High blood pressure in the very young is rare but has serious implications. Pediatric nephrologist Elizabeth Black, MD, offers a lesson in accurate BP measurement, explains which populations should have additional screening, and notes the benefits of ambulatory monitoring as well as when to order it. Get tips on history taking, follow-up tests, and exam-room apps that put useful figures at your fingertips. Also: a rundown of the medications she commonly prescribes.
So today I'm going to be talking about pediatric hypertension. Um And it's sort of I think the basics of what every community pediatrician needs to know. Um And there are some interactive elements I am not a person who is good at sitting and watching a presentation for an hour. Um So feel free to put comments or answers in chat um or just shout them out. Okay so a brief overview. I'm just going to go over some blood pressure basics including defining hypertension and also um best practices for measuring blood pressure accurately. I'll go briefly over some causes of hypertension work up. And the things that I'm thinking about when I'm seeing a patient in clinic for hyper for evaluation of hypertension and then how I make therapy decisions. So starting with the basics. So basically most of them are going to be talking about comes out of the 2017 clinical practice guidelines. Um These are published by the ap and are authored by Dr Flynn from University of Washington. And the rest of sort of the subcommittee on high blood pressure in Children. Um The 2017 guidelines are an update to the fourth report That was published in 2004. Um there are some important things to know about them. So the first thing is that at the same time the American Heart Association updated their guidelines for adult hypertension. Um so the 2017 guidelines redefined hypertension to put it more in line with the adult guidelines. And then it also um included new normative blood pressure tables that excluded patients with obesity. So it was a healthier population from which the blood pressure norms came. Okay, so overall um hypertension is not that common in Children. Um It's about 3% 3.5% of kids in the US have hypertension but there are um certain populations where that number is much higher. So Children with obesity um have up to a 20 that Uh prevalence in that population is up to 25%, particularly patients with chronic kidney disease, have a really high chance of having hypertension. And as a pediatric nephrologist, that's something I really need to know about and to manage. And then also um in Children with prematurity there's a high risk. Um and we care so much about hypertension in the childhood years because higher blood pressure and childhood continues to increase the risk of hypertension in adulthood and all of the sort of cardiovascular um consequences of that. So I'm gonna start with a case. Um so this is Rebecca she's a six year old who presents with her parents tear clinic to establish care. Her weight is at the 50th%ile and her height is at the 75th and her home medications are just zone which uses twice a day and albuterol as needed And you can see her vital signs there. So including her weight at the 50th%ile and her height of 122 cm of the 75th%ile and an initial blood pressure of 132 over 88. Um So my first question and like I said feel free to unmute, mute yourself and shout it out or just put the answer in the chat is what is your first step in evaluating Rebecca? So you're gonna do urine tests, Are you gonna do that ultrasound? Are you going to repeat the blood pressure? Are you gonna recheck it in two weeks, yep. And I see a bunch of answers of C. Coming through uh in the chat perfect or of confirming the blood pressure. This is a little bit of a gimme. Right? So the most important thing um when you encounter a patient with an elevated blood pressure and clinic is to confirm that that is an accurate measurement and I'll talk about that. Um So the best way to confirm a high blood pressure um is to um first of all repeat with a manual or an exculpatory blood pressure. We know that those are more active accurate than osceola metric devices. Um The other thing that I always do um is I always confirm that it was checked with an appropriately sized cuff. Um So I always actually get I carry a tape measure around with me and clegg. Um And I always measure the upper arm circumference on my patients. Um So best blood pressure practices right? We want the child to be seated um in a quiet room for 3 to 5 minutes. So oftentimes I think um when we're in a busy clinic, uh there's lots of patients, the army or the nurse brings the kid back is doing height and weight and you know, um and checking vitals and then they just check the blood pressure sort of, well all of this is going on and that can that can definitely cause a falsely high blood pressure. Um I also have my so I want them sitting sitting and calm for at least a few minutes before I check, making sure that the feet are uncrossed and flat on the floor um ideally with the back supported and the arm up at the level of the heart. Um I always measure the right of the blood pressure in the right arm when I can unless there's a specific reason why that's contra indicated in the patient. Um This is because the um the normative values those that created the tables, those measurements were all done in that right arm. And that's also to avoid a falsely low reading in a patient with a possible court. Okay, so like I said, making sure that you have an appropriate size cuff is really the most important first step. So when we think about the bladder, so we measure um from the the circumference of the arm at the midpoint between the a chromium and the electron in Um and we look at what I'm paying attention to, is the size of the bladder, not the cuff itself. Um so I want that bladder to be about 80%, at least 80% of the arm circumference and about 40% of the length of the upper arm. Um So cuffs tell you what size they're appropriate for. So I also always look at the cuff to make sure that it is in line with the um with the arm circumference that my patient has. And then there's just some sort of standard ones up there in that table. Okay, so who should we be checking? Blood pressure's on in the pediatrician's, you know, routinely in the in the general Pete's office. So I think everyone is already checking all patients yearly at their well child visits starting at age three. But there are kids where I would ask that you do it a little bit more frequently. So patients who are at high risk of developing hypertension. That's patients with obesity or medications that are known to increase blood pressure. Anybody with kidney disease or congenital heart disease or diabetes. I would want their blood pressure to be checked at all health encounters. Um And then when do we start checking? Less than three years. Um So I would also ask to start this process in the littler kids um with uh, if they have prematurity or nicu stay, particularly if they had umbilical lines. Um, anybody with congenital heart disease, any kidney issues. Um any organ transplant patients. Again, kids that are on blood medications that put them at risk for developing high blood pressure or who have illnesses um that put them at risk of high blood pressure. And then if there's any evidence of increased intracranial pressure. Now I know how hard that it can it can be to get an accurate blood pressure on a six month, you know, on a baby or on a toddler. Um So I what I say is blood pressure measurement should be attempted at each visit. Um uh So you know, sometimes that we will get more accurate blood pressures than others and it's just important to document, you know, we tried to get a blood pressure today but and it was super high, but that baby was screaming his head off, you know, um it's not always gonna go super well on the little guys. Okay, So moving on to my back to Rebecca so you ensure that you are using an appropriately sized cuff and check to Oscar territory measurements in her right arm. Um She's calm during these measurements and denies feeling anxious. Um So you check to you average them together and you get a blood pressure of 1 31/87. So the next question is this patient's blood pressures are consistent with what degree of hypertension are they normal, elevated stage one or stage 2? Um And if you don't know the answer, you can also um say how you would figure this out because I don't expect anybody to have the table is memorized. Okay, so we're definitely elevated for sure. Um and then we would diagnose her with hypertension based on three separate measurements. So I like that everybody is saying elevated. I would call her elevated without diagnosis of hypertension at this point, but it's certainly it's concerning. Right? So, um, when we're defining hypertension, Um again, that goes back to the 2017 guidelines and we are looking at those high blood pressure. Um we're looking at the normative tables. So it is important to keep in mind that the difference between definitions of adult and pediatric hypertension have to do with how normative values Were derived. So in Children, right. It's based on, you know, some I think it's like 1100 healthy Children. And this is sort of the range that those blood pressures were. So anything over the 95th%ile, that's probably high, right? But unlike in adults where blood pressure cutoffs are based on clinical outcome data, we actually don't have adequate data in Children to say this blood pressure is too high. Um, so we are guessing a little bit and then we know that in Children with certain diseases, particularly in chronic kidney disease, we actually don't want them to be under the 95th%ile. I want a child with chronic kidney disease to have their blood pressure under the 50th%ile to reduce progression of CKD. So it's a little bit trickier than it is in adults. Okay. But so the other thing that the 2017 guidelines updated from the 4th report um is that they added in those adult cutoffs. So we generally say if you're over 13 we just use or 13 and older we just use the adult values. And then um aged 1 to 13 were based on percentile. So whether you're under the 90th, uh you would be normal 90th to less than 95th, elevated greater than the 95th to less than the 95th plus 12 would be stage one and stage two is over the 95th. Um But again important to keep in mind that those um if you are the the the the normative values may have blood pressures that are way above these. Right? So a 17 year old six ft boy, his 95th percentile blood pressure may be in the one forties. But that doesn't mean that we consider that normal. So this is what I mean. I'm sure you all know this this is what the tables look like. Um And so for Rebecca we said um I've got to fix that. We said she was 100 and 22 centimeters at the 75th percentile on the 82nd. I apologize and her Bp is 1 31/87. So if I were to classify her degree of hypertension, I would say this is these blood pressures are consistent with stage two hypertension. Um I think if you don't know there are app versions of these tables um It's much easier to just look at it, look at it on an app on your phone than it is to look um at the you know going to up to date or wherever to trying to kind of match things up. Um The one that I use is called pediatric blood pressure. And I think it cost me 99 cents also for those of you on Epic. Um Oftentimes Epic can do it for you. Um I think it's a dot B P 95 will give you the 95th percentile for your patient and will classify the the recorded blood pressures into this sort of schema. Okay. Um So other things to think about when we're thinking about diagnosing classifying hypertension is ambulatory blood pressure monitoring. So um a Bpm is we actually consider the gold standard for diagnosis of hypertension. That's in adults and Children. Um And it gives us a lot more information. So basically what it is is is that you can see our uh small patient there it is a blood pressure cuff that is placed on the upper arm, it's connected to a tube and then into a box um and that is put in the pocket or clipped on the pants. Unlike in when we're checking a blood pressure in clinic where I really want to do the right arm consistently Because this is something my patient is going to wear for 24 hours, I place it on the non dominant arm. Um and what it does is it checks blood pressure every uh usually every 20 minutes during the day and every 30 minutes overnight. And it gives me a lot more information that lets me um diagnosed some masked hypertension. Um So some patients may have normal high blood pressure in the office, but overall they're actually hypertensive or white coat syndrome and kids who are anxious being in the physician's office. And also lets me look at circadian blood pressure patterns. We should have dipping in our blood pressures um while we sleep. And if we see non dipping, that is a risk for adults, we know that's a risk for cardiovascular events and that can be indicative of secondary hypertension in Children particularly sleep apnea. And there were actually new, a new update just came out about a bpm in Children in May of this year. So the first thing it did was um the 2022 guidelines revised classification for a Bpm. Again to be more in line with adult standards. So until recently there was a lot of debate about whether we should be using those 95th percentile cut off or the adult cutoffs in pediatric patients. Um and they are officially saying yes, most of us were doing it already. Um and so you can see those definitions there um in adults. So we actually are a little bit more permissive on a BPM about sort of the specific blood pressure. So um there are different normative values at night and during the day. So adults and people over 13 we expect their blood pressure to be under 1 10/65 when they're sleeping. But we say up to 100 and 30/80 while you're awake is okay. Okay So when when should you think about sending your patient for an ambulatory blood pressure monitor? Um and part of this new 20-2022 guidelines also expanded sort of indications for ambulatory blood pressure monitoring. So you know of course to confirm the diagnosis of hypertension in patients who are at risk for secondary hypertension. Um on anybody who has CKD we're doing them um annually. But the thing that the new report added is that we should be considering ambulatory blood pressure monitoring and patients with diabetes, severe obesity and obstructive sleep apnea is a way to screen for hypotension. Um And those that's because of those those three categories are in such high risk for high blood pressure. Um There are some limitations to ambulatory blood pressure monitoring. So those monitors are quite expensive and interpretation of the tests really should be done by people who are experienced and experts at that. Um So generally um that means a referral to nephrology if you're concerned. Alright so moving on um during the visit the patient is cooperative and has a pleasant demeanor. She does not report any specific problems such as headache, vision changes, nausea, vomiting, chest pain or materia. But her parents and her parents deny that she has any known history of urinary tract infection. Um Her physical exam appears normal. Um You tell her parents that you would like to get a detailed history and order some additional tests to evaluate her blood pressure. So what questions do you ask? What kind of when you have a patient in your office who has higher blood pressures? What are things that you're sort of thinking about and feel free to and you drop them in the chat. Whatever makes you more comfortable. Okay so I see um snoring and lifestyle in the chat. Those are definitely things that I ask about That's perfect. How about anything about past medical history that you might be thinking about. Family history of hypertension definitely. Yeah and prematurity. That's kind of what I was looking for. Yeah medications can you? Disease in the family prematurely definitely. So what I'm doing um when I see a patient like Rebecca is I always ask about gestational history right birth weight if they had umbilical catheter placements. Um I asked about you t any history of U. T. I. S. At all or any medications um snoring to screen for os a family history nutritional and physical activity history. And then the other thing I wouldn't do it in a six year old so much but really it's important for psychosocial to look at psychosocial histories and to ask about drug use and stressors. I can't tell you how many patients I've had referred to me for hypertension who I diagnosed with panic disorder. That's been quite a few and more after the covid pandemic. And often several of those patients when I've done ambulatory blood pressure monitoring screening on them are normal intensive but they are just very anxious in the physician's office and have you know sort of overall high stress. Okay so you ask these questions. Um So and you learned that Rebecca was born at 32 weeks and she weighed two kg. And she had a U. A. C. N. A. U. V. C. Placed. Um She has no U. T. I. S. She's not taking a lot of medications. She doesn't snore. There's an older relative with high blood pressure in his sixties she eats a good diet. She's physically active and new major stressors. Um And then on the physical exam when you're seeing a patient with high blood pressure you really want to look evaluate for murmurs and heart rate. Doing really good cardiovascular exam. I also look sort of in general at body habitants. I look for evidence of metabolic syndrome like synthesis. Um or abdominal street. Um I look for a team a vascular apathy. Um I always listen for abdominal breweries. I've never heard one and in any patient where I'm concerned about hypertension. I do actually do a good G. U. Exam because I'm looking for evidence of the realization or ambiguous genitalia. Okay and then um in a patient who you're working up for hypertension what tests would you order and you don't have to be shy yep I would definitely look at renal function bu and creatinine fasting glucose. Is it definitely a consideration and your analysis? Yeah. Yeah. So I can tell you kind of what my practices and what's recommended urine culture. I don't necessarily do a urine culture. Um But in anybody with high blood pressure I always do your analysis and I will usually do a urine protein to the first morning protein to creatinine ratio as well. Um Looking for any urine evidence sort of a renal disease. I do a chemistry panel to look at electrolytes. View and creatinine. Um There are multiple kind of causes of hypertension that can cause um changes in electrolytes. So if you know I think somebody is in a high elderhostel own state I may see their potassium may be low. Um I do a lipid profile That's kind of to look um for um just assessing cardiovascular risk. Um And then anybody under six years of age or six years and under with abnormal your analysis. A renal function gets an ultrasound no matter what. Okay so in patients with obesity I always do a one c I look at the liver enzymes and the fasting. Then I do a fasting lipid panel. Um And then optional tests are thyroid studies. I will usually just do thyroid studies because they're quite easy to do with other blood tests. Of course. Drug screen sleep study cbc um urine and serum cata column. E coli means if I hear a a history that is concerning for fio fio chromosome toma like episodes of flushing and sweating um uh Brennan and valdosta rone. I do if there's abnormalities on the kIM panel. Oh yes, definitely. Allison is asking if they can get a copy of the list. Um And I am happy to make my slides available in whatever way our physician liaison say I can. Um And then um an echocardiogram. I will do an echo if I'm concerned about. You know if I hear a weird murmur or if my cardiovascular exam is at all abnormal. If I feel um unequal pulses or if I've done a four point and that looks abnormal. Um and then in any patient where I confirm hypertension, I also do an echocardiogram to look for end organ damage. Specifically left ventricular hypertrophy. Okay, So the reason we do all of this, right um the majority of hypertension in young Children is secondary. So basically any infant with hypertension. It's secondary hypertension. And it's um 70 probably 70% of kids in 1 to 12 years. This is changing with the obesity epidemic. That has worsened during the COVID-19 pandemic. Um But in at once you hit adolescence, um primary hypertension is much more common. Um So Rebecca you do a lipid panel, complete metabolic panel, your analysis, echocardiogram and renal ultrasound. Um the radiologist tells you that her right kidney is an age appropriate eight cm in length, but her left kidney is only 5.7 and has no cortical medullary differentiation. Her echocardiogram is normal and her lab results look normal. Okay, so what is your differential for causes of hypertension in a patient like Rebecca? To think about that And then I'm going to move along. Oh sorry. Um I'll kind of keep moving along because I think I'm getting a little bit shorter on time. Um But so secondary causes. So she likely has secondary hypertension. And we did see an abnormal ultrasound. So of course secondary causes can come from various organ systems. You can have any kind of kidney disease can give you um hypertension and then various endocrine diseases like hyperthyroidism, um Congenital adrenal, hyperplasia, hyperplasia. Peronism, um DiSarcina mia. We can see high blood pressure or brain injury and then things like Wilms, tumor and neuroblastoma. Um There can also be vascular causes or the corrective the aorta a renal artery stenosis. Any kind of vasculitis. So it's not uncommon for me to take care of patients with something like purpura who may have been hypertensive while they're sick because of vascular tick changes. Um pulmonary causes can be or most commonly sleep disordered breathing, but broncho pulmonary dysplasia. And those nicu babies um medications and drugs of abuse like cocaine amphetamines and marijuana can actually cause hypertension. So in that birth to one year age group right overwhelmingly it's going to be secondary and I've got some of the most common secondary causes listed there. And in those in the infants I really do a pretty big work up. Um When I'm evaluating them for hypertension though. Oftentimes the history will give me some good ideas. Okay? Um And then in the older kids um it shifts a little bit. Um Then I'm thinking less about sort of congenital issues, more about um like reno parent Kimmel disease. Um But still definitely all of those same things can apply And it's about the same you know from that 1-18 year age group. Okay so what is the most likely cause of Rebecca's hypertension. So we said that um she was a nicu baby. She is on inhaled zone. Um She has a history of umbilical like a nicu stay with umbilical um catholic umbilical catheters. Um And she has a renal size mismatch on her ultra zone and you know I realized that it's not A. B. C. D. So I apologize. Yeah he be coming up in the chat arena vascular disease. Mhm yep. And that would definitely be on the top of my list. Um She is at risk right? So she was premature. So loan Ephron endowment is something that I'm definitely thinking about though when I think about hypertension and prematurity. Um most of our nephew genesis is completed by 32 weeks which is her post gestational age. So usually that risk the risk of hypertension just as a result of loan Effron endowment and prematurity is much less. Once you hit 32 weeks. Of course in our babies who are 24, week ear's um then it's quite common. Okay So some diagnostic clues that I think other people picked up on right at 32 weeks. Um and that abnormal ultrasound. So most likely she had a renal artery thrombosis from that U. A. C. Um So in anybody who with renal vascular disease, what we're talking about is this decreased renal blood flow that causes activation of Rendon Rendon angiotensin and Valdosta Rome syndrome. Angiotensin two is um effective in vaso constriction. And then of course Valdosta Rhone um causes um uh increased reabsorption of sodium and increases in blood volume and that leads to hypertension. Okay so other tests that I would consider for Rebecca um And anybody where I'm concerned about reno vascular disease. You know a Brennan and Valdosta Rhone is a good way to help confirm it as well as a. C. T. Um Angie S. C. T. Angiogram to look in a patient like her though where that right kidney is really small. And there's no cortical medullary differentiation. That kidney is probably dead. So there's likely not a lot to do about it. Okay, so management decisions. So who do we start on antihypertensive therapy? Of course, anybody with symptomatic hypertension, anybody with stage two hypertension or stage one hypertension with evidence of end organ damage. I also give my stage one hypertension. Kids. I give them six months of non pharmacologic intervention. But if things aren't getting better than I do start medication, Um I talked about chronic kidney disease patients, right. We actually want them to be under the 50th%ile for blood pressure. So if they're abnormal at all, we start them on medication. And then again, patients with diabetes are at such high risk of CKD from diabetic neuropathy were quite aggressive with them about hypertension management. Okay, so after discussion with Rebecca's parents, you all agree that she should have an intervention to control her blood pressure. In addition to starting a medication they'd like to know about non pharmacologic interventions. And so what kind of advice do you give any patient with high blood pressure? What non pharmacologic interventions can you recommend? And I'll let people drop them in the chat or unused and say and uh and shout it out if they like. Yeah, salt intake lifestyle changes, definitely increased salt. Yes. So of course salt restriction. Right, They should be eating a normal salt diet all of us in the United Most of us in the US are eating quite a high sodium diet. So I recommend a restriction to, oh sorry that should be milligrams to less than 2300 mg per day. No I don't think anybody is eating two kg of salt. Um I recommend 30-60 minutes of exercise. So really getting that recommended amount of exercise that the ap recommends and then avoiding high caffeine beverages and particularly sugary beverages. Okay. Um and then choosing an antihypertensive. So um oftentimes you know we're in nephrology were consulted in the hospital where we get patients referred to us to help direct antihypertensive therapy. Um And so a question that I get is you know, how do you decide what medication is right for each patient? How do you choose an anti hypertensive medication? Um So one of the most commonly used medications are um As um Little Pine, which is a calcium channel blocker, It causes vaso dilation and it's extremely safe in Children even in those with coexisting conditions. So um it you know, it doesn't cause acute kidney injury. It doesn't need to be monitored on labs. Um It tends you know like adverse effects like any antihypertensive theoretically could cause hypotension but I generally don't see that as a significant side effect. Um the biggest thing that I see with it is in some patients that gets peripheral edema from the and it seems to be you know I see 100 patients and 99% of them have no edema. And one of them gets a lot of edema. Um it seems to be some people just can't tolerate it but we stopped the and the Adama goes away. Um it is contraindicated in sinus node dysfunction. So I generally will reach for calcium channel blocker in a in a small infant. Right? Because it's they're very safe um In um patients who where I'm concerned about sort of their adherence to medication or really in a patient where the diagnosis is it all kind of up in the air like are they really hypertensive? I'm not totally convinced and loaded Pine is a really safe option. Okay so now ace inhibitors and angiotensin receptor blockers are an astrologist best friend. Um So they are well tolerated and widely used in kids. Um And there is a commercially available liquid form. Um And the reason that nephrologist love this is because it has a renal protective effect to basically the effect of rest inhibition is to decrease in pressure. And that preserves renal function in the long term. So it does cause a slight decrease in G. F. R. When we started and we tolerate that because we know that um in the long term we will see a slower G fr decline in patients with chronic kidney disease but it does require laboratory monitoring. So whenever I start and these are arab or increase the dose. I always ask my patients to get blood tests to make sure that their potassium is okay that they're creating has not jumped too much um 7 to 10 days after adjusting that dose. Um And then the other thing that does limit their use is that they are highly terra to genic so they can cause fetal exposure to ace inhibitors can cause um issues with renal development but also they get facial deformities. Um So I counsel all of my um female patients of childbearing age. You know this medication can cause birth defects if you think you're pregnant you need to tell us right away. I always do this in the room with um with the parents still there before. I've had a private chat with the patient. So there's no you know concern that they've disclosed something to me but and it's really important to stress this. And we've had I've had a couple of scares um that makes me it makes me a little bit nervous sometimes in some of our kids. Okay other options are beta blockers so they're not um as good as other antihypertensive they tend not to be as efficacious. Um They we have to be cautious in infants because they can cause hypoglycemia of course they can trigger asthmatic attack. Um And beta blockers are also be psychogenic. So I try to avoid them when I can. Um But I will sometimes use them preferentially in a patient with a history of severe migraines or in human gliomas um alpha agonists. This is primarily cloNIDine. Um And it's used in the treatment of a few different conditions. So you can sometimes have a double effect with this medication. So A. D. H. D. Insomnia, opiate withdrawal. Um It is also available in a patch form. So um patients who may not be very good at taking medications, you know kids where the parents really have to fight them to swallow pill, fight with them to swallow pills or to um take a liquid or in patients who have you know just sort of chronic gi issues where they have a really low tolerance to things like medications I like quantity. And um the uh big side effects from it are sedation. So oftentimes we will start quality on the patient and they're pretty sleepy for a few days. But usually that effect is transient and after you know three days or so they're kind of back to their baselines. But the biggest thing to know about alpha agonist is that there is a risk for rebound hypertension and this can be quite severe. Um And especially with a patch right? The concern is that has the patch come off and the family hasn't noticed or have they applied the patch incorrectly and then so the patient isn't getting the effect of the medication and then they can have very severe rebound hypertension and be at risk for you know hypertensive emergency. Okay. Um Other things this is more commonly used in adults with diuretics. Um So these can be considered alone or with another antihypertensive. Um And they do require salt restriction to work. So you can um you can over eat salt and to basically get the effects of pesticides. Um and they do have some adverse effects. Uh So I don't use them as much so they can cause Hyperloop anemia. They can cause all kinds of electrolyte arrangements and insulin resistance. So I'm cautious with my asides in patients with obesity or evidence of metabolic syndrome. I'm cautious in patients who already who have existing electrolyte arrangements. But what I do love them for our patients with hypertension and nephrology dialysis. And I will sometimes use them in patients with hyper calc area and kidney stones. Um who have not responded well to just sort of more conservative measures like diet changes and fluid intake. Okay there's a few other agents that I we sometimes use a nephrology for hypertension. Um These are used less commonly. So one is hydraulic scene that is a Visa dilating um a Visa dilating agent. It has a very short half life even in oral form. So we don't use it very commonly. Um Just because it has to be just ideally four times a day. Um And then minoxidil which is quite a powerful Visa dilating agent. But it's really our last line for resistant hypertension because it has a terrible side effect profile. Um There's a risk for pericardial effusion with um Minoxidil which is our biggest concern and then it also turns kids into little werewolves. They get super super hairy with it. So I I have used Minoxidil only extremely rarely and in really severe cases. Okay so um for Rebecca I'm just gonna plow through because we're getting almost out of time. So for a patient like Rebecca who has reno vascular hypertension I would expect her to respond really well to an ace inhibitor. So that's kind of what I would start for her. Okay but thank you everybody for your attention. Um And I'm gonna open it up for any questions.