Transcript: Resistant Hypertension Part 2 

Liz Rohr:                                              

Well, hey there, it's Liz Rohr from Real World NP. You are watching NP Practice Made Simple, the weekly videos to help save you time, frustration, and help you learn faster so you can take the best care of your patients. In this week's video. I want to continue the conversation about resistant hypertension evaluation. And before I jump in, I just want to share that I have a brand new course coming up this fall/ winter, and it's all about Chronic Care Management. It's the top three most common chronic conditions in primary care. So diabetes, hypertension, and CKD in terms of the medication management, as well as assessment and diagnostic workups for and management of, monitoring and management of CKD. So if you want to join us or you want to learn more information head over to realworldnp.com/courses, and then we'll email you first, when there's more information coming out.

So getting back into resistant hypertension now, I made a video resistant hypertension part one. So definitely go watch that before you watch this one or in any order, I guess. But in that video, I talked about the steps to working up resistant hypertension, which just as a refresher is a patient who is on three or more hypertensive medications, including a diuretic that are optimized doses, and they're still not at goal for their blood pressure. So in part one, I talked about all the different steps for evaluation and workup, and then this video I'm delving a little bit more into a subset of investigation, which is high aldosterone. So hyperaldosteronism is an under-recognized cause of resistant hypertension in primary care. And it is a place that I certainly have learned about more recently. And I want to, not that I learned about more recently, but I'm doing a little bit more in my practice getting comfortable with taking the step of evaluation, right?

Because it is underrecognized. So, and the rationale for, well, first of all, you can just learn about this and not adopt these practices if you don't want to, based on your personal comfort level of practice, however this is important to know about as an etiology and can help you determine with a couple of simple blood tests who to refer to for help with your resistant hypertension patient. So three referrals, three specialists can help us with resistant hypertension. So one is cardiology, two is endocrine, if it's thought to be an adrenal aldosterone related cause, and then the third one is renal because they can help for patients who have CKD with resistant hypertension. Those are the people you want to talk to. So doing this blood test can help us determine who is the best person to refer to if the patient's blood pressure is still not within goal, even though they're on all of those meds, right?

Okay, so at first let's start with some basics quick refresher. So what are the adrenal glands, right? Those are those endocrine glands that are on top of the kidneys and they release a number of hormones, aldosterone of course, glucocorticoids, sex hormones and epinephrine. I have my notes here. That's why I'm taking a peek at my screen. So, and then what is aldosterone? So aldosterone works in the kidneys and it helps with sodium reabsorption as well as potassium and it's part of the renin and angiotensin system. That wonderful thing that you learned about in patho. Maybe you loved it, maybe you didn't. So why do we care about it? So if it's too high, it's going to cause resistant hypertension. What are the causes of that? So one of the causes, there's primary and secondary hyperaldosteronism. The first one, the most common one is idiopathic meaning like we have no idea.

We have normally looking and normally sized adrenal glands on top of our kidneys. But for some reason that we don't understand they're producing more aldosterone than they should. The next most common ones have to do with adrenal adenomas, little growths on top of the adrenal glands that are secreting aldosterone. And then also we can have things like pheochromocytoma, which is another type of growth and has its own specific symptoms, as well as hypertension. I'm not going to get into that in this video cause I think that's a little bit information overload, but just keep in mind, pheochromocytoma is a potential option for high blood pressure, but it comes with a constellation of other symptoms. And then the other main causes for high aldosterone is it can be secondary, meaning it's not directly coming from the adrenal glands, but something is stimulating the adrenal glands to make more aldosterone.

And the main causes for that are a carcinoma of some kind. Ovarian and renal are the most common causes. So those two can stimulate the adrenal glands to make more aldosterone or actually perhaps make more themselves and actually don't quote me on that. But having a tumor can cause that release of aldosterone. So when would you want to think about high aldosterone checking for this in a patient? So the reason I would check this is if somebody had resistant hypertension, I did the other workup that was available and we still couldn't figure it out before I sent them to a specialist, because that would help us determine who the best person is, right? And so the other constellation of symptoms that can go along with high aldosterone are low potassium, unrelated to any other medications that they take unrelated to any other reason, they just happen to have low potassium and high blood pressure.

And then the third one is metabolic alkalosis. Signs of that, which you can see on the BMP a little bit, it's getting a little fancy, but that's the classic triad, but in the real world, most people do not have low potassium. So don't let that be a barrier for you. Let it be included in your resistant hypertension workup, if you feel comfortable ordering and interpreting those labs. And again, if you don't definitely seek out either continuing education or your colleagues or and/or supervisor. So I guess just to throw in a couple of other symptoms, if you are thinking about a pheochromocytoma they have hypertension, may or may not be resistant, they can have sweating, headaches, they can also have hyperglycemia or this like hyper metabolic state. But if you have like sweating and hypertension, you might think about a pheochromocytoma included in your differential diagnosis.

But again, treading lightly getting support because that's a little bit of a zebra diagnosis that we're bringing in there. So not like jumping to that and just know that they can also have pyrexizimal symptoms as well. So if they have hypertension with like sweating and tachycardia and that kind of stuff here and there definitely think about it, but, and again, get some support with that. So for the workup, so if you're thinking about this as a potential workup, there's a first pass that we can do to let us think if there's a possibility because it needs a number of confirmatory tests to make the diagnosis of hyperaldosteronism. But the first pass that we can make in primary care reasonably safely is a morning renin and aldosterone, two different labs, serum renin, and serum aldosterone and it might be termed a little bit differently depending on your lab.But what we're looking for is to see the patients with hyperaldosteronism, will have a high aldosterone with a suppressed renin level. And that would be your kind of first clue of like, "You know what, I think this person probably should see endocrine, right?" And that's simple, like the reason I'm making a video about this is again, number one, it's under-recognized and two, we can pretty easily do those two blood tests to help us figure out what specialists to go to because we all know referrals can take a long time for patients to get an appointment, to get there, to get worked up, et cetera. And like I said, there's like a whole cascade of other lab tests and potentially an abdominal CT that might be involved to look at the adrenal glands itself. But I probably would stop there.

I probably would just start with those two myself personally, without collaboration with a colleague or my supervisor, unless it was in under guidance of an endocrinologist who said, who would say, like if the patient couldn't get into an endocrinologist in a reasonable amount of time, I might do a cold call or a little email and say, "Would you recommend X, Y, and Z tests?" And then they would give their advisement. So that's pretty much it that's the kind of quick and dirty about hyperaldosteronism as a potential cause of resistant hypertension. And if you want to learn more about hypertension medication and management inside of the Chronic Care Course, that's coming up brand new this fall, head over to realworldnp.com/courses. And you can get on the wait list and be the first to know when there's more information available and when the course is open for enrollment. Thank you so very much for watching hang in there and I'll see you soon.