Malignant Hypertension: Management Without Headaches

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Malignant HypertensionManagement Without
Headaches

• Peter Yorgin, M.D.
• Associate Professor
• Loma Linda University

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Case Presentation

• A 27 year old woman comes to your office with
  complaints of
• A throbbing headache
• Vomiting
• Nose bleeds

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Case Presentation

• Blood glucose 87 mg/dL
• Temperature 37.7 C
• Pulse 67
• Blood Pressure 189/120 mmHg

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Case Presentation

• What did you see?
• What is happening?
• Have you seen this problem?
• What is causing her problem?
• What can we do about it?

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Choose the appropriate blood pressure cuff!
Cuff width 0.4 -0.55 X Arm length Bladder
circumference 0.8-1.0 x Arm circumference
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Is the patient hypertensive?
JNC 7 Recommendations
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Is the patient hypertensive?

• Borderline/ Mild Consistently above the 90 th
  and occasionally gt 95 th percentile. The
  measurement needs to be repeated twice over the
  next 6 weeks.
• Moderate Blood pressures consistently gt95 th
  percentile.
• Severe Blood pressure consistently gt95 th
  percentile by 10-15 mmHg or greater.

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DIFFERENTIAL DIAGNOSIS
Essential/Primary
CNS Seizures Increased ICP Polio/Guillian Barre
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Hyperthyroidism Endocrine Cushing
syndrome Hyperaldosteronism Pheochromocytoma Hyper
calcemia CAH
Cardiac Coarctation
Renal Glomerulonephritis Reflux
nephropathy Obstruction Renal artery
stenosis Pyelonephritis ARPKD/ADPKD Multicystic
kidney
67
Hypervolemia
Steroids Drugs/Toxins BCP Lead Mercury
Arar MY et al, Pediatric Nephrol 8(2)186-189,
1994.
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Laboratory Evaluation of Hypertension
Borderline / mild Electrolytes BUN, Creatinine
and glucosel, Urinalysis, calcium, and
cholesterol (HDL, LDL) Moderate Tests above and
renal sonogram with Doppler, plasma renin,
aldosterone, desoxycorticosterone (DOC), cardiac
echo, thyroid function tests (TSH, Free T4),
aldosterone levels, 24 hour urinary HVA,VMA,
metanephrines and norepinephrine Severe Tests
above CT renal angiography, DMSA to determine if
renal scarring exists
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Acute Treatment

• Intravenous therapy
• Labetalol Beta Blocker
• Hydralazine Vasodilator
• Nicardipine drip Calcium Channel Blocker
• Nitroprusside drip Vasodilator
• Convert to oral therapy

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If we do not treat the hypertension
http//www.lifespan.org/adam/graphics/images/en/18
166.jpg
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Consequences of Hypertension
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Consequences of Hypertension
http//www.massgeneral.org/vascularcenter/body/str
oke.jpg
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In Children
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Hypertensive nephropathy
http//www.ndt-educational.org/images/Marcantonifi
g1.jpg
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Laboratory Testing

• Electrolytes BUN, creatinine and glucose
  Normal
• Urinalysis Normal
• Calcium Normal
• Cholesterol (HDL, LDL) Normal
• Plasma renin High, 83 ng/mL/min
• Aldosterone Normal
• Desoxycorticosterone (DOC) Normal
• Cardiac echo Mild left ventricular hypertrophy
• Thyroid function tests (TSH, Free T4) Normal
• 24 hour urinary HVA,VMA, metanephrines and
  norepinephrine Normal

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Renal Angiogram
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Antihypertensive drugs
Centrally acting agents

• Alpha blockers
• Vasodilators
• Calcium Channel
• Blockers
• Angiotensin
• Receptor
• Blockers

Angiotensin Converting Enzyme Inhibitors
Beta Blockers
Diuretics
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Treatment of adults
JNC 7 Recommendations
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References Hypertension

• JNC7 Reports
• http//www.nhlbi.nih.gov/guidelines/hypertension/
• http//www.nhlbi.nih.gov/health/prof/heart/hbp/hbp
  _ped.htm
• http//www.nhlbi.nih.gov/guidelines/hypertension/j
  nc7card.htm5.