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Amlodipine
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Hydrochlorothiazide
Lisinopril
Losartan
Spironolactone
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This patient presents with a triad of hypertension, hypokalemia, and metabolic alkalosis, which is suggestive of primary aldosteronism (Conn syndrome). First-line treatment for primary aldosteronism is with a mineralocorticoid antagonist such as spironolactone. Primary aldosteronism can be caused by either an aldosterone-secreting unilateral adrenal adenoma or bilateral adrenal hyperplasia. Its symptoms are mediated by the physiologic effects of aldosterone, including activation of sodium resorption at the distal convoluted tubule with concomitant potassium and hydrogen ion secretion, which results in hypokalemia and metabolic alkalosis. While aldosterone has fluid-retaining effects that result in the hypertension seen in this syndrome, sodium levels are usually normal due to the aldosterone escape mechanism; thus, peripheral edema is not seen. This is thought to be mediated by compensatory release of atrial natriuretic peptides and/or pressure natriuresis. First-line treatment is with a mineralocorticoid antagonist such as spironolactone to directly counteract the effects of elevated aldosterone. When this is caused by an adrenal adenoma, surgical removal is curative. Brown et al. characterize the prevalence of primary aldosteronism. They found that the prevalence varied from 15.7% in stage I hypertension to 22.0% in resistant hypertension. Incorrect Answers: Answer 1: Amlodipine is a non-dihydropyridine calcium channel antagonist that is commonly used as a first-line agent for essential hypertension, particularly in patients with Raynaud phenomenon. Answer 2: Hydrochlorothiazide is a thiazide diuretic that is commonly used as a first-line agent for essential hypertension and occasionally for recurrent calcium nephrolithiasis. Answers 3 and 4: Lisinopril and losartan are an angiotensin-converting enzyme (ACE) inhibitor and angiotensin II receptor blocker (ARB), respectively. ACE inhibitors and ARBs have demonstrated benefit for patients with essential hypertension and comorbid diabetes as they effectively slow the progression of diabetic nephropathy. Bullet Summary: Primary aldosteronism presents with the triad of hypertension, hypokalemia, and metabolic alkalosis and is treated with spironolactone.
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