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There is been, we've been running throughout uh the last few weeks, um even months. Um I'm very excited to invite doctor. Does she? Um does she who's a specialist endocrine registrar in London um at Bart's uh to discuss hypertension. So he's got four very interesting cases of hypertension. Um Please do ask as many questions as possible. Um Throughout the session, I'm sure a cash will be very happy to take your questions. Um And all feedback is very valuable. Um I think in the interest of time will start. Um And people can join in later on. Um If, if you're feeling shy, you can always ask questions in the chat box and I'll pick it up and raise it to a cash as we go through the talk. Um But I'll let a cash take it away. Hi, thank you so much for that introduction. Um Yeah, so exactly as I'm going to discuss more cases of hypertension and in terms of who I am, I'm an endocrinology and diabetes registrar. Um as fish mentioned in London, also the founder of Mindedly, um currently doing a masters medical education. I love to cook. Hence I thought I put a couple of pictures of different food items that cooked in the past couple of months. Um And also mind the bleep is on various different social media platforms. Um So do click on each of those and these slides will be recording uploaded to youtube. I'll talk today covers a little bit about hypertension. Um What we're gonna cover is different cases, understanding the red flags, know, overview secretary hypertension causes some of the common causes. How we kind of approach management. There'll be various pictures of animals throughout the sites because I think that's important and hopefully it will have a calming effect to reduce your own hypertension. I very much value questions, I can see the chat at all times. So at any point I'm going too fast, too slow or you've got anything that you want to add, just, just let me know. So we'll start with Lucy. Here's Lucy. She's a 36 year old female. She's got a headache for the past three days. So she presents to the G P and her BP is 195 over 100 and 14 G P is very worried. So sends her over to A and E where she's assessed to see whether there's any signs of the hypertension causing problems, key things that we need to look for. Is there whether there's any focal neurology? I, is there any signs that the patient has had a stroke? Are there any visual symptoms because again, stroke, but also because hypertension can affect the eyes. Is there any chest pain or palpitations or sweating? Um This initially looks and sees whether the patient's having a myocardial infarction as a result or also gives us a clue to some of the possible causes. Again, for the heart, we might want to know if there's any leg swelling. Um suggesting to put full edema, nausea or vomiting and which could be a sign of raised intracranial pressure or hematuria to suggest that the kidneys have been affected. Well, then proceed with an examination to have a look and see whether there's any concerns or on eyes. Um whether there's any concerns to do with the heart and with this abdominal bruit to suggest that there may be a renal artery stenosis and whether there's any peripheral edema for that art with a urine dip to look and see whether there's any protein blood or whether the patient might be pregnant. Because all of these situations, uh red flags um in the context of hypertension um or complete an E C G. Um normal sinus rhythm is actually uh concerning UCG in this situation because if it was longstanding hypertension, one would expect the left ventricular hypertrophy. Similarly, normal Codec examination without left ventricular heave suggest that this perhaps, maybe acute, she has some bloods completed and these are normal except that the creatinine is slightly raised. So all in all we've got a patient who's presented with severe hypertension above a systolic above 100 880. It's diastolic above 100 and particularly if it's above 100 and 10. And there's signs that some of the organs have been affected and a possible cause has been identified um with the note of abdominal bruit. Wow. So this is a hypertensive emergency, defined as a severe symptomatic hypertension. The patient has got a systolic of above a 1 80 diastolic above 100 and 10. And there's evidence of damage to the kidneys but not the eyes, the brain or the heart, the patient is not pregnant. And so in this situation, we need to get urgent hypertensive control. This is because this has imminent danger for the patient because they're organs are being affected. And so it's important that we get the main arterial pressure down by 2025%. We may consider various agents to do. So often people prefer intravenous agents in the context of having a patient with kind of emergency hypertension. Some people might try oral agents, but we need to note that some oral agents were better than others. Often in these situations, people tend to use um Lodipine, but actually, amLODIPine is a very slow acting drug. It takes about eight hours for it to have a peak effect and it gets to a steady state in about 5 to 6 days. This is a slow drug to use in this situation. And isn't the ideals ideal thing to do. It's important to get urgent hypertensive control because ultimately this patient is having damage to the kidney damage to the kidneys as a result. And so it's important that we get that control pretty promptly by reducing the BP by about 2025% within the 1st 24 hours. And much of this specifically 10 to 15% depending on what damage is happening and needs to be done within the first hour or so. So it's important. This case is discussed with your friendly medical registrar or anyone else. Um In, in the unit is able to help with management of hypertension depending on your setup in your local hospital to get this very much under control. Let's contrast that with this case, again, the patient's reporting headache for the past three days and she's got hypertension very much the same in terms of symptoms. There are not apart from the headache. Examination, demonstrates a left ventricular heave, there's no peripheral edema. The urine dip doesn't show any signs of blood protein or pregnancy. The E C G shows evidence of left ventricular hypertrophy and the bloods are normal. What's the treatment now? So you in this situation, it's very, very similar to the past one. But actually the really the only difference here is the fact that this patient doesn't have any signs of end organ damage. You're welcome to take a moment in the chat to write what you think we should do for this patient and the options might be do nothing. Um, give some medication if so, um, any suggestions of what medication you'd like to do, what I'll do is I'll give you 30 seconds to write something down if you'd like. Or you can have a think about it and keep it in your head. Yeah. Yeah. Always like, oh, wow. Yeah. Lovely. Hope you have had a chance to think of what you might do in this situation. Um Let's have a think. Thanks again for posting the chat with your suggestion. Um There was a paper actually in December 2021 several different papers which looked at the management of hypertension. And this one was the one I guess that spoke most about this with, with quite a robust and set of uh with, with a number of patient's. So this was looking at treatment and outcomes of impatient hypertension among adults with noncardiac admission's. It looked at just under 23,000 people and they followed them up for a year in the U S assessing whether they had AKI myocardial injury or stroke. This is a case controlled studies. Um and they showed that patient's who were treated by hypertension in the absence of hard indication to treat them in hospital for, for hypertension. So in the absence of end organ damage or a specific organ that you're treating, for example, if your patient's come in with a stroke or a heart attack. Well, it's important to get BP control, but the patient's come for something else and they happen to also be hypertensive in that case. Um Actually, this, this study suggested um and that patient actually may have more consequences of, of treating that than avoid then ignoring it completely. And at one year, they did not, those who were treated did not have better hypertension control and subgroup analyses of all the different patient groups found no better group. There were, there was no group that if they did receive treatment um that they're hypertension was found to be and that they're kind of end consequences were found to be better. What does this suggest? Well, they suggest that actually there may be more risk of treating patient's who are a symptomatic and have no real consequences of hypertension in, in a very acute and severe or aggressive manner. I guess this makes them logical sense. Perhaps if you treat somebody very acutely and you bring down their BP and other things are going on or when they're otherwise. Well, you may actually drop the BP too quickly and as a result of dropping it too quickly, um you may precipitate uh ischemia to the brain or the heart or the kidneys. Hence why those increased rates of AKI and M I and I guess we're not really treating or addressing the underlying problem here. Are we, the patient is hypertensive and what they need is um follow up observation. Um an acknowledgement of whether this hypertension is true and real or whether it's in the moment because they're anxious, stressed and worried because they're in hospital. It suggests that perhaps we need to think about how when, when we manage this patient of hypertension and focus on the fact that they've got the hypertension um and organizing appropriate follow up in care and addressing their concerns. And then that's what's actually going to lead to better engagement with treatment, better monitoring of treatment and that opportunity in a non hospital setting for them to measure and monitor their BP and see whether this is actually a persistent pathology or whether or whether this is just a transient thing related to anxiety or stress. I guess the fact is if you start a patient on um anti hypertensives, you're often committing them to lifelong treatment for BP, which they may not need. But also if you don't take that opportunity to explain why it's necessary, then they may not take it either because ultimately, patient's don't want to take a medication for something that they don't feel they have any consequence of um where they feel they've got to take it lifelong to prevent something. They don't know that they need to prevent. It's very different if the patient's come in with hard indications for BP control, uh such as they come in with a heart attack or they come in with a stroke or they've come in and have malignant hypertension, also known as hypertensive emergency. I. Um there is some sort of end organ damage in that situation. It's quite clear that that patient certainly needs hypertensive control, which is why it's really key to do that thorough review. The hypertensive emergencies are exactly that it's evidence of end organ damage. Uh So patient's with acute renal failure like we had in Lucy, but also those who've got hypertensive encephalopathy signs of raised into criminal pressure such as nausea or vomiting or that headache or confusion too. It's just that acute coronary events or m eyes, acute aortic dissection, acute cardiogenic or palm redeemer preeclampsia. And that's why we do that review, which focuses on each of these end organs, ask the history and examines reach of these end organs to see whether it's what, what is right to do. So, in the case of Lucy, perhaps actually, in that second case where she didn't have any end organ damage, jumping in and giving her treatment was the right thing to do. Actually having a discussion with her about the BP and about the effects and why and the consequences that are occurring on her and getting her appropriately seen in primary care so that she can be monitored appropriately is actually more helpful in the long run. His case of pizza, Peter's a 49 year old male who's come in to his GP for a routine hypertension review or this might be Peter who comes uh to A and E and um in amongst all the other things that uh found, um his hypertensive Peter could be presenting anywhere and Peter is a common case, his BP is suboptimal. It's 1 56/93. And despite his reasonably young age, uh he's on a lot of agents for his BP, amLODIPine, fine ramipril doxazosin, That's three agents. That's another red flag in itself. Just like our previous patient who was under 40 with hypertension. This patient has sub optimally controlled hypertension. Despite three agents, his bloods are reasonably normal. That said his sodium is there on the upper end of the reference range. His potassium is a little on the low side and his creatinine is normal. What's the next test? Again? Have a moment to think. Um Please do post your comments in the chat so we can all have a think together what we might do next. Please don't be shy. Please do post and chat and comment because honestly, I would love for it to be a nice interactive talk where we can all help each other and learn from each other. And I again, welcome, welcome. As many questions as you've got. Yeah. So ambulatory monitoring is definitely critical here because a once off hypertense um evidence of hypertension doesn't mean we should immediately intensify treatment. It also be reasonable to say what is he even taking his medication because ultimately patient with hypertension, when I was doing the hypertension clinic, I think it was almost 50% weren't taking their medications. And so intensifying treatment that people don't take. Is this not, not really helpful? What about that? Low potassium and that's slightly on the upper end. Um, sodium is that point towards any diagnosis? Yeah, it's really important to consider kidney injury um in any patient with hypertension. So, thank you for that Glenn. Um We should always make sure with any patient with hypertension that we think what are the effects on your kidney and considering a urine PCR, we should also think about the effects of the eyes in the heart. Um as we mentioned before. So here we're seeing a patient who's hypertensive and a youngish age on lots of different agents. And so you're thinking or could something else be driving this just like the first patient who had BP at under the age of 40 being on three agents for your BP and having such severe BP. Despite that suggest that there may be secondary hypertension in this situation. We've got a patient who has got uh a potassium on the low side. And so we wonder whether there may be some sort of hormone that might be driving some of these changes. And so the test of choice here is a running and aldosterone. It's really important to always consider primary our external is um or Concentra. The reason is, is that it's actually really common. So studies show anything between six and 10, some even go up to 15% of patients with hypertension. That's a lot of people who have excessive aldosterone. Um, when I first met those figures, I thought, wow, that's crazy because that must mean we're missing lots and lots of patient's, that's, that's actually genuinely the case. Ultimately, patient's very rarely have hypochelemia. It's important to our bodies that we really manage our potassium within the normal reference range. And it should stay within the reference range for, for, for the reasons that actually potassium is a very integral part of all of our channels working properly. And so you only have hypochelemia in, in the case of of an actual problem. Usually, in this case, it's because of aldosterone excess al stare own leads to the retention of salt sodium and causes wasting of potassium in the urine by retaining onto salt and increasing the amount of fluid in in the vascular space. You end up having BP problems. And we see that here, we see this patient having um a high sodium and a low potassium, as evidenced by salt retention and the loss of potassium. You may also do a venous blood gas and find a little bit of alkalosis that would further support this. And so this in this patient, um you've got a situation of a patient with secondary hypertension, the low Renan is also very, very supportive of this. This patient has a low Renan despite them being on Ramipril, which would be expected to actually raise their uh Renan by being an ace inhibitor. The take home message from all of this is if you've got a patient on three agents for their BP, particularly if they're young, that is a sign that is a red flag in itself. And you need to think about referring these patient's because these patient's may well have um conditions such as an excessive aldosterone. And in this situation, they've gone on to have a CT adrenal which has shown left sided adrenal adenoma that maybe and where the xs eldest area is coming from. And in secondary care, one of the things that we will do in our endocrine clinic is to find out whether that left side adrenal adenoma is the thing producing excess out stirring and consider surgery to remove it if so, because then actually, we could very much cure them of hypertension rather than having to take so many agents and still not be controlled. That's why it's really important to take home. This message that young patient's with hypertension need to have this. You need to strongly think whether you need to refer them patient's on three agents for their BP, particularly any patient who's hypertensive with hypokalemia needs to be considered for referral because they may have aldosterone excess, which is very common effecting about perhaps one in 10 patient's with hypertension. Does anyone have any questions so far? If they do, please post them in the chat. Meanwhile, I'll carry on and talk about Lana. No, no. Is the third case. She reports that she's got a pounding headache, paroxysmal purple, perspiration and palpitations. Cough has a little bit of a tongue twister. Her BP is raised at 1 60/91. As you would expect given this is a hypertensive lecture and everyone's gonna have hypertension. Uh and she's got no focal neurology, no visual symptoms, chest pain, leg swelling, nausea, vomiting and hematuria. Again, very key things to ask because what we're looking for is any patient with hypertension, whether they are symptomatic and whether each of their organs affected, particularly their brain, their eyes, their heart and their kidneys. The examination is again done to look for the exact same things, their eyes fine. Her heart is fine. She's got no bruit to suggest that that perhaps this is renal artery stenosis and there's no peripheral edema to again support their heart is normal. A urine dip to check with her kidneys are okay or whether she's pregnant, she has no protein blood or pregnancy. Her HCG is normal sinus rhythm and her bloods are normal by blood. So, I mean, a full blood count, urinary electrolytes, crp LFTs, some of the common bloods that everyone routinely does. I see here we have a patient. It's not So, hypertensive has quite profound symptoms of headache, paroxysmal perspiration and palpitations. What might be going on here, please take a moment and put some suggestions in the chat. Yeah. So it's important to consider stress. Um And so it's important to always ask patient's uh whether they are undergoing any stress or whether there might be something um driving that it would be unusual for patient's to have um this degree of symptoms paroxysmally, which means from time to time it or intermitted Lee um in the context of stress, but it can happen. These, these are very classic symptoms of stress. I would always put stress there at the bottom of my list because whilst it's important, it's important to rule out anything that could be life threatening because that's what you're doing when you're the first doctor seeing a patient, is there anything very dangerous that I need to think? Is there anything very common that I need to think about? And then finally, what is the most likely cause toxicity? Yeah. And so toxicity could be referencing uh drugs, there are many drugs that can cause hypertension and so cocaine use, for example, could cause very much this constellation of symptoms. So I think that's an excellent suggestion. Um we should very much think about whether this patient may be taking her again and ask for that. And toxicity could have also referred to thyroid toxicity and the patient being thyrotoxic. And I think that's also a fairly reasonable thing to consider. Um, certainly, um, palpitations, perspiration, weight loss, diarrhea, and all of these could suggest that that Lana is perhaps hyperthyroid. And so it would be reasonable um, to measure her thyroid function tests. Are there any other calls? Is that anyone can think of clue whilst all the symptoms also start with P so does the diagnosis. It's true very much. So, it's very much an endocrine disorder. You're getting very close. Excellent glen well done. We're thinking this might be pheochromocyto Chromos it toma an excess of adrenaline where these symptoms are very much an excessive adrenaline. These are the symptoms we get just before we're about to do an exam or something that we're very stressed about. It tends to present with the peas, pounding, headache, paroxysmal perspiration, palpitations. Um You can also get pallor and other piece. So the next test is to look exactly for that plasma metanephrines or a urinary 24 hour collection of uh catecholamines means God, my uh I'm having a bit of a tongue twist today, but essentially you're looking for the presence of adrenaline or nor met adrenaline or, nor adrenaline depending on how you want to say it, whether you're in the UK or the US because this patient has an excessive adrenaline. This is a really dangerous diagnosis to have that. The fact is adrenaline is a dangerous drug to give. Um, a patient having excess adrenaline is a really dangerous disorder these patient's are constantly having an overproduction of adrenaline, constantly causing these kind of paroxysmal symptoms. And what happens is that the vessels are getting progressively squeezed, the perfusion of all their organ organs getting um slowly squeezed. So these patient's have a low circulating volume to try and compensate for the fact that they've got this constant school squeezable, the blood vessels trying to supply some major organs. So this patient could have a stroke or various other really life threatening problems. And those life threating problems can occur even a greater frequency if they're given any precipitants that might cause a fair chromosome a crisis, medications that can cause a release of these hormones such as an aesthetic drugs or opiates, topia antagonist, decongestions, tricyclics, lots and lots of things, um which are very commonly given. And so it is important that you always, this is our third learning point. It's important that you always take a clear history of headache, sweating and palpitations because those three symptoms usually occurring all three of them in the context of a pheochromocytoma is critically important because you may be the first person to identify a patient with the pheochromocytoma that we may have been going on for years, getting worse and worse and worse. And you may be the person who saves them by asking those really key questions to diagnose it, um including um urine or blood tests. Um The blood test being more reliable. Um The urine test usually been quicker to get the results of that things with the urinary tests. Many things can interfere in process. Um It can interfere with the urinary tests in conjunction with that imaging and genetics. Um Once we've got that confirmatory diagnosis, um imaging a CT adrenal to have a look and that will again be after we have the confirmatory blood tests. Endocrine is very common for lots of disorders which affect uh affect the glands all the time. And about 10% of patient's uh more or less depending on the age group may have a CT, may have adrenal adenoma on CT. That doesn't mean that adrenal adenoma is doing anything. And so hence why it's really important to make sure you get the diagnosis first and then try and find where it might be. The treatment here is to block that hormone excess because the last thing you want to do is go in with surgery to try and take it out, end up releasing all those hormones. Um and, and causing the world's biggest crisis. And so we aim for blockade with phenoxybenzamine, um usually uh followed by surgery uh to, to treat these patient's. And next week up, Ryan Ryan is noted to be hypertensive at 100 and 60/90 for his poor sleep with snoring daytime, some in a less ins what's the next test? The diagnosis? Again, you would be going through all the classic things to look and see where there's any symptoms or signs um on examination of harm to his brain, to his eyes, to his kidney or to his heart. Please take a moment to have a think either what the next diagnosis, sorry, what the next test is or what the diagnosis is here. Suicide. Yeah, perfect. Lovely obstructive sleep apnea, well done abigail. This is a very classic history of storing daytime somnolence since which may suggest this patient has obstructive sleep apnea. We know that obstruction state apnea is a very common cause of hypertension because ultimately, you aren't really going to have a normal BP if you don't sleep all the time. And so that's a common cause of, of hypertension and certainly something that is worth addressing. However, when you examine Ryan, you find a few um interesting features, you find that he's got abdominal striae that has got excessive breast tissue, that he's got thinning of his arms, he's got rounded face that he appears to have a little bit of a scapula fat pad. And so Glenn is right on the mark with all the endocrine disorders. Today, this is a patient that has Cushing's. So when it comes to Cushing's, um it's really, really key to take that history and examination because Cushing's is a diagnosis of clinical excellence. It's of you noticing that a patient's got bruising stretch marks weakness, but they've got unexplained weight gain that they've got these classic features on examination because ultimately our tests to diagnose. Cushing's are rubbish. The problem is, is that Cushing's is a condition, a cortisol excess and that cortisol excess could be at any time during the day, any amount during the day. Or it may just be low grade all day, all night. And it's the every under the curve that relate, that results in a patient having excess exposure to cortisol with all those things in mind. It's really difficult at times to diagnose called soul access. Some people might think, well, why don't I just do a cortisol a random time? Well, that's not always helpful because if you do it in the morning, well, the quarters was already expected to be high. So if it's high, it tells you nothing because that might just be the normal really high course, all that a patient has if you do it in the afternoon or the evening. Well, it depends on what the patient sleep cycle is. Uh, it depends on how stressed the patient is. When you take it, they're called saw maybe raised and, and that uh for all that time of day. And it might not mean anything really because you can't really test for area under the curve with a single measure. Of course. But there are, there are things that you can do to give you a bit of a clue. We know that cause sores highest in the morning and then slowly over the day it goes lower and lower and lower until essentially it's undetectable around midnight and mashed you asleep. So perhaps you could do a late nights library cortisol or a midnight called soul and assess whether the patient has evidence of excess cortisol when otherwise they should have a very low. One. Another thing you could do is um test um whether that quarter soul is responsive when you give them DEXAmeth. So ordinarily a patient who is excessive um steroid exposure would completely lose. Um the, if the body was working well, it would stop producing any quarter self. But if it's producing cortisol inappropriately, then it doesn't listen to outside instructions. So you may find that cortisol remains elevated. Another thing that you perhaps could do is measure the cortisol in A C T H because then you could have a look and see. Well, are the instructions really, really heavy suggesting that the pituitary or other sources of ACTH maybe producing excess cortisol or are the instructions very, very, very low. I the ACTH, the instruction of the brain are very low, suggesting the ACTH is uh low, but the cortisol is still high. When that situation, you wonder whether cortisol is being produced autonomously without instruction from ATTH. But again, all of these tests are not very helpful um in themselves. It's actually difficult diagnosis to make. Finally, last test that I haven't mentioned is a urine free quarter cell where you can collect the course of 24 hours to see whether over the 24 hours it's successive. What I'm trying to get the point across is that actually working out whether someone's producing excess courses are really difficult. And so it relies on all of you picking up these key signs. So if you see these violations, striae, you see a patient who's got this central adiposity with wasting of the muscles in the arms that rounded face or, or that fat pad at the shoulders at the back, I should say upper back, these should all prompt you to think. Could this patient have Cushing's because that is a much better way to assess the patient than any blood test or any other tests because they are really difficult to interpret. And we spent a lot of our time interpreting them. I'm trying to work out whether the patient truly does have course the access, which is autonomous or whether they're called success because of other reasons. And so what we've learned is an approach to assessing the patient with hypertension with some key learning points. The first we've asked is whether the patient's got symptomatic hypertension, whether there's evidence that the brain, the heart, the kidneys are being affected or the eyes. Yeah, we're also asking key questions for the endocrine system, headache, sweating, palpitations are key questions that we must ask. Is the patient hypokalemic. It's important in patients with severe hypertension to see whether there's any end organ damage because if there is, it's important that that patient is urgently treated. So, is there any evidence that their eyes, their brain, the heart or kidneys have been affected and we must also investigate them for end organ damage. Have a look at the E C G performed endoscopy, look at their blood specifically looking at their creatinine, do a urine dip, looking for blood or protein or whether they may be pregnant and finally investigating for the relevant causes based on the thing on the patient you're seeing in front of you and given the fact that secondary hypertension is so common and hypertension is so common. Whatever specialty you do, you are likely to see these patient's regularly and so being able to comfortably assess these patient's is important. You must consider whether the patient meets criteria for referral again and these are patient's who are below 40 or are multiple agents for their BP, particularly if they're resistant, either continue to be hypertensive. Despite this, any patient who's got hypertensive emergencies or features of endocrine causes the calls us to consider and the ones that we've gone through obstructive sleep apnea, renal disease, primary aldosteronism. There, you're Chromos it toma Cushing syndrome, hyperthyroidism for O S A. It's a simple question of asking about their sleep where they're sleeping during the day and whether they're sleeping during the night for renal disease, urine dip, an examination and considering an ultrasound K, you be in patient who are hypertensive or it's all important for primary aldosteronism that family history. But more importantly, that patient is hypokalemic. The pheochromocytoma, asking about headache, sweating, palpitations. The Cushing Syndrome, that clinical diagnosis of seeing those classic features and finding for hyperthyroidism. If they've got any of the symptoms, it is worth doing the test. So whether they've got palpitation, sweating, diarrhea, weight loss, irregular periods, all of these things are key features to suggest. Further investigation is warranted, the red flags of hypertension. Uh The patient who is severe and symptomatic, particularly if they've got headache, sweating and palpitations, which could suggest a via Chromos I toma and which is a really dangerous life threating disorder where they got any features of end organ damage. And finally, hypochelemia, hypochelemia, hypertension should immediately make you think could this be cons or primary aldosteronism? And then finally, when we think about the management, think about whether the patient should have rapid BP control or not. If they've got signs of end organ damage or they've got signs of hypertensive emergency, it's reasonable to get their BP under control to protect the organ. Otherwise, if they don't have signs of end organ damage or organ dysfunction, you may end up causing that organ dysfunction by rapidly controlling their BP. And so it's important to monitor their BP, start medications that tend to work slowly. So pick the right drug. AmLODIPine tends to work slowly. So if you're trying to get an emergency emergency control of the BP, it's not the right thing. But if you're trying to get it done slowly, then it may have been well within reason. And if you're lowering the BP and emergency, ultimately, you're trying to reduce it by about 10 to 20% depending on the diagnosis within the first hour and a max of 25% in the 1st 24 hours. And often you do this with intravenous agents like G T N Libby to low or others. So what key messages have we taken from this lecture? We now know that it's important to check if any patient with hypertension is symptomatic, particularly looking for features to suggest that there's end organ damage to the eyes, brain heart or kidneys. We thought that a referral is important for those who are young or multiple agents severe or of signs of secondary hypertension. And finally, we thought whether it's appropriate to control their BP quickly because there's signs of these end organ damage or slowly because actually, we may cause more harm than good by dropping it too quickly. I'd be really grateful if you could complete some feedback. But in the meantime, this is a wonderful opportunity for you to ask any questions that you may have. I'm more than happy to go back and cover any more material in in detail, if you would like, why is there hypochelemia in cons? This is because there is an excess of our steering this excessive aldosterone and acts on the potassium channels in the kidney causing potassium to be lost in the urine because it's lost in the urine. Patient's total body potassium is low and that's the cause of the hypokalemia. Any other questions? It's hypertension caused by obstructive sleep apnea, reversible foreign commencing of treatment very much. So, actually, we find that patient's who begin their treatment for obstructive sleep apnea suddenly find that their BP is so much better controlled by just getting a good night's sleep. And so the treatment for patient's with hypertension called bio essay is not to give them drugs, but to actually treat their obstructive sleep apnea. And that's why it's really important to ask them whether they've got excessive sleepiness during the day. I daytime, some of the lessons or whether they're not sleeping during the night, are they snoring and they're waking up with a headache? It's important to ask all of these classic symptoms. These are great questions, guys. Keep them coming. Um And thank you so much for, for enjoying this lecture. He better uh to anyone else with any more questions. Yeah, we'll just stick around for a couple more, couple of minutes for any more questions. But I just want to advertise the next talk, which is next week. Um again given by an excellent decline, um, registrar on thyroid function tests. I'm just gonna put the link on to the chat. Uh We do have one more question. So I'll hand over back to a cash from Glenn. Could you go back to the slide of how to approach my potential against? Of course, I can, did you mean this slide or did you mean the slide Glenn before that? Actually, you perhaps meant this one? Is this the one ah brilliant. Whatever the case, all of these slides will be available afterwards is a recording up on youtube. So rest assured if you felt like you missed anything, you'll be able to watch it all over again. So, yeah, apologies for all of those who don't want to listen to me again. Any other questions? Yes. I certainly think that this is a reasonable approach to begin looking at the patient in the emergency department with severe hypertension. It's certainly um part of the plan that I advise when I'm called about patient's with hypertension as medical registrar, all the endocrine registrar. It's my absolute pleasure. Glenn. Brilliant Fish if you want to take it away. Perfect. Well, thank you so much. I guess that was excellent talk on hypertension. Um, like, like actually said, we'll upload all the slides and the recording on to both medal and onto youtube eventually. Um, if there are any further questions at all, please do, um, send them, um, either through the chat, we have further talks planned as part of the series. So next week we're going to talk about thyroid function test and the week weeks after we talk about uh more about hypoglycemia sliding scales, hyponatremia and whatever. Um you want. So if there's any other suggestions of topics that you want to cover as part of your education that you feel there's a gap in, we'll be more than happy to facilitate that. Thank you so much for joining us on this Thursday evening. Um I'll stick around for any further questions or suggestions and please do fill in the feedback forms. We love feedback, helps us plan for future sessions um and think about how we can improve the series going forward. Lovey. Thank you so much and uh all have a lovely evening. Right.