60 Hypertension TREATMENT ISSUES (CONT’D) Condition Drug of Choice Hyperkalemia A/B/C/D Avoid aldosterone antagonists Hyponatremia A/B/C Avoid D Pregnancy B/methyldopa/vasodilators Avoid ACE inhibitors and ARB where A=ACE inhibitors/ARBs, B=b blockers, C=calcium channel blockers, C1=long acting dihydropyridine CCB, C2=non dihydropyridine CCB, D=diuretics SPECIFIC ENTITIES RENAL ARTERY STENOSIS (RAS) PATHOPHYSIOLOGY causes include atherosclerosis and fibromuscular dysplasia CLINICAL FEATURES systemic atherosclerosis, uncontrolled hypertension, flash pulmonary edema, asymmetrical kidneys, renal failure with ACE inhibitor, and renal bruits DIAGNOSIS MR angiogram (preferred as non inva sive and high sensitivity/specificity), CT angio gram, duplex U/S (anatomic and functional infor mation), captopril enhanced radioisotope renogram (functional scan but out of fashion), contrast angiogram (gold standard) TREATMENTS medical (risk factor reduction with emphasis on blood pressure control ACE inhibi tors/ARBs are particularly useful in renal artery stenosis, but should be used with caution in severe bilateral renal artery stenosis Diuretics should be added if hypertension persists), angioplasty (con sider if severe or refractory hypertension, recurrent flash pulmonary edema, acute significant decline in renal failure due to renal artery stenosis Unlikely to reverse renal failure if small kidneys or high creatinine >300 mmol/L [3.4 mg/dL]), surgery NEJM 2001 344:6 DIFFERENTIAL DIAGNOSIS OF ABDOMINAL BRUITS CARDIOVASCULAR abdominal aortic aneurysm, aortocaval fistula RENAL VASCULAR renal artery stenosis GI VASCULAR celiac artery compression syn drome, mesenteric ischemia HEPATIC VASCULAR cirrhosis, hepatoma, AV malforma tion, arterioportal fistula, Cruveilhier Baumgarten sign (cirrhosis, portal hypertension, and caput medusa) SPLENIC VASCULAR splenic AV fistula, splenic artery dissection, splenic enlargement PANCREATIC VASCULAR pancreatic carcinoma SPECIFIC ENTITIES (CONT’D) RATIONAL CLINICAL EXAMINATION SERIES: IS LISTENING FOR ABDOMINAL BRUITS USEFUL IN THE EVALUATION OF RENOVASCULAR HYPERTENSION? Sens Spc LR+ LR Systolic and diastolic 39% 99% 39 0.6 abdominal bruit Any epigastric or flank 63% 90% 6.4 0.4 bruit, including isolated systolic bruit Systolic bruit 78% 64% 2.1 3.5 APPROACH ‘‘given the high prevalence (7 31%) of innocent abdominal bruits in the younger age groups, it is recommended that if a systolic abdom inal bruit is detected in a young, normotensive, asymptomatic individual, no further investigations are warranted In view of the low sensitivity, the absence of a systolic bruit is not sufficient to exclude the diagnosis of renovascular hyperten sion In view of the high specificity, the presence of a systolic bruit (in particular a systolic diastolic bruit) in a hypertensive patient is suggestive of renovascular hypertension In view of the lack of evidence to support characterizing bruits as to pitch, intensity and location, bruits should be reported only as systolic or systolic/diastolic’’ JAMA 1995 274:16 Related Topics Aortic Dissection (p 25) Hyperaldosteronism (p 349) Pheochromocytoma (p 349) 61 Hyperlipidemia Hyperlipidemia Canadian Cardiovascular Society Dyslipidemia Guidelines 2006 DIFFERENTIAL DIAGNOSIS OF HYPERCHOLESTEROLEMIA INVESTIGATIONS PRIMARY polygenic, familial (suspect when total cholesterol >6 mmol/L [>232 mg/dL], LDL >5 mmol/L [>193 mg/dL]) SECONDARY obesity, diabetes, hypothyroidism, nephrotic syndrome, medications (estrogen, tamoxifen, b blockers, glucocorticoids) LABS BASIC DIFFERENTIAL DIAGNOSIS OF HYPERTRIGLYCERIDEMIA PRIMARY dietary, familial (suspect when TGL >5 mmol/L [>440 mg/dL]) SECONDARY obesity, diabetes, nephrotic syn drome, hypothyroidism, alcoholism, drugs (tamox ifen, cyclosporine, glucocorticoids) DIFFERENTIAL DIAGNOSIS OF LOW HDL PRIMARY SECONDARY obesity, smoking, inactivity CLINICAL FEATURES TELLTALE SIGNS Lesions I Tendon xanthoma (LDL) Palmer xanthoma Eruptive xanthoma X Xanthelasma X Tuberous xanthoma (LDL) IIa IIb III IV V X X X X X X X X X X X X Cr, fasting glucose, TSH, total chol, TGL, LDL, HDL, apoB, Lp(a), CRP, CK, AST, ALT, ALP, bilirubin, LDH MANAGEMENT LIFESTYLE CHANGES diet (" fruit and vegetable intake, " mono and polyunsaturated fats, # saturated fats and trans fatty acid to