And just know that they can also have paroxysmal symptoms as well.
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So if they have hypertension with like sweating and tachycardia
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and that kind of stuff here and there, definitely think about it.
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But and again, get some get some support with that.
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So for the workup.
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So if you're thinking about this as a potential workup,
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there's a first pass that we can do to let us think
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if there's a possibility, because it needs a number of confirmatory tests
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to make the diagnosis of hyperaldosteronism.
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But the first pass that we can make in primary care reasonably safely
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is a morning renin and aldosterone, two different labs,
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serum, renin and serum aldosterone.
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And it might be termed a little bit differently, depending on your lab.
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But what we're looking for is to see the patients
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with hyperaldosteronism will have a high aldosterone
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with a suppressed renin level.
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And that would be your kind of first clue of like, you know what?
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I think this person probably should see endocrine. Right.
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And that simple like the reason I'm making a video about this is, again,
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number one, it's under recognized.
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And two, we can pretty easily do those two blood tests
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to help us figure out what specialist to go to, because we all know
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referrals can take a long time for patients to get an appointment,
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to get there, to get worked up, et cetera, et cetera.
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And like I said, there's like a whole cascade of other lab tests
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and potentially an abdominal CT that might be involved
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to look at the adrenal glands itself.
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But I probably would stop there.
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I probably would just start with those two myself personally
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without collaboration with a colleague or my supervisor,
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unless it was an under guidance of an endocrinologist
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who said who would say, like, if the patient couldn't get into
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an endocrinologist in a reasonable amount of time,
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I might do a cold call or a little email and say, you know what?
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Would you recommend X, Y and Z tests?
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And then they would give their advisement.
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So so that's pretty much it.
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That's the kind of quick and dirty about hyperaldosteronism
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as a potential cause of resistant hypertension.
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And if you want to learn more about hypertension,
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medication and management inside of the chronic care course
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that's coming out brand new this fall, head over to realworldnp.com
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That's our episode for today.
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Thank you so much for listening.
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