Welcome to ATCM the emergency medicine channel. A 60 year old male presented to the ER with complaints of generalized tiredness and headache since two days of duration. Based on the SOAD criteria, the patient has been triaged on the basis of GCS, BPN respiratory rate into the green area. On our initial 10 second assessment, patient was conscious, oriented and obeying commands. Coming to airway, airway was patent.
and no gurgling, no pooling of secretions. Coming to breathing, respiratory rate of 24 per minute, saturation of 95% in room air. Coming to circulation, heart rate of 90 beats per minute with a BP of 200 by 110 millimeters of mercury. All peripheral pulses were equally palpable. At this point of time, we have took the upper limb and lower limb BP, which was found to be normal.
Coming to disability, GCS of 15 by 15, bilateral pupil equally reacting to light. Coming to exposure, GRBS of 190 mg per deciliter with a temperature that was found to be normal. The patient has a pain score of 4 by 10. Two large bore IV cannulas were inserted at this point of time and injection PCM 1 gram IV stat was given.
Coming to adjuncts of primary survey, ECG was taken showing a normal sinus rhythm with a heart rate of 85 beats per minute. minute no acute STT changes were noted. We were taken a VBG which showed a pH of 7.42, PCOT of 43, bicarb of 23, potassium of 3.8, creatine of 1.2. No acute acid-base disorders was also noted.
Coming to sample history, a 60 year old male who was an alcoholic presented the ER with complaints of generalized tiredness and headache since two days. Alcoholic is different from those who are taking alcohol. What is alcohol? Daily consumption.
Daily consumption is not alcoholic. A person takes alcohol and it impairs or it disturbs his life and others life. Then only he will become alcoholic. somebody takes alcohol like 30 ml or 60 ml per day is not alcoholic it takes alcohol that's all what are the adverse effects of alcohol if it is more than 30 ml to 30 ml alcohol normally it is not a problematic thing more than that it may create problems what are the problems it can create acutely what are the problems it can create long term acutely sir alcohol binge drinking can lead to alcohol intoxication What happens to BP?
BP can be raised. When you take alcohol, transiently it can increase BP. That's why we advise patients not to take alcohol 24 hours prior to BP checkup.
If they are taking alcohol, normally BP shoots up. Pulse. tachycardia how many it produces tachycardia some chronic alcoholics it can produce autonomic dysfunction the patient complains of generalized tiredness and on and off headaches since two days due to which he went to a clinic and checked the routine bp which was around 200 100 milligrams of mercury and was referred to here on arrival the patient complaint was headache which was on and off and the patient expressed the headache as a fullness or tightness over the frontal region mainly during the morning hours which decreases on analgesics the patient also gives history of snoring and He also gives history of choking episodes during sleep. There was associated personality and mood changes as per the history from the bystander.
What it indicates? Daytime sleepiness, night time choking sensation, high BP, all these things indicate what disease it is. Obstructive sleep apnea syndrome. No history of any photophobia, vomiting, fever, no changes with any bending or lifting or coughing, no local pain, no weakness and no signs of any dangerous headache.
No history of any weakness, deviation of angle of mouth, seizure. involuntary movements blurring of vision and altered behavior to rule out a CV and hepatitis even hyperdense you in cafe Lopati now history of any chest pain breathlessness orthopnea P and E thus symptoms were not suggestive of any MI aortic dissection or pulmonary edema you know Stephanie decrease you would now put or pedal edema drug in day thus ruling out renal symptoms no history of any palpitations sweating giddiness on standing abdominal pain no features of any pheochromocytoma no history of any muscle weakness stye bruising over the body Thus, no suggestive of any Cushy syndrome. No suggestive of any hyperactivity, irritation, loss of weight, cold or heat intolerance, constipation.
Thus, ruling out thyrotoxicosis and hypothyroidism. The patient has similar complaints in the past 3 months back, following which he went to outside hospital and found to have elevated BP and the patient was started on Ayurvedic medications. No history of any allergies in the past.
The last meal was taken at 6 am. Coming to general examination, the patient was conscious and cooperative, well built and nourished. BMI was 32. According to the latest Asian population guidelines, 32 corresponds to grade 2 obesity. No pallor.
ecterosis, cyanosis, clubbing, generalised lymphadenopathy or pedulity. Coming to systemic examination, CNS-wise, GCS 15 by 15, bilateral... BP so much?
BP was 200, 110. was the standing BP checked or not? It's a postural hypertension and both upper limb and lower limb BP's also. Same and there is no postural?
No postural. What is the importance of postural hypertension in the early phase of the hypertension? What is the importance of postural hypertension in late or after starting the treatment?
How do it differ? In the early stage itself, you are getting postural hypotension. What it indicates? One disease which can point to postural hypotension is pheochromocytoma. Postural hypotension initially always indicates a second stage.
secondary hypertension. Whereas after starting your treatment there are lot of conditions, there are lot of drugs which can produce postural hypertension like Acinvitas, ARBs, Hydrolacin, so many drugs can produce postural hypertension. if you are getting a positive hypotension you have to always be careful about piachromocytoma what is the typical feature of piachromocytoma the triad of piachromocytoma is episodic hypertension palpitation and profuse sweating sir tachycardia sweating and hypertension that all episode most of the time they are episodic some patients will have persistent hypertension they also can have positive hypotension Coming to systemic examination, GCS was 15 by 15. Bilateral pupil equally reacting to light. The patient was moving all four limbs.
Power 5 by 5. Coming to respiratory system, normal vesicular breath sounds, no added sounds. Serious examination examination, S1, S2 present, no murmurs. GAT examination, the abdomen was soft, non-tender and bowel sounds were present, no bruy was noted.
So, our provisional diagnosis was asymptomatic markedly elevated blood pressure which was formerly called hypertensive urgency. According to the Endocrine Society of India, we can approach hypertension in two ways. One patient present with emergency or urgency. In the case of urgency, we can either go ahead with 24-hour ambulatory BP monitoring. so that we don't miss out white coat hypertension, nocturnal dipping or episodic hypertension.
Others, triaging into hypertensive emergency and urgency. According to the endocrine society guidelines, we can... classify a patient as diagnosed as hypertension if the first visit the patient comes with hypertensive emergency or in the second visit patient comes with a bp of more than 180 bar 110 or 140 bar 90 with a target organ damage or ckd or diabetes mellitus or a third visit with a bp of more than 160 bar 100 millimeters of mercury in this case the patient had multiple episodes of elevated bp and went to outside hospital and started on Ayurvedic medications. So this patient can be a case of diagnosed case of hypertension but not on regular medications. First of all you tell me how to manage this condition in emergency room and we will discuss.
This patient has come to you, what do you do? First we need to classify whether it is a hypertensive emergency or a hypertensive urgency. In case of hyperdense emergency, the systolic BP has to be more than 180 mg per mercury or diastolic BP has to be more than 120 with target organ damage should be present. That is AHM model should be present.
Acute hypertension mediated organ damage. to the brain, retina, heart, renal or the larger arteries. If it is a hypertension emergency, then the BP should be normally more than or equal to 160 to 180 systolic or diastolic around the range of 100 to 120 without target organ damage.
In this case, the patient was not having any symptoms of any target organ damage. Sir, this patient is having high BP, but there is no symptom. How do you manage this case and another patient who is having high BP? with pulmonary edema.
How do you manage that case? Both are different. This patient has come with high BP but he is not having any symptoms. In hypertension urgency in this case.
How do you know that this patient is having long term hypertension? First time he is coming to Amudhan's room. How do you know that? She never tells I have hypertension. Now she has told that she is on some treatment.
Otherwise she will never tell because hypertension is known as silent killer. most of the time you don't get any history how do you manage that the degree of hypertension should be proportionally to the you know that this patient is a you can take ECG is the most important thing what we can do in emergency room is is your echo echo will tell you LVH ECG also will tell LVH that both things if it is there then it's a long-term hypertension if you can see the retina and find out changes that also will help you if urine examination shows protein that also will help you Otherwise, it will be difficult for us to diagnose whether the patient is having long term hypertension or it is only a recently increased hypertension or a transiently elevated BP because of fear of crassoma, fear of brombocytoma. How do you manage a patient who is having high BP with no symptoms like this? We will start the patient on oral antihypertensive. What oral antihypertensive you would like to start in this patient?
We can start the patient on basically three levels. lines of drugs ACE inhibitors or calcium channel blockers or diuretics. Usually we will ARB, calcium channel blockers or diuretics.
So now how you select the drug? Usually the first line we go ahead with ACE inhibitors or ARBs. Before starting ACE inhibitors what renal status has to be assessed?
The creatinine has to be rolled out. Second thing? Is there any hereditary angio neurotic edema?
contraindications for AC inhibitors in a patient with hypertension only as you told renal failure they are in more than three better to avoid this drug AC or IRB other contraindications for AC or IRB contraindication pregnancy is a contraindication then hereditary angina urtica patient is only if there is AC inhibitors can produce this one that's that is contraindication after starting the drug only you will come to know that you Ok, if you already know that you avoid it. Not a common condition also. You have to check for something before starting AC inhibitors. What is that? Off is a side effect of AC inhibitor.
You have to look for carotid stenosis, you have to look for renal artrosis. That two things also you have to rule out. So basically creatinine should be normal. Second thing, what you told? One more thing, pregnancy.
Third one is stenosis of renal artery especially renal artery or parotid stenosis all these things that is not there you can safely start ac inhibitor or arba okay how do you reduce that bp immediately slowly sephora I can see an urgency we need to slowly reduce the you take more than 24 hours you can slowly reduce the BP can take more than 24 hours there is no hurry it will start like sublingual what is it nipidipine hot lemon that is the most common practice done to reduce the BP unnecessarily what is the problem rapid reduction what is the problem When we have rapid reduction BP, there will be sudden derangement in the perfusion of the body leading to cardiomboleic events. Cardioembolic events? Cardio... Schemia. Schemia.
So all your body system is set for that high BP. Your brain, your kidneys, all are set for that high BP. And suddenly if you are dropping your BP, kidneys and brain, these are the two organs will suffer mostly. They don't get blood. that regulation of blood will be completely distorted so there will be acute ischemia of kidney acute ischemia brain patient can develop problem of that and cardiac events also more in that type of BP reduction that's why that J curve if you see that the curve increases okay so the problem increases as you reduce the BP suddenly the problem part will increase mortality will increase we are not supposed to reduce the BP like that slowly you can reduce the BP whereas conditions like high BP with pulmonary edema high BP with cerebral hemorrhage all those things how do you manage usually pulmonary edema so for example commonest thing is pulmonary edema In Amazon's room, high BP, permanent ready mark.
What are the precautions you take? How do you manage it? Our target BP should be able to reduce the BP 10 to 20 percentage in the first one hour.
Then 10 to 20 percent next 23 hours like that. There is a patient who is having very high BP like you told 220 by 130. What is the BP here? And he is having pulmonary demyel.
What you do? Initially we will keep the patient in propped up position. Two lines we will keep. And we will start the patient on NDG infusions.
Diuretic. Whatever may be your diagnosis, first thing is always diuretic. Second thing is NTG.
What is the action of NTG? Both artiline and venous dilators. So, lesser blood will go to heart, lesser pressure in the peripheral circulation.
So, heart can easily pump out blood to the peripheral circulation. That is the advantage of NTG. Any other drug can be given in that type of conditions.
any other drug other than antigel reduce the BP but any other drug to be started and if you are starting what precautions you take Nitroprus, Hydalysin. Hydalysin is the next line drug in that condition. If you want to start beta blocker what you have to rule out? Initially we have to rule out any heart blocks anything is there.
Heart block is okay. Then second thing is? Asthma, bronchial asthma.
Asthma is also okay. And then we need to attain the euvolumic status before starting beta blocker. You want to do an echo before starting beta blocker. You want to do an echo.
Yes or no? What is the action of beta blocker on cardiac muscle? Decreases the heart rate thus increases the diastolic interval.
Decreases the contraction of the cardiac muscle. So before starting beta blocker in a patient who is having pulmonary edema, we don't know what is the reason of pulmonary edema, we have to always... rule out the cardiac failure and you have to give beta blocker then only okay and cardiac failure produces diastolic bp high normally what we learned is cardiac failure means low systolic bp low diastolic bp in a cardiac failure what happened suppose somebody is having a hypertension with cardiac failure what happened to the bp hypertension with cardiac failure Cardiac failure patients will not have good pumping. So systolic BP will be always low.
But in a patient who is having hypertension with cardiac failure, diastolic BP increases. That is a problem. So if you see the diastolic BP, you can probably know whether the patient is having hypertension or not.
But whatever it is, it is always better to do echo and rule out cardiac failure than only give beta blocker. That is very important. Hydrolysin, what is the action?
What is the action of hydrolysin? It's a vasodilator, it's an arterial dilator, better than any other drug. But IV preparations are not available at present, so you can give oral tablets. Okay.
Calcium channel blocker, can you give calcium channel blocker? What are the... indications of calcium general blocker in emergency or emergency?
Second line agents we usually give. As a second line agent you can give calcium general blocker in patients who is having tachycardia, high BP with tachycardia. Again same problem, if the patient is having cardiac failure you cannot give calcium general blocker. What is the action of calcium general blocker in the heart muscles? What happened to the contraction?
It is a calcium channel blocker. Calcium is required. So contraction suddenly reduces. That's why when you give sublingual, what is that drug?
Nufidipine. The patient can deteriorate very fast. If the patient is on cardiac arrest, suddenly the patient can deteriorate. So you should avoid such drugs.
But if you want to give, you have to do an effort and you can give. What you have given for this patient? We have given sir, amlodipine was given sir.
Amlodipine, what is the action of amlodipine? What are the advantages of amlodipine over other drugs? Where will you give amlodipine? Don't give drugs like that.
You should know the action. Then you will avoid all these things. Calcium gel blocker. It's a calcium gel blocker. Where all it can be used.
Amlodipine is used in dash dash dash dash. What are the conditions? In CKD patients we can prefer.
CKD patients normally we don't give. Why we don't give? Suppose you want to give CKD patient calcium jhanabakar, nipidipine is a choice.
Why it is like that? What is the duration of amlodipine? Action duration. Amlodipine is given once daily or twice daily? Once daily it has got 24 hours action whereas nifedipine it has got only six hour action if you give amlodipine in a patient with renal failure what will be the duration of action then it will extend more than 24 hours it may be 36 hours action will occur so never give amlodipine in a patient with renal failure if you want to give calcium general locker better drug is nifedipine normal tablets nifedipine there are two preparation sustained release and normal preparation you have to give only normal tablets okay so amlodipine is not a good choice in renal failure what are the other indications for amlodipine We cannot throw the drugs like that.
We should know what is the indication, what are the contraindications. Whether it is useful or not useful. It definitely reduces the BP rate.
There is no question of that. Where will you give? Tell me indications for amlodipine.
amlodipine is indicated in high systolic BP isolated systolic hypertension that is a drug of choice elderly individual that is a drug of choice okay it is not a drug of choice in diastolic BP it is not a drug of choice in renal failure ok but effect wise it is a very good drug amlodipine there is no adverse effects only thing it can produce some pedal edema that is not a clinically not that important so you should be very careful this patient amlodipine may not be a very good choice in since she has come to emergency room acute attack amlodipine once you give you cannot withdraw the drug you want to give a calcium gene blocker then nifedipine oral tablets are better not sustained release oral tablets not subliminal okay that will be better because the action will subside within six hours suppose there is a problem occurring due to your calcium gene blocker then you can immediately withdraw the drug after six hours the effect will go off product happens to the heart rate because of amlodipine and nipidipine? Heart rate decreases or increases? Decreases.
In decreases. You have to tell properly. Decreases.
Amlodipine decreases the heart rate. Sure. Amlodipine increases the heart rate. It increases the heart rate. That's why it is always combined with beta blocker.
Amlodipine, a 10-law combination. So, Amlodipine actually increases the heart rate. What is the heart rate here?
Once you give amlodipine it is for 24 hours you have already given. So never try to give amlodipine in an emergency but once the patient is stabilized you can switch over to amlodipine. Okay amlodipine that is the only problem otherwise amlodipine can be continued. Okay what else you can give here? We are given a choice.
You take ACD rule only. AC inhibitor, ARB. AC is calcium channel blocker, D.
What will you give here in this patient? You can select a what is a what is a a single case in your air be and we give in this patient there is no there is no contraindication because the renal failure is not there she is not pregnant she is not a real actress not we can safely give ac inhibitor or arv can be given okay so that can be given calcium general blocker which one you prefer nifedipine nifedipine oral tablet not sublingual not sustained release okay once the patient is stabilized you can go for amlodipine or nifedipine sustained release whatever it is diuretic you have to give diuretic in this patient because high bp the The safest drug will be diuretic because that will not produce drastic reduction in the BP. That removes the sodium and water from the body. Okay, what is the sodium level in this patient?
Sodium is normal. Normal. Do you think that patients who is having hypertension, sodium levels will be high in blood and we should advise not to take salt to the patient? The patient will be admitted here.
Patient want to take salt. Will you see the sodium level and advice or not like that? Then why we are restricting sodium?
What is the action of sodium? There are two types of hypertension. One is salt dependent hypertension. One is salt independent hypertension. Some patients, there are some reasons for that.
BP will increase after taking salt. Some patients, their BP will not increase with salt. So even if you tell the patient to take salt, nothing will happen.
Only problem is salt can retain water. Salt can increase the renin-angiotensin aldosterone mechanism and retain water. That's all. But But some patients their BP will be dependent on the sodium, their BP increases with sodium but that doesn't mean that serum sodium will be elevated.
Ok, serum sodium will be always normal. What is the difference between sodium chloride and potassium chloride? Both are salt only.
Sodium chloride is what we are taking normal salt. Some doctors prescribe potassium chloride. It is available everywhere.
Both are having that same taste. What is the difference? Where will you advise potassium chloride?
Hypokalemia? What is the action of potassium on blood vessels? Huh?
Where'd that accent come from? A patient who is having hypertension, low sodium, we make some diagnosis. Sorry, low potassium, we make some diagnosis. What is that?
Primary aldosterone. Aldosterone. Concentrate.
So, potassium is one element which can, low potassium can increase the BP because potassium can really dilate the blood vessels. Okay. If potassium is not there, constriction occurs and patient will have hypertension. Okay. So, potassium chloride is another type of salt.
that can be advised if the patient does not have renal failure okay so along with your regular salt we can advise even potassium chloride salt also okay but do not avoid salt for any patient in your ICU what advice you give when the patient is having hypertension in your ICU salt how do you control the salt your ICU patients are there with high VP they are admitted Will you give salt or not give salt? That is the question. Yes or no?
Give salt. You have to give salt. Salt is very much required for your brain.
Okay. So salt, normal diet has to be given. You should restrict salt.
What is restriction of salt? Addition of salt. Addition of salt. Salt should not be given to the patient. Whatever taking in curry and all, they can take.
Additional salt like pappad, achar, all these things should be avoided. That's all. So, salt restricted diet.
Not salt reduced diet. Okay. So, salt has got minimal role in hypertension.
management. That you should understand. But due to some reason it can retain water and other things that can add on your BP. So you should avoid taking extra salt. Now what happened after that?
The patient was admitted sir and echo ophthalmology consultation 24 hour urine protein Ophthalmology consultation is given for what? Turbulent hyperdense retinopathy What are the grades of hyperdense retinopathy? Kethwagner classification we will take grade 1 there will be arterial constipation grade 2 we can see grade 2 and 3 we can see cotton wool sports, grade 2 we will see AV nicking, grade 3 we will see cotton wool sports and grade 4 we will see optic disc edema.
So this patient is normal? Normal sir. Then all the lab parameters was also normal, RFT was normal, Renal artery Doppler was done, USG was done. Where will you ask for Renal Doppler in patients? Which are the type of patients you ask for Renal Doppler?
Every patient admitted with high BP you should not ask for it. ask either clinically you should get a like renal bruit otherwise there are indications for that either young patient or elderly individual young patients can have renal artery stenosis elderly individual BP starting after 60 years 70 years then they are also renal artery stenosis one of the important factor in that conditions you have to really look for that and elevated creatinine is an early elevation of creatinine is another reason for that okay the parameters was normal ultrasound the kidney was done yes there was no asymmetry in the kidneys there was no no asymmetry was there normal normal normal what happens to the kidney in ultrasound in high BP what are the changes you anticipate Why you are looking for the kidneys? One is in the symmetry of the kidney whether we can understand whether it is a long standing hypertension hormone.
Cortico-medullary differentiation will be lost in chronic kidney disease. Then suppose the size is large, what else you look for? Cysts are there in the kidney.
Polycystic kidney disease. Polycystic kidney disease. They are more prone for?.
I am more prone for aneurysm. It is very important. Okay.
Okay. So, all these things you have to look. Then what else was done?
Potassium is done? Yes, sir. Potassium was used for potassium.
Is potassium done or not? Yes, potassium. What is?
Potassium level was 3.5. 3.5 is low. What are the conditions you get low potassium with hypertension?
Primary hyper-allocytes. That is the first thing you are going to see. You tell common things first, then only think rare things. What is the commonest condition you get high BP with low potassium? That could probably be patients who are on Lasix.
Diuretics. Patients who are taking diuretics. That is the commonest cause.
Second thing only, you have Kohn's syndrome. There is a rare condition where first itself patient is having hypokalemia. Okay. Urine potassium will be high.
What will happen to urine potassium in Lasix? There also it will be high. Okay. So, that you have to think. So, unnecessarily don't do all investigation.
If you have already given lasix then urine will definitely show high potassium. What do you mean by high potassium in urine? More than 20. More than 20 millie currents is high potassium in urine. Then what is the magnesium level?
Magnesium is also normal. Only potassium is low. So what do you do for that?
Urine support potassium was done and it was normal. Potassium low in hypertension is not a good. good situation even if it is 3.5 it is not good then how do you manage it started down even spoke work of us dancer would sport potassium was around normally 18 was there even so what you do go potassium correction was done and how do you correct potassium in this case every point three corresponds to hundred million loss so how much losses a hundred milligrams okay so how do you correct it we can correct it by I IV correction or oral correction can be done. IV correction is required here? No.
What are the indications for IV correction of potassium? Patients having symptoms like weakness. Muscle weakness, cardiac arrhythmias. These are two indications that is not there. So you have to give oral.
What is the problem of IV correction? Why we avoid IV correction? Slow. I will give 100mcg through your IV what will happen?
The vessels will get obstructions will be there. Vessels will have? Thrombophlebitis.
Thrombophlebitis. So we avoid. We don't want to give that potassium through peripheral line at all unless until there is an emergency we don't want and more than 40 milligrams we never give through an IV line so that we have to keep in mind unnecessarily IV potassium is should not be given we can give a easily you can correct it with oral potassium or you can give lemon juice okay that is enough more than enough okay then Then last the patient was sent for sleep study. Ok, what happened in sleep study?
He was diagnosed with OSSR and the patient was started on CPAP. Ok, CPAP is already started. Then BP control? BP control. Ok, day time sleepiness all.
So what tablet you have given for this patient? Initially patient was started on Fumasartan sir. What?
ACE inhibitors initially it was started. Okay, ARB? ARB is started.
16 G was started. Okay, then that's all, that is enough? Yes, sir. Then only the CPAP the patient all righted well. Okay, okay.
What else you wanted to tell something about BP? According to now we will follow the 2018 European Society of Cardiology guidelines where the optimal BP is less than 120, normal is 128 to 129, high normal is 130 to 140 and further we divide into grade 1, grade 2 and grade 3. The normal is 120 to 129 and systolic BP will be 80 to 84. Then as I said earlier, the Indian Society of Hypertension, for diagnosis of hypertension, we made in first visit, second visit and third visit. The main criteria for looking at the target organ damage is the central systolic blood pressure.
We are not prescribing beta blockers now because it is the drug that increases the central systolic blood pressure, whereas terastri agents will decrease the central systolic blood pressure. So the mainstay drugs are ACE inhibitors or ARBs and cancer blockers. Where all you cannot use beta blocker tell me. One is now it is removed from the first line drug. In emergency room where all you cannot use beta blockers.
Accidentally already given there is no issue. Long term we don't continue. Where all you cannot give.
Tell some solid contraindications for beta blocker. Heart blocks itself. Heart blocks you cannot give. Lungylasma.
Lungylasma you cannot give. COPD. COPD also you better avoid. Okay. Will beta blockers produce asthma in any patient?
Sometimes, in some patients it will exacerbate, not in all patients. But we better avoid it. Then?
Acute heart failure. Cardiac failure. Whether acute or chronic, better avoid high dose of beta blockers. You are not telling the most important reason.
You should not give beta blocker as a first-line drug in this condition. What is that? But you have to give beta blocker but not as a first-line drug. What is that? What is the treatment options for pheochromocytoma?
Alpha blockers. First alpha blocker, second only beta blocker. If you start beta blocker what will happen? Unopposed hypertension. Unopposed.
So you have to be very careful if you are giving beta blocker BP increases. This is called as paradoxical hypertension. Where all you get paradoxical hypertension?
Tell me two conditions where you get paradoxical hypertension. Paradoxical hypertension means you are doing something good for reducing the BP. But that is. Bilateral drenulatory synopsis. Drenulatory synopsis AC inhibitor.
Here because of pheochromocytoma beta blocker both can increase the BP sometimes not always. So, you have to be very careful. Ok. So then according to the BP targets are like less than 120 bar 80 sir. According to the SPRINT trial that was latestly conducted, the target BP is less than 120 bar 80 in the absence of diabetes and helps reduce the cardiovascular risk and the mortality sir.
Okay. Then coming to the hypertensive emergencies, all firstly diagnosed hypertension we need to rule out the secondary cause of hypertension mainly the endocrine and the renal causes. According to the ESI 2020 guidelines, we need to suspect primary hyperaldosteronism in a patient with young hypertension, resistant hypertension, hypertension that is out of proportion to target organ damage, hypokalemia with hypertension, and mainly diastolic hypertension.
And 2021, they modified as every newly diagnosed hypertension must be screened for primary hyperaldosteronism. And how do you rule out primary hyperaldosteron? We will send the aldosterone and renin levels. What happened to aldosterone and renin? Hyper renin and hyper aldosterone.
That is primary hyper aldosterone. If the renin is high? That is secondary.
Hyper renin and hyper aldosterone due to hypo bulimia, hyper perfusion, the system will get activated. So there are conditions where renin alone is elevated. Especially like what you told is correct. Then kidney diseases.
That is also one important reason for hyper renin. hypertension okay they also will have tachycardia hypertension all these things there what is a drug of choice that is a new drug it is not available it may be available now but you can give ac inhibitors or arps Then also the Endocrine Society of India recommends the screening of Cushing's syndrome sir. How do you understand that this Cushing's syndrome is clinically?
Most common symptom will be the central obesity sir. But most discriminating features will be proximal myopathy, muscle weakness, facial plethora and osteoporosis at a young age, bruising and dilated cardiomyopathy like that. Central obesity with these discriminatory features are present, we need to suspect Cushy syndrome and has to be screened in the patients. So this patient is okay.
The reason for hypertension is here. Here it is due to OSA. OSA is the reason for hypertension. So clinical features of OSA are hypertension, obesity, then?
Day time sleepiness, headache, personality and mood changes. Hyperthyroidism is ruled out? Yes sir. Thank you.