Dear Richard

Good day. Can you please add some patient details as regards to age, co-morbid, life style, any hypertension related complications, gender,any nutritional advice he is being supplemented,any heat disease or medication, nature of job,and have secondary causes of hypertension been ruled out like hyperaldosteronism, pheo, other endocrine ones.

Without this data i guess it will not be appropriate to comment further even if its a case of essential hypertension.

And i guess your major concern is being the "non-dipper status"?

Regards

I have two suggestions:

1. With the patient having large variations in supine and ambulatory blood pressure one should consider hypovolemia likely secondary to the diuretic (chlorthalidone). This is a frequently missed cause for poor blood pressure control and can even precipitate malignant hypertension.

Here is the URL to a nice paper demonstrating this:

https://www.nejm.org/doi/full/10.1056/NEJM196609222751205

2. Dosing one of the antihypertensives at night may reintroduce nocturnal dipping status.

The patient is in his 60s, retired, exercises regularly, thin, optimum cholesterol, had a prodromal period of white coat hypertension before frank hypertension began a month ago. Side effects of diuretics would be a likely explanation but the pattern began prior to diuretics, when patient was on escalating doses of candesartan. We will double check the pattern off diuretics. Adrenal causes like pheochromocytoma, aldosteronism, and cushings have not been ruled out, but I don't see the complete symptom pattern for any of these. I would expect pheochromocytoma to present with episodes rather than diurnal variation, the hypertension is not refractory as in aldosteronism and there is no hypokalemia, and there are no physical signs of cushings. The patient follows a healthy diet, takes b12 monthly, and vit d during the winter. Dosing at night seems advisable, and we are pursuing that course. Mogamet, than you for the reference.

Interesting case. Agree with you. I would evaluate adrenals Starting with CT not hormones.

Workup for pheochromocytoma is pending. However, we started with plasma metaneprines, which are almost 100% sensitive, though not specific. Why start with CT? Am I missing something?

I think Cushings would present with s/s in addition to these. Blood pressure is not refractory and potassium is normal, so workup for hyperaldosteronism may be unrewarding. Following up on Mohamet's suggestion, diuretic was discontinued. Blood pressure is more stable, but remains high in the morning and lower in the evening, with elevated pulse sitting and standing. A typical sitting bp in the am is 142/90 or 138/95 with pulse in the 90s, supine bp in the evening is about 100/61 with pulse in 60s. Some readings are lower. Patient's blood pressure increases on standing, but decreases over a few minutes. Standing pulse is high 80s to high 90s, but decreases. I'm not sure whether the adverse effect of diuretics was due to hypovolemia- patient lost only 1.5 pounds, sodium remained normal, and he did not appear dehydrated. I think there is increased sympathetic tone, particularly when sitting or standing. Patient currently takes candesartan 32 hs. Evening dosing may help with am bp surge.

Apart from all that has been mentioned, I will consider some differential diagnosis of renal tubular acidosis after appropriate testing for same. I will also like to review the medications which may involve changing the medications and reducing or stopping the diuretics.

I do not recommend doing a CT scan as the initial test to rule out phaeochromocytoma as up to 10% of patients may have an incidentaloma which is non-functional.

I agree Mogamat.

Plasma metanephrines and normetanephrines should be checked. Pheochromocytom patients can present with blood pressure variability.

The patient seems to be suffering from Autonomic Nervous System ( ANS ) dysfunction causing postural variations in BP . There needs to be caution in treating hypertension aggressively . Should we treat the morning or evening BP ? Is there any target organ damage or co-morbid risk factors ?

Thank you for all the replies. Metanephrines are normal. I agree that there is autonomic dysfunction, without a specific identifiable cause, other than aging. Dosing with candesartan HS has led to much more stable pressures and reduced diurnal variability and, to an extent, postural variability in BP. There is still significant postural variability in pulse, e.g. 56-59 supine and 70-85 standing. In retrospect, treatment with the combination of the arb and thiazide led to overtreatment and an exaggeration of postural and diurnal variation. A possible added benefit of the current HS dosing is reproduction of a more normal fall in sleeping pressure. Interestingly, there is some support in the literature for a general survival advantage for HS dosing in the treatment of HTN.

With the background of the normal variability pattern of blood pressure coupled with the effect of drugs on the profile of this patient, I will suggest a reduction of medication and a possible change of medications to properly take care of the postural hypotension. I will not support doing a CT as the possibilities of incidentalomas may be a major factor.

Abiodun has been adopted and has been beneficial.

Apart from autonomic dysfunction

Obstructive sleep apnea may be present and sleep polysomnography study indicated to role out

Treatment 1 . decrease dose of candrastatin given 2 time daily

2 . decrease half dose of hygroton

3 . added small dose of tenormin 25 mg to overcome autonomic dysfunction

Singh Shivakumar: I tend to agree with him. Some examples of ANS dysfunction that could cause the described pattern are: Pure autonomic failure, Diabetic neuropathy, Uraemic neuropathy, Familial amyloidotic polyneuropathy or Obstructive sleep apnoea syndrome.

Based on the provided information, I would consider obstructive sleep apnoea syndrome (OSAS) highly suspect.

Is the patient a consistent non-dipper? Or even a reverse dipper? I recall there are some studies with calcium antagonists that could restore dipping status when taken in the morning and with diuretics when taken at bedtime. If it turns out to be OSAS, CPAP might restore BP and dipping profile and medication would not be needed at all.