michigan hypertension core curriculum - State of Michigan

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90 Hypertension Core Curriculum Pheochromocytoma Susan Steigerwalt, MD Men and women are equally affected by pheochromocytoma. (Approximately 85 - 90% of these tumors are 90% found within adrenal glands) and other catecholamine secreting tumors (extra adrenal are known as catecholamine secreting paragangliomas) are extremely RARE occurring in (less than 0.2% of all hypertensives ) causes of uncontrolled hypertension. Ninety eight percent of pheochromocytomas are intra-abdominal;the other 2% are located either in the intrathoracic > neck locations. The majority of extra-abdominal pheochromocytomas are located below the diaphragm. Approximately 10% of pheochromocytomas are malignant; extra-abdominal pheochromocytomas as well as very large tumors are more likely to be malignant. Roughly 10% of pheochromocytomas are familial. Familial tumors are more likely to be bilateral than unilateral. The diagnosis of pheochromocytoma is akin to tying to find a needle in a haystack. Further complicating the diagnosis of pheochromocytoma is the fact that individuals with pheochromocytoma may not be persistently hypertensive. The classic symptom triad in persons with pheochromocytoma is paroxysmal hypertension (85 – 95%), headache (90%), and generalized sweating (60 - 70%). Orthostatic hypotension is commonly encountered. Other symptoms may occur such as palpitations, panic disorder, psychiatric disturbances, weight loss, and cardiomyopathy. Factors triggering the aforementioned symptoms can also help identify those with pheochromocytoma. Accordingly, precipitation of this symptom cluster by anesthesia, exercise, urination, defecation, bending over, pregnancy or palpation of the abdomen, the ingestion of tyramine containing foods, or use of monoamine oxidase inhibitors, should heighten ones suspicion regarding the presence of pheochromocytoma. A list of differential causes mimicking pheochromocytoma is shown in table 1. Clinical presentation includes discovery in the work up of an incidental adrenal mass, suggestive history in a symptomatic patient, or family history in the case of familial disease pregnant patients who have hypertension of unknown etiology or duration should be tested for pheochromocytoma.
Table 1 Differential diagnosis of pheochromocytoma and type spells Endocrine Pheochromocytoma "Hyperandrenergic spells" Thyrotoxicosis Primary hypogonadism (menopausal syndrome) Medullary thyroid carcinoma Pancreatic tumors (eg, insulinoma) Hypoglycemia Carbohydrate intolerance Cardiovascular Labile essential hypertension Cardiovascular deconditioning Pulmonary edema Syncope Orthostatic hypotension Paroxysmal cardiac arrhythmia Angina Renovascular disease Psychologic Anxiety and panic attacks Somatization disorder Hyperventilation Factitious (eg, drugs, valsalva) Pharmacologic Withdrawal of andernergic-inhibitor MAO-inhibitor RX + decongestant Sympathomimetic ingestion Illegal drug ingestion (cocaine, PCP, LSD) Chlorpropamide-alcohol flush Vancomycin ("red man syndrome") Neurologic Postural orthostatic tachycardia syndrome (POTS) Autonomic neuropathy Migraine headache Diencephalic epilepsy (autonomic seizures) Stroke Cerebrovascular insufficiency Other Unexplained flushing spells Mast cell disease Carcinoid syndrome Recurrent idiopathic anaphylaxis Reproduced with permission from: Young, WF Jr. Pheochromocytoma and primary aldosteronism. Cancer Treat Res 1997; 89:239. Copyright © 1997 Springer Science and Business Media. NKFM & MDCH 91
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MICHIGAN HYPERTENSION CORE CURRICUL
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April 2010 Dear Colleague: In 2005,
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Kevin L. Piggott, MD, MPH, FAAFP Pr
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Blood Pressure Measurement........
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10 Hypertension Core Curriculum Blo
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of the wrist. Additionally, there i
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asis. National guidelines recommend
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Post-Test Questions: 1. High BP is
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18 Hypertension Core Curriculum Ess
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Masked Hypertension is when the off
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TABLE 1. Prevalence of Awareness, T
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Blood Pressure, Circulatory Physiol
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side of the vascular tree. Arterial
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upon the other co-morbidities prese
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Table 3. Clinically Available Clues
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In the setting of chronic hypertens
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34 Hypertension Core Curriculum Tab
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cause greater disruption of CBF aut
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References/Suggested Reading Agabit
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Page 88 and 89: Figure 1; Clinical presentation and
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Page 98 and 99: Definition Prevalence Clinical Feat
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Page 106 and 107: INTRODUCTION 106 Hypertension Core
Page 108 and 109: Renal manifestations. Renal ischemi
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Page 138 and 139: 2001;12(6):1235-1241. 40. Subramani
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78. Tami LF, McElderry MW, al-Adli
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142 Hypertension Core Curriculum Pr
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monitored hypertension screening an
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Policy Development: Public health p
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Med Clin North Am. Jan 2004;88(1):2
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mind they will have no problem iden
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Role of Race in the Selection of An
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individuals of any race or ethnicit
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Older Patients Need Elevated Systol
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sister, mother and father. A family
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ecause pressure-related retinopathy
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pulses (lower in the left arm). 4 C
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Vital signs suggestive of OSAHS. 20
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may shed light on underlying medica
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References: patients. 8 However, th
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Objectives: 170 Hypertension Core C
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and evidence that anti-hypertensive
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When subjects are given instruction
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interestingly found only a 6.0/4.6
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pressure: a meta-analysis of random
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isolated systolic hypertension have
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Compelling Indications for Specific
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3.) Beta-blockers, ACE inhibitors,
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treatment levels - albeit though at
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Preparations and Dosage: Oral antih
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Preparations and Dosages: The Oral
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patients with tachy-brady syndrome
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significant proteinuria. Pharmacolo
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the effect found by the ACE inhibit
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and nominally statistically signifi
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sensitive K+-channels in vascular s
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clonidine (Catapres†) 0.1-0.8 mg
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Learning Objectives 204 Hypertensio
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general, the response to beta-block
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Table 2: (JNC VII, 2004) 208 Hypert
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Learning objectives: 210 Hypertensi
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ecently published RCT investigated
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Post-test question: 35y/o male w/ h
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Orthostatic Hypotension Pretest que
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BP. It is important to note that la
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1- Fludrocortisone : a mineralocort
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References: 1. Hiitola P, Enlund H,
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www.neuroanatomy.wisc.edu/.../Image
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Learning objectives: 226 Hypertensi
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controlled BP to have been victimiz
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Treatment of Secondary Causes of Hy
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4-Direct vasodilators (e.g.minoxidi
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Hypertension. Aug 2003;42(2):161-16
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emergency by virtue of the associat
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PATHOPHYSIOLOGY The underlying mech
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trials included a placebo arm. Seve
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an indication for careful and modes
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ACUTE KIDNEY INJURY (AKI) In additi
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Blood Pressure Research Council, an
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[ACE inhibitors (ACEIs), angiotensi
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y sodium restriction or the use of
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44 months 24 , and were also seen i
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• Hypertension in dialysis patien
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GISEN Group (Gruppo Italiano di Stu
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258 Hypertension Core Curriculum
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DEFINITION AND CLASSIFICATION Hyper
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etween adult socioeconomic position
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women treated with atenolol in earl
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Obstet Gynecol. Dec 12 2008. 5. Vol
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able to dissipate the pressure rise
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Use of Dihydropyridine Calcium Anta
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272 Hypertension Core Curriculum Ca
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Case 4 Hypertensive patient with CK
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Case 6 276 Hypertension Core Curric
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year. Sodium restriction and weight
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What may be causing these new sympt
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