Thread by @AdiG1993

1) Gen med residents are taught to think of secondary hypertension, especially primary hyperaldosteronism, if the following conditions are met.

- young onset HTN (age < 40)
- family history
- resistant HTN
- hypokalemia

2) First of all, young onset HTN is a controversial term nowadays --> with the rise of fast food and sedentary lifestyles with pediatric obesity and metabolic syndrome --> it is entirely possible that the age may need to be shifted even lower!

3) This study, done in AIIMS with @DrSarahAlam as the lead author looked at PA epidemiologically.

202 patients with young onset HTN (YH) were evaluated.

Surprisingly the mean age was 43.9+/- 10.9 years!
pubmed.ncbi.nlm.nih.gov/33393127/

4) Family history is a nebulous term --> Indian families are close knit and love to eat and not exercise together.

Metabolic syndromes run in families because they don't run together.

Amidst all this essential hypertension, how does one rule in PA with any degree of accuracy?

5) Resistant HTN is defined by Harrison 20th ed as BP > 130/80 with at least 3 classes of drugs one of which is a diuretic.

AHA 2018, ACC/AHA 2017 and ESC/ESH 2018 guidelines agree.

But the definition of resistant HTN is broad and requires several caveats!

6) ijph.in/article.asp?is…

ncbi.nlm.nih.gov/pmc/articles/P…

These studies show that noncompliance is common --> especially in the rural and slum areas where the disease burden is high.

There is no reason to think that urban, wealthy patients will fare a lot better!

7) So, its impossible to predict how much of the resistant HTN is 'true' resistance!

Asymptomatic nature of the disease, cost of drugs, lifelong duration, simple forgetfulness --> these are the common causes of drug noncompliance!

8) Hyperaldosteronism was considered rare till the 1990s with prevalence <1%.

But widespread screening and use of the aldosterone/renin ratio (ARR) --> the disease is far more prevalent going upto 30% in referral centres!

But hypokalemia is present in less than 50% cases!

9) HypoK --> this indicates a more florid clinical phenotype with more hypertensive emergencies.

But milder forms of PA are the rule and the most common form of HTN now is normokalemic!
ahajournals.org/doi/10.1161/HY….

kidney360.asnjournals.org/content/1/10/1…

10) As you can see, not one of this tetrad is clinically useful --> the disease picture is changing and we have to change with the times.

It is important to remember that secondary HTN is common and hides among the masses of essential HTN!

Keep this in mind!

#hypertension
#aldosteronism
#CardioTwitter
#Nephro
#health
#savelives

Please retweet if you find this useful! Thank you!

@anujtiwari11 @DrPyaricetamoI @prernachettri @DrDeepakKrishn1 @DrSarahAlam and others --> your opinions please!