# Clinical Cases: Hypertension Management

## Case 1: Hypertensive Emergency

### Patient Presentation
A 52-year-old man with a history of poorly controlled hypertension presents with severe headache, blurred vision, and chest discomfort that started 4 hours ago. He ran out of his blood pressure medications 2 weeks ago and has not been taking them. He reports nausea and admits to recent cocaine use approximately 8 hours ago.

### Vital Signs
- Blood Pressure: 228/134 mmHg (confirmed in both arms)
- Heart Rate: 102 bpm
- Respiratory Rate: 22/min
- Oxygen Saturation: 95% on room air
- Temperature: 37.3°C

### Physical Examination
- General: Anxious, diaphoretic
- HEENT: Papilledema on fundoscopic exam, AV nicking
- Cardiovascular: S4 gallop, no murmurs
- Pulmonary: Bibasilar crackles
- Neurologic: Alert and oriented, no focal deficits
- Extremities: Trace bilateral edema

### Initial Workup
- **ECG**: Sinus tachycardia, left ventricular hypertrophy with strain pattern
- **Troponin I**: 0.12 ng/mL (mildly elevated)
- **BNP**: 680 pg/mL
- **Creatinine**: 2.1 mg/dL (baseline 1.2)
- **Urinalysis**: 2+ protein, occasional RBC casts
- **Chest X-ray**: Cardiomegaly, pulmonary vascular congestion
- **CT Head**: No hemorrhage

### Clinical Image
![Hypertensive Retinopathy](image_01.png)
*Figure 1: Grade IV hypertensive retinopathy with papilledema, flame hemorrhages, and cotton wool spots indicating malignant hypertension.*

**Image Source**: Educational illustration for teaching purposes.

### Questions

1. **What distinguishes a hypertensive emergency from hypertensive urgency?**
   - A) Blood pressure level above 180/120 mmHg
   - B) Presence of acute target organ damage
   - C) Duration of elevated blood pressure
   - D) Patient symptoms

2. **Which target organs are affected in this patient?**
   - A) Eyes only
   - B) Eyes, heart, and kidneys
   - C) Brain and heart only
   - D) Kidneys only

3. **What is the appropriate blood pressure reduction goal in the first hour?**
   - A) Reduce to normal (<120/80) immediately
   - B) Reduce mean arterial pressure by no more than 25%
   - C) Reduce to <140/90 mmHg
   - D) Reduce systolic by 50 mmHg

4. **Which intravenous antihypertensive would be most appropriate for initial management?**

5. **Why should beta-blockers be avoided or used cautiously in this patient?**

### Answers

1. **B) Presence of acute target organ damage** - Hypertensive emergency is defined by severely elevated BP WITH acute target organ damage (encephalopathy, AKI, heart failure, aortic dissection, retinopathy). Hypertensive urgency is severely elevated BP WITHOUT acute organ damage.

2. **B) Eyes, heart, and kidneys** - This patient has papilledema (eyes), elevated troponin and pulmonary edema (heart), and acute kidney injury with proteinuria and RBC casts (kidneys). Multiple organs are affected.

3. **B) Reduce mean arterial pressure by no more than 25%** - Rapid BP reduction risks hypoperfusion of vital organs adapted to high pressures. Goal is to reduce MAP by no more than 25% in the first hour, then gradually to 160/100-110 over the next 2-6 hours.

4. **Appropriate IV antihypertensives**:
   - **Nicardipine** (calcium channel blocker): First-line, titratable, no reflex tachycardia at clinical doses
   - **Labetalol** (combined alpha/beta blocker): Good option but use cautiously given recent cocaine
   - **Clevidipine**: Ultra-short acting CCB
   - **Nitroprusside**: Alternative but requires monitoring for cyanide toxicity
   - Avoid hydralazine (unpredictable response) and sublingual nifedipine (precipitous BP drop)

5. **Beta-blocker caution with cocaine**:
   - Recent cocaine use causes sympathetic surge with both alpha and beta receptor stimulation
   - Beta-blocker monotherapy leads to unopposed alpha-stimulation
   - This can worsen coronary vasoconstriction and hypertension
   - If beta-blockade is needed, use combined alpha/beta blocker (labetalol) or benzodiazepines first
   - Benzodiazepines help control cocaine-induced sympathetic excess

---

## Case 2: Resistant Hypertension

### Patient Presentation
A 58-year-old woman with hypertension for 15 years presents for follow-up. Despite taking amlodipine 10 mg, lisinopril 40 mg, and hydrochlorothiazide 25 mg daily, her blood pressure remains uncontrolled. She confirms taking her medications as prescribed. She has a history of type 2 diabetes and reports occasional headaches and fatigue.

### Vital Signs
- Blood Pressure: 162/98 mmHg (average of 3 readings)
- Heart Rate: 72 bpm
- BMI: 32 kg/m²

### Physical Examination
- General: Obese, cushingoid appearance not evident
- HEENT: No thyroid enlargement
- Cardiovascular: Regular rhythm, S4 present, no murmurs
- Pulmonary: Clear
- Abdomen: Obese, no bruits
- Extremities: Trace edema

### Laboratory Results
- **Sodium**: 144 mEq/L
- **Potassium**: 3.2 mEq/L (low)
- **Creatinine**: 1.0 mg/dL
- **Fasting glucose**: 132 mg/dL
- **Aldosterone**: 22 ng/dL (elevated)
- **Plasma renin activity**: 0.4 ng/mL/hr (suppressed)
- **Aldosterone-to-renin ratio**: 55 (elevated, >30 is positive)
- **24-hour urine sodium**: 180 mEq/day (adequate salt intake)

### Clinical Image
![Adrenal Adenoma CT](image_02.png)
*Figure 2: CT scan of the abdomen demonstrating a left adrenal adenoma (arrow) in a patient with primary aldosteronism causing resistant hypertension.*

**Image Source**: Educational illustration for teaching purposes.

### Questions

1. **What defines resistant hypertension?**
   - A) BP >140/90 on one medication
   - B) BP above goal despite 3 optimally dosed antihypertensives including a diuretic
   - C) BP >160/100 despite any treatment
   - D) Hypertension requiring hospitalization

2. **What is the most likely cause of this patient's resistant hypertension?**
   - A) Medication non-adherence
   - B) Primary aldosteronism
   - C) Renal artery stenosis
   - D) Pheochromocytoma

3. **What confirmatory test should be performed for primary aldosteronism?**
   - A) Repeat aldosterone level
   - B) Salt suppression test or fludrocortisone suppression test
   - C) MRI of adrenal glands
   - D) 24-hour urine catecholamines

4. **What is the appropriate treatment if a unilateral adrenal adenoma is confirmed?**

5. **What medication should be added if surgery is not an option?**

### Answers

1. **B) BP above goal despite 3 optimally dosed antihypertensives including a diuretic** - Resistant hypertension is defined as BP above goal despite adherence to 3 or more optimally dosed antihypertensive medications of different classes, one of which should be a diuretic.

2. **B) Primary aldosteronism** - The combination of resistant hypertension, hypokalemia, elevated aldosterone, suppressed renin, and elevated aldosterone-to-renin ratio (>30) is highly suggestive of primary aldosteronism.

3. **B) Salt suppression test or fludrocortisone suppression test** - Confirmatory testing is required after positive screening. Options include:
   - Oral salt loading test (aldosterone remains elevated despite sodium loading)
   - IV saline infusion test
   - Fludrocortisone suppression test
   - Captopril challenge test
   Imaging (CT/MRI) is for localization, not confirmation.

4. **Treatment for unilateral aldosterone-producing adenoma**:
   - Laparoscopic adrenalectomy is the treatment of choice
   - Often curative for hypertension (35-60% cure rate)
   - Always improves blood pressure control even if not cured
   - Adrenal vein sampling should be performed to confirm lateralization before surgery

5. **Medical management if surgery not an option**:
   - Mineralocorticoid receptor antagonist (spironolactone or eplerenone)
   - Spironolactone 25-100 mg daily is highly effective
   - Eplerenone is an alternative with fewer anti-androgen side effects
   - Amiloride can be used if MRAs not tolerated
   - Often requires continuation of other antihypertensives

---

## Case 3: Secondary Hypertension - Renal Artery Stenosis

### Patient Presentation
A 65-year-old man with a 20-pack-year smoking history and known peripheral arterial disease presents with new-onset hypertension at age 62. His blood pressure has been increasingly difficult to control despite multiple medications. He reports episodes of sudden shortness of breath ("flash pulmonary edema") that resolve without clear explanation.

### Vital Signs
- Blood Pressure: 178/102 mmHg
- Heart Rate: 80 bpm
- Respiratory Rate: 16/min

### Physical Examination
- General: Well-appearing
- Cardiovascular: Abdominal bruit appreciated in right upper quadrant
- Pulmonary: Clear
- Extremities: Diminished pedal pulses bilaterally

### Laboratory Results
- **Creatinine**: 1.8 mg/dL (was 1.2 one year ago)
- **Potassium**: 3.8 mEq/L
- **Urinalysis**: Trace protein

### Imaging
- **Renal duplex ultrasound**: Right kidney 8.5 cm, left kidney 11 cm; elevated resistive indices on right

### Clinical Image
![Renal Artery Stenosis](image_03.png)
*Figure 3: MR angiography demonstrating severe right renal artery stenosis (arrow) due to atherosclerotic disease.*

**Image Source**: Educational illustration for teaching purposes.

### Questions

1. **What clinical features suggest renovascular hypertension in this patient?**
   - A) Age of onset and family history
   - B) New-onset hypertension after age 55, flash pulmonary edema, asymmetric kidneys, abdominal bruit
   - C) Obesity and sleep apnea
   - D) Palpitations and sweating

2. **What are the two main causes of renal artery stenosis?**
   - A) Diabetes and hypertension
   - B) Atherosclerosis and fibromuscular dysplasia
   - C) Glomerulonephritis and polycystic kidney disease
   - D) Aortic dissection and aneurysm

3. **What is the gold standard diagnostic test for renal artery stenosis?**
   - A) Renal duplex ultrasound
   - B) CT angiography
   - C) Catheter-based renal angiography
   - D) Captopril renogram

4. **What precaution must be taken when using ACE inhibitors in patients with renal artery stenosis?**

5. **When is revascularization indicated for atherosclerotic renal artery stenosis?**

### Answers

1. **B) New-onset hypertension after age 55, flash pulmonary edema, asymmetric kidneys, abdominal bruit** - These are classic features of renovascular hypertension. Flash pulmonary edema (Pickering syndrome) occurs due to fluid retention in bilateral RAS or unilateral RAS with a solitary kidney.

2. **B) Atherosclerosis and fibromuscular dysplasia** - Atherosclerotic RAS accounts for 90% of cases, typically in older patients with cardiovascular risk factors. FMD accounts for 10%, typically in younger women, and has a "string of beads" appearance.

3. **C) Catheter-based renal angiography** - Digital subtraction angiography is the gold standard but is invasive. CT angiography and MR angiography are preferred for initial evaluation due to less invasiveness with good sensitivity and specificity.

4. **ACE inhibitor precautions in RAS**:
   - In bilateral RAS or RAS in a solitary kidney, ACE inhibitors can cause acute kidney injury
   - Efferent arteriolar dilation reduces intraglomerular pressure needed to maintain GFR
   - Monitor creatinine within 1-2 weeks of starting ACE inhibitor
   - >30% rise in creatinine warrants discontinuation and further workup
   - ACE inhibitors may still be used in unilateral RAS with careful monitoring

5. **Indications for revascularization**:
   - Resistant hypertension despite optimal medical therapy
   - Recurrent flash pulmonary edema
   - Progressive chronic kidney disease
   - Unstable angina with significant RAS
   - Recent trials (CORAL, ASTRAL) show limited benefit for revascularization over medical therapy in most patients
   - Best reserved for patients with clear clinical indications and >70% stenosis

---

## Learning Points

1. **Hypertensive emergency** requires IV medications and ICU monitoring with gradual BP reduction to prevent hypoperfusion injury.

2. **Resistant hypertension** warrants screening for secondary causes, particularly primary aldosteronism (most common endocrine cause).

3. **Primary aldosteronism** screening involves aldosterone-to-renin ratio; confirmatory testing and adrenal imaging guide treatment.

4. **Renovascular hypertension** should be suspected with new-onset hypertension >55 or <30 years, flash pulmonary edema, or worsening kidney function on ACE inhibitors.

5. **Blood pressure goals** are <130/80 mmHg for most adults with hypertension according to current guidelines.