Page 125 - fbkCardioDiabetes_2017

Cardio Diabetes Medicine 2017 101

be measured during follow-up to detect orthostatic tion. Measurement of 24-hour urinary metanephrines
complications with treatment. or plasma metanephrines is an effective screen when
pheochomocytoma is suspected.
Physical Examination
A fundoscopic examination should document the Noninvasive Imaging
presence and severity of retinopathy. The presence Imaging for renal artery stenosis should be reserved
of carotid, abdominal, or femoral bruits increases the for patients in whom there is an increased level of
possibility that renal artery stenosis exists. Dimin- suspicion. This would include young patients, particu-
ished femoral pulses and/or a discrepancy between larly women, whose presentation suggests the pres-
arm and thigh blood pressures suggest aortic coarc- ence of fibromuscular dysplasia and older patients
tation or significant aortoiliac disease. Cushing’s dis- at increased risk of atherosclerotic disease. Due to
ease is suggested by abdominal striae, particularly if poor specificity, abdominal CT imaging is not rec-
pigmented; moon facies; or prominent interscapular ommended to screen for adrenal adenomas in the
fat deposition. absence of biochemical confirmation of hormonally
active tumors (hyperaldosteronism,pheochromocyto-
Ambulatory Blood Pressure Monitoring ma , Cushing’s syndrome).
Documentation of a significant white-coat effect Treatment Recommendations
requires reliable assessment of out-of-office blood
pressure values. This is accomplished most objec- Resistant hypertension is almost always multifactori-
tively with the use of 24-hour ambulatory blood pres- al in etiology. Treatment is predicated on identification
sure monitoring. and reversal of lifestyle factors contributing to treat-
ment resistance; accurate diagnosis and appropriate
A significant white-coat effect should be suspected treatment of secondary causes of hypertension; and
in patients with resistant hypertension in whom clinic use of effective multi-drug regimens.Lifestyle chang-
blood pressure measurements are consistently high- es, including weight loss; regular exercise; ingestion
er than out-of-office measurements; in patients who of a high-fiber, low-fat, low-salt diet; and moderation
repetitively show signs of overtreatment, particularly of alcohol intake.
orthostatic symptoms; and in patients with chronical- Potentially interfering substances should be with-
ly high office blood pressure values but an absence drawn or down-titrated as clinically allowable. Ob-
of target organ damage (LVH, retinopathy, CKD). In structive sleep apnea should be treated if present.
such cases, 24-hour ABPM is recommended. A mean
ambulatory daytime blood pressure of >135/85 mm
Hg is considered elevated. If a significant white-coat Maximize Adherence
effect is confirmed, out-of-office measurements Prescribed regimens should be simplified as much as
should be relied on to adjust treatment. possible, including the use of a long-acting combina-
tion of products to reduce the number of prescribed
Biochemical Evaluation pills and to allow for once-daily dosing. Adherence
is also enhanced by more frequent clinic visits and
Biochemical evaluation of the treatment-resistant hy- by having patients record home blood pressure mea-
pertensive should include a routine metabolic profile surements. Involving the patient by having him or
(sodium, potassium, chloride, bicarbonate, glucose, her maintain a diary of home blood pressure values
blood urea nitrogen, and creatinine); urinalysis; and should improve follow-up and enhance medication
a paired, morning plasma aldosterone and plasma adherence, while involvement of family members will
renin or plasma renin activity to screen for primary likely enhance persistence with recommended life-
aldosteronism. Even in the setting of ongoing antihy- style changes.
pertensive treatment (excluding potassium-sparing
diuretics, particularly aldosterone antagonists), the
aldosterone/renin ratio is an effective screening test Nonpharmacological Recommendations
for primary aldosteronism, having a high negative Weight Loss: Weight loss, has a clear benefit in terms
predictive value. of reducing blood pressure and often allows for re-
duction in the number of prescribed medications.
A 24-hour urine collected during ingestion of the While difficult to achieve and even more difficult to
patient’s normal diet can be helpful in estimating di- maintain, weight loss should be encouraged in any
etary sodium and potassium intake, calculating cre- patient with resistant hypertension who is either
atinine clearance, and measuring aldosterone excre-
overweight or obese.

Cardio Diabetes Medicine