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Here's a clean summary of the table, followed by quiz questions to test yourself.
Cause-Specific Treatment of Secondary Hypertension
Summary
Renovascular HTN
| Subtype | Definitive Treatment | Medical Management |
|---|---|---|
| FMD (Fibromuscular Dysplasia) | PTA — often curative | ACEi/ARB (watch K+ & creatinine); avoid in bilateral RAS |
| Atherosclerotic | Revascularization/stenting — benefit less certain | Aggressive CVD risk reduction; ACEi/ARB ± CCB |
Key distinction: FMD is younger women, PTA is curative. Atherosclerotic is elderly/smokers, stenting is controversial.
Primary Aldosteronism (Conn's)
| Subtype | Definitive Treatment | Medical Management |
|---|---|---|
| Adenoma (unilateral) | Laparoscopic unilateral adrenalectomy | Spironolactone or eplerenone pre-op and if bilateral |
| Bilateral hyperplasia | Medical (no surgery) | Spironolactone 25–100 mg/day; amiloride if intolerant |
Key rule: Adenoma = surgery. Bilateral hyperplasia = lifelong medical therapy.
Adrenal / Catecholamine Causes
| Condition | Definitive Treatment | Medical Management |
|---|---|---|
| Pheochromocytoma | Laparoscopic adrenalectomy | Alpha-blocker FIRST (phenoxybenzamine), then beta-blocker. NEVER beta first |
| Cushing's Disease (pituitary) | Transsphenoidal pituitary surgery | Metyrapone, ketoconazole (steroid synthesis inhibitors) |
| Cushing's Syndrome (adrenal adenoma) | Adrenalectomy | Medical bridging with adrenal enzyme inhibitors |
Pheo mnemonic: "Alpha before Beta" — giving beta-blockers first causes unopposed alpha vasoconstriction → hypertensive crisis.
Structural / Systemic Causes
| Condition | Definitive Treatment | Medical Management |
|---|---|---|
| Coarctation of Aorta | Surgical repair or percutaneous stenting | Beta-blockers for pre-op BP control |
| Hypothyroidism | Levothyroxine replacement — normalizes BP in most | Standard antihypertensives if BP persists |
| Obstructive Sleep Apnea | CPAP therapy — reduces BP 2–3 mmHg | Weight loss; positional therapy; antihypertensives |
| CKD / Renal Parenchymal | Treat underlying disease; dialysis/transplant | ACEi/ARB (reduce proteinuria); diuretics; low-salt diet |
| Drug-Induced HTN | Discontinue offending drug | Substitute with non-HTN-causing alternative |
Quiz Questions
Try to answer before revealing each answer:
Q1. A young woman with renovascular HTN due to FMD — what is the preferred definitive treatment and what is the expected outcome?
Answer
Percutaneous transluminal angioplasty (PTA) — it is often curative in FMD.Q2. In primary aldosteronism due to bilateral adrenal hyperplasia, why is surgery NOT performed?
Answer
Both glands are affected — removing one would not resolve the problem. Medical therapy with spironolactone is the treatment.Q3. A patient with pheochromocytoma is prescribed a beta-blocker before adequate alpha-blockade. What dangerous complication can occur?
Answer
Unopposed alpha-adrenergic stimulation → severe hypertensive crisis. Alpha-blocker (phenoxybenzamine) must always come FIRST.Q4. What drug is first-line medical management for primary aldosteronism, and what is the alternative if the patient is intolerant?
Answer
Spironolactone (25–100 mg/day); amiloride if intolerant.Q5. What is the definitive treatment for Cushing's Disease (pituitary source) vs. Cushing's Syndrome (adrenal adenoma)?
Answer
Cushing's Disease → Transsphenoidal pituitary surgery. Cushing's Syndrome (adrenal) → Adrenalectomy.Q6. Which two conditions have ACEi/ARB as a cornerstone of medical management, and why must ACEi/ARB be avoided in bilateral renal artery stenosis?
Answer
Renovascular HTN (FMD/atherosclerotic) and CKD. In bilateral RAS, ACEi/ARB block angiotensin II-mediated efferent arteriole constriction → loss of GFR → acute kidney injury.Q7. What is the medical management of Cushing's Disease pre-op or when surgery fails?
Answer
Metyrapone or ketoconazole — both are steroid synthesis inhibitors.Q8. CPAP therapy for OSA reduces blood pressure by approximately how much?
Answer
2–3 mmHg.Let me know if you want me to go deeper on any condition, add mnemonics, or quiz you interactively one question at a time!
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Cause-Specific Treatment of Secondary Hypertension
1. Renovascular HTN — FMD
Condition: Fibromuscular dysplasia narrows renal arteries → high renin → HTN.
Typically young women.
Mnemonic: "FMD = Fix Me Definitively"
- Definitive: PTA (Percutaneous Transluminal Angioplasty) — curative!
- Medical: ACEi/ARB — but monitor K⁺ and creatinine, and avoid in bilateral RAS
2. Renovascular HTN — Atherosclerotic
Condition: Plaque narrows renal artery. Older patients, smokers.
Mnemonic: "Ath = Aggressive but Ambiguous"
- Definitive: Revascularization/stenting — benefit less certain (unlike FMD)
- Medical: Aggressive CVD risk reduction + ACEi/ARB ± CCB
3. Primary Aldosteronism — Adenoma (Conn's)
Condition: Unilateral aldosterone-secreting adenoma → HTN + hypokalemia.
Mnemonic: "One gland = One surgeon"
- Definitive: Laparoscopic unilateral adrenalectomy
- Medical (pre-op or if bilateral): Spironolactone or eplerenone (aldosterone antagonists)
4. Primary Aldosteronism — Bilateral Hyperplasia
Condition: Both adrenal glands overactive → can't surgically cure.
Mnemonic: "Both = Bottles of pills"
- Definitive: Medical only (spironolactone first-line)
- Medical: Spironolactone 25–100 mg/day; amiloride if intolerant
5. Pheochromocytoma
Condition: Adrenal medulla tumor secreting catecholamines → episodic HTN, sweating, headache, palpitations.
Mnemonic: "Alpha Before Beta — ABB" (Always Block with Alpha Before Beta)
⚠️ NEVER give beta-blocker first — causes unopposed alpha vasoconstriction → hypertensive crisis!
- Definitive: Laparoscopic adrenalectomy
- Medical pre-op: Phenoxybenzamine (alpha) FIRST, then add beta-blocker
6. Cushing's Disease (Pituitary)
Condition: Pituitary adenoma secretes excess ACTH → bilateral adrenal hyperplasia → cortisol excess.
Mnemonic: "Pituitary Problem = Poke the Pituitary"
- Definitive: Transsphenoidal pituitary surgery
- Medical: Metyrapone / Ketoconazole (block cortisol synthesis)
7. Cushing's Syndrome (Adrenal Adenoma)
Condition: Adrenal adenoma secretes cortisol autonomously.
Mnemonic: "Adrenal Adenoma = Adrenalectomy"
- Definitive: Adrenalectomy
- Medical: Bridging with adrenal enzyme inhibitors (metyrapone, ketoconazole)
8. Coarctation of Aorta
Condition: Narrowing of aorta → upper body HTN, weak femoral pulses, rib notching.
Mnemonic: "Coarct = Correct it Surgically, Beta for BP"
- Definitive: Surgical repair or percutaneous stenting
- Medical pre-op: Beta-blockers for BP control
9. Hypothyroidism
Condition: Low thyroid hormone → increased SVR → HTN (diastolic predominantly).
Mnemonic: "Replace the hormone, replace the pressure"
- Definitive: Levothyroxine — normalizes BP in most patients
- Medical: Standard antihypertensives only if BP persists after replacement
10. Obstructive Sleep Apnea (OSA)
Condition: Repeated hypoxia → sympathetic activation → HTN (especially nocturnal/morning).
Mnemonic: "CPAP Caps the pressure"
- Definitive: CPAP — reduces BP by ~2–3 mmHg
- Medical: Weight loss, positional therapy, antihypertensives
11. CKD / Renal Parenchymal Disease
Condition: Damaged kidneys retain sodium, activate RAAS → HTN worsens kidney function (vicious cycle).
Mnemonic: "ACE the Kidney"
- Definitive: Treat underlying disease; dialysis/transplant if advanced
- Medical: ACEi/ARB (reduce proteinuria + BP); diuretics; low-salt diet
12. Drug-Induced HTN
Condition: NSAIDs, OCPs, steroids, decongestants, stimulants, calcineurin inhibitors, etc.
Mnemonic: "Stop the drug, stop the pressure"
- Definitive: Discontinue offending drug
- Medical: Substitute with a non-HTN-causing alternative
Flashcards
Test yourself on each — cover the right side!
| Question | Answer |
|---|---|
| Definitive Rx for FMD renovascular HTN? | PTA — curative |
| Why avoid ACEi/ARB in bilateral RAS? | Blocks efferent arteriole tone → acute kidney injury |
| Adenoma vs. bilateral hyperplasia in Conn's — what changes? | Adenoma → surgery; Bilateral → medical only |
| First-line medical Rx for primary aldosteronism? | Spironolactone; amiloride if intolerant |
| Why is beta-blocker dangerous first in pheo? | Unopposed alpha activation → hypertensive crisis |
| Alpha-blocker of choice pre-op for pheo? | Phenoxybenzamine |
| Cushing's Disease source? Definitive Rx? | Pituitary (ACTH) → Transsphenoidal surgery |
| Cushing's Syndrome (adrenal) definitive Rx? | Adrenalectomy |
| Medical therapy for Cushing's? | Metyrapone or ketoconazole |
| Coarctation pre-op BP drug? | Beta-blocker |
| Hypothyroidism HTN — will treating it help? | Yes — levothyroxine normalizes BP in most |
| CPAP reduces BP by how much? | ~2–3 mmHg |
| ACEi/ARB in CKD — main benefit? | Reduce proteinuria + slow progression |
| Definitive Rx for drug-induced HTN? | Discontinue the offending drug |
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