A 28-year-old man comes to the office for follow-up of hypertension. The patient has a 6-month history of fatigue and occasional headaches. When he came for evaluation 3 weeks ago, his blood pressure was 160/100 mm Hg. Medical history is unremarkable and he takes no medications. He has no family history of stroke or early heart disease. The patient smokes a pack of cigarettes daily but does not use alcohol or illicit drugs.
Blood pressure is 164/102 mm Hg and pulse is 82/min. BMI is 28 kg/m². Physical examination is unremarkable.
Laboratory results are as follows:
ECG shows normal sinus rhythm without ischemic changes. Urinalysis shows 1+ proteinuria. CT scan of the abdomen reveals normal adrenal glands.
Which of the following is the best next step in management of this patient's disorder?

Question

A 28-year-old man comes to the office for follow-up of hypertension. The patient has a 6-month history of fatigue and occasional headaches. When he came for evaluation 3 weeks ago, his blood pressure was 160/100 mm Hg. Medical history is unremarkable and he takes no medications. He has no family history of stroke or early heart disease. The patient smokes a pack of cigarettes daily but does not use alcohol or illicit drugs.
Blood pressure is 164/102 mm Hg and pulse is 82/min. BMI is 28 kg/m². Physical examination is unremarkable.
Laboratory results are as follows:

ECG shows normal sinus rhythm without ischemic changes. Urinalysis shows 1+ proteinuria. CT scan of the abdomen reveals normal adrenal glands.
Which of the following is the best next step in management of this patient's disorder?

Quizplus · Accepted Answer

11ec193a_97ca_a3d8_853d_4329cbdc239c_MD0002_00 Primary hyperaldosteronism (PH) is characterized by hypertension associated with hypokalemia and metabolic alkalosis. Some patients may not have spontaneous hypokalemia but rapidly develop hypokalemia if given diuretics. Despite increased renal reabsorption of sodium, edema and hypernatremia are usually minimal or absent due to aldosterone escape. aldosterone escape The initial evaluation for PH should include a morning plasma aldosterone concentration (PAC) to plasma renin activity (PRA) ratio. A PAC/PRA ratio >20 with plasma aldosterone >15 ng/dL suggests PH. The diagnosis is most often confirmed with an aldosterone suppression test (either an oral sodium load test or a saline infusion test); persistent aldosterone production despite an oral or intravenous sodium load confirms PH. However, for patients with spontaneous hypokalemia, undetectable PRA, and PAC >30 ng/dL (as seen in this patient), confirmatory adrenal suppression testing may be omitted as the findings are unlikely to be from any other cause. Once PH is confirmed, adrenal imaging (usually with CT scan) should be obtained to differentiate bilateral adrenal hyperplasia (50%-60%) from aldosterone-producing adrenal adenoma (40%-50%). However, CT has low sensitivity for small tumors; therefore, if CT does not reveal a discrete unilateral mass (as with this patient), adrenal venous sampling should be obtained to differentiate between hyperplasia and adenoma. (Choice B) Renal CT angiogram is used to diagnose renovascular hypertension due to renal artery stenosis or fibromuscular dysplasia. However, renovascular hypertension is associated with secondary hyperaldosteronism (elevated renin and aldosterone levels), not primary. secondary hyperaldosteronism (Choice C) A dexamethasone suppression test is used in evaluation of Cushing syndrome. In addition to hypertension, patients typically have central obesity, purple striae, proximal muscle wasting, and glucose intolerance. (Choices D and E) Surgery is the preferred treatment for PH due to an adrenal adenoma, whereas medical therapy (eg, spironolactone, eplerenone) is preferred for bilateral adrenal hyperplasia. However, this patient needs further testing to identify the etiology before undergoing treatment. Educational objective: Primary hyperaldosteronism (PH) is characterized by hypertension, hypokalemia, and an elevated plasma aldosterone to plasma renin activity ratio. The diagnosis is confirmed with an aldosterone suppression test. CT of the adrenals can differentiate adrenal adenoma from bilateral adrenal hyperplasia, but if no adenoma is seen adrenal venous sampling is recommended. Surgery is preferred for an adrenal adenoma; medical therapy (eg, spironolactone, eplerenone) is preferred for bilateral adrenal hyperplasia. __________ References: Primary aldosteronism: challenges in diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/26038205)

A 28-Year-Old Man Comes to the Office for Follow-Up of Hypertension