J. Brian Byrd

Happy to see our commentary with @jbrianbyrd.bsky.social suggesting that Angiotensin II should be part of the evaluation of primary hyperaldosteronism. @nu-nephrology.bsky.social @nufeinbergmed.bsky.social
www.ahajournals.org/doi/10.1161/...

I'm visiting soon to give cardiology grand rounds. Maybe we can meet up and think about it & other interesting topics!

2) you can't confidently establish whether aldosteronism is primary without measuring the main aldosterone secretagogues (Ang II, K+). So, renin's interpretation really depends on assumptions about Ang II, or measured Ang II levels. The latter makes more sense, I propose

Thanks! I hope so, too. It's important to note that 1) renin is not a marker of mineralocorticoid receptor activity except once you have established that the condition is primary (vs secondary in which high renin->high Ang II->high aldo->high MR activity) &/

Dan Batlle & I wrote about testing for primary aldosteronism, bringing a critical lens to the usual approach

www.ahajournals.org/doi/full/10....

Hydralazine inhibits cysteamine dioxygenase to treat preeclampsia and senesce glioblastoma The decades-old preeclampsia drug hydralazine vasodilates and senesces glioblastoma cells via the same enzyme target, ADO.

Woah, it’s possible hydralazine may be (rarely) useful outside of preeclampsia! www.science.org/doi/10.1126/... 🤯

H/t @jbrianbyrd.bsky.social

Description of a prescription cascade, when an initial prescription for pregabalin or amlodipine causes leg oedema leading to addition of furosemide which causes urinary incontinence. This leads to a RX for Solifenacin which causes cognitive decline and a prescription for Don Pascale. The subsequent anorexia and an insomnia leads to mirtazapine prescription and a hip fracture from a fall. This of course leads to many other cascades, including delirium, haloperidol and levodopa, risedronate, and pantoprazole, or iron and constipation with peg.

From @carolyntan.bsky.social

This is a work of art

Have to agree that amlodipine and gabapentin/pregabalin often lead to heart failure misdiagnosis

#MedSky #PharmSky

h/t @davidjuurlink.bsky.social and @jbrianbyrd.bsky.social

Yes, MRAs can cause mild hyponatremia. Usually not a major issue but can be a factor. I have not seen severe hyponatremia (eg <125) and use a lot.

Aldosterone deficient mice are mildly hyponatremic (inconsistently)
Primary aldosteronism is associated with mild hypernatremia

We do see the occasional hyponatremia even with spironolactone (though often attributed to something else and not well documented)

cc @drjmluther.bsky.social for more

T4e
5️⃣Primary aldosteronism screening – screen all adults with resistant HTN regardless of potassium level (COR I, LOE B-NR). Continue most antihypertensives except MRA before testing (COR I, LOE C-EO).
📝Is screening worthwhile or should we just be using MRAs earlier? #NephJC

Starting next week, Apple’s new hypertension notification feature will be coming to Watch Series 9 and later and Apple Watch Ultra 2 and later with the launch of watchOS 26. That’s according to an emailed statement from Apple spokesperson Zaina Khachadourian saying the feature that monitors blood pressure has been cleared by the FDA. Apple’s new hypertension notifications — announced Tuesday alongside the new Apple Watch SE3, Series 11, and Ultra 3 — use data from the watches’ existing optical heart sensor to “analyze how a user’s blood vessels respond to the beats of the heart.” An algorithm will review this data over a 30 day period and notify users if it detects signs of high blood pressure.

And it looks like it is cleared by the FDA

apple.news/AFT61lWmgRfG...

The confusion on whether it will actually show numbers or just ‘you may have hypertension’ still persists

To me, It sounds like a PPG sensor analyzing the pulse transit time "Apple Watch use data from the optical heart sensor to analyze how a user’s blood vessels respond to the beats of the heart. The algorithm works passively in the background reviewing data".

Hypertension Notifications Building on its suite of advanced health features, Apple Watch Series 11 introduces groundbreaking hypertension notifications, which can alert users if signs of chronic high blood pressure — or hypertension — are detected.5 Hypertension is the leading modifiable risk factor for heart attack, stroke, and kidney disease, and impacts approximately 1.3 billion adults globally. It is frequently undiagnosed because it often has no symptoms, many people do not see a doctor regularly, and even during a clinical visit, it can be easily missed with a single measurement. Hypertension notifications on Apple Watch use data from the optical heart sensor to analyze how a user’s blood vessels respond to the beats of the heart. The algorithm works passively in the background reviewing data over 30-day periods, and will notify users if it detects consistent signs of hypertension. These notifications provide users with valuable insights into their health as it relates to this widespread condition simply by wearing their Apple Watch, so they can begin making potentially lifesaving behavioral changes, or start treatment to reduce their risk of serious, long-term health events. Replay video: Apple Watch Series 11 Hypertension Notifications Hypertension notifications use data from the optical heart sensor on Apple Watch to analyze how a user’s blood vessels respond to the beats of the heart. Like all of Apple’s health features, hypertension notifications are grounded in rigorous scientific validation. The feature was developed with advanced machine learning and training data from multiple studies totaling over 100,000 participants. Its performance was then validated in a clinical study of over 2,000 participants. While hypertension notifications will not detect all instances of hypertension, with the reach of Apple Watch, the feature is expected to notify over 1 million people with undiagnosed hypertension within the first year.

Hypertension notifications use data from the optical heart sensor on Apple Watch to analyze how a user’s blood vessels respond to the beats of the heart. Like all of Apple’s health features, hypertension notifications are grounded in rigorous scientific validation. The feature was developed with advanced machine learning and training data from multiple studies totaling over 100,000 participants. Its performance was then validated in a clinical study of over 2,000 participants. While hypertension notifications will not detect all instances of hypertension, with the reach of Apple Watch, the feature is expected to notify over 1 million people with undiagnosed hypertension within the first year. “Hypertension is the leading preventable cause of heart attack and stroke, yet millions remain undiagnosed,” said Harlan Krumholz, MD, SM, cardiologist and scientist at Yale University and Yale New Haven Hospital. “Making accurate detection easy and part of daily life can help people get care earlier and prevent avoidable harm.” A user’s iPhone and Apple Watch Series 11 show “Possible Hypertension” and offer more details. Hypertension notifications were developed with advanced machine learning and training data from multiple studies totaling over 100,000 participants. If users receive a hypertension notification, it is recommended that they log their blood pressure for seven days using a third-party blood pressure cuff and share the results with their provider at their next visit, which is consistent with the latest American Heart Association guidelines for the diagnosis and management of hypertension. Clearance for hypertension notifications from the FDA and other regulators is expected soon, and the feature will be available in more than 150 countries and regions — including the U.S. and the EU — this month. Hypertension notifications will be available on Apple Watch Series 9 and later, and Apple Watch Ultra 2 and later, with watchOS 26.

Hypertension Notifications Hypertension notifications use data from the optical heart sensor on Apple Watch to analyze how a user’s blood vessels respond to the beats of the heart. Like all of Apple’s health features, hypertension notifications are grounded in rigorous scientific validation. The feature was developed with advanced machine learning and training data from multiple studies totaling over 100,000 participants. Its performance was then validated in a clinical study of over 2,000 participants. While hypertension notifications will not detect all instances of hypertension, with the reach of Apple Watch, the feature is expected to notify over 1 million people with undiagnosed hypertension within the first year. “Hypertension is the leading preventable cause of heart attack and stroke, yet millions remain undiagnosed,” said Harlan Krumholz, MD, SM, cardiologist and scientist at Yale University and Yale New Haven Hospital. “Making accurate detection easy and part of daily life can help people get care earlier and prevent avoidable harm.” A user’s iPhone and Apple Watch Series 11 show “Possible Hypertension” and offer more details. Hypertension notifications were developed with advanced machine learning and training data from multiple studies totaling over 100,000 participants. If users receive a hypertension notification, it is recommended that they log their blood pressure for seven days using a third-party blood pressure cuff and share the results with their provider at their next visit, which is consistent with the latest American Heart Association guidelines for the diagnosis and management of hypertension. Clearance for hypertension notifications from the FDA and other regulators is expected soon, and the feature will be available in more than 150 countries and regions — including the U.S. and the EU — this month. Hypertension notifications will be available on Apple Watch Series 9 and later, and Apple Watch Ultra 2 and later, with watchOS 26.

The new ⌚️ will have hypertensive notifications

This doesn’t seem like a cuffless BP - but more like a notification ‘you may have hypertension, go check your BP’ ?

From www.apple.com/newsroom/202...

@jordybc.bsky.social @drwanpen.bsky.social @spjuraschek.bsky.social @daichishimbo.bsky.social?

Join us for the #nephjc chat on this topic sooon!
cc: Dr. @jbrianbyrd.bsky.social

bsky.app/profile/neph...

Primary Aldosteronism: An Endocrine Society Clinical Practice Guideline AbstractBackground. Primary aldosteronism (PA), a primary adrenal disorder leading to excessive aldosterone production by one or both adrenal glands, is a

New PA Endo guideline is also out by experts @anandvaidya17.bsky.social #Cardiosky @hswapnil.medsky.social doi.org/10.1210/clin...

Efficacy and Side-Effect Profile of Baxdrostat in Patients with Primary Aldosteronism.

A medical adrenalectomy?

ASIs advance - Baxdrostat in primary aldosteronism now www.nejm.org/doi/full/10.... n = 15 single arm trial from @adinaturcu.bsky.social and @astra-zeneca.bsky.social in @nejm.org

~ 25/10 mm Hg BP lowering and impressive aldosterone level drop

#Hypertension #EndoSky

Canadian finerenone is so cheap! In US, insurance does not approve unless you have both CKD and DM. at least that's why they told us why our request fails prior authorizations

Amiloride instead of finerenone unless per FDA label indication would be my general thinking

Dose equivalence of eplerenone seems roughly correct to me

Spironolactone vs Amiloride for Resistant Hypertension This randomized trial assesses whether amiloride is noninferior to spironolactone in reducing home-measured systolic blood pressure among patients with resistant hypertension.

Amiloride getting another look

jamanetwork.com/journals/jam...

However also includes
- hydralazine (🤦🏽‍♂️)
Excludes
- guanfacine (sorry @jbrianbyrd.bsky.social )

Related commentary from @jbrianbyrd.bsky.social and colleagues

academic.oup.com/ajh/article/...

Is Hypertension too important to be left for physicians?

New Support for Old Medications in Resistant Hypertension The term resistant hypertension has been variably applied to patients with high blood pressure (BP) since at least the 1960s.1 Specific definitions have evolved over time to align with advances in tre...

& with this interesting editorial by Dr. Brook (cc: Dr. @jbrianbyrd.bsky.social) & Dr. @jordybc.bsky.social et al too: jamanetwork.com/journals/jam...

@drjmluther.bsky.social actually did speak about it briefly!

I would like to use it in some select patients - also guanfacine!

@jbrianbyrd.bsky.social

old drugs in HT

Plenary at @hypertensioncanada.bsky.social with @drjmluther.bsky.social on new drugs

He starts of with the really old drugs!

#CHC25

Global journey of clonazepam: A) Clonazepam transportation routes and distances. B) API and excipient salt extraction and production. C) Journey through North America.

Global journey of clonazepam: A) Clonazepam transportation routes and distances. B) API and excipient salt extraction and production. C) Journey through North America.

Global journey of clonazepam: A) Clonazepam transportation routes and distances. B) API and excipient salt extraction and production. C) Journey through North America.

Delightful read of the day (with terrible implications)

The journey of clonazepam from API in Guangzhou to the tablet being consumed is 63,162 kms

www.cfp.ca/content/71/4...

From McMaster (school of engineering and family medicine)

h/t Chris Hannah of @theglobeandmail.com

The Na-K Exchange Saves Lives — NephJC This week, we will discuss the SSASS trial. in which a simple switch of table salt with a K-enriched salt works miracles. Is it about the sodium or the potassium?

K issues
#NephJC www.nephjc.com/news/salt-su...
Podcast www.nephjc.com/freelyfilter...

K switch mechanism
pubmed.ncbi.nlm.nih.gov/38081406/ in @ajkd.bsky.social

pubmed.ncbi.nlm.nih.gov/37772757/ from @amjhypertension.bsky.social

journals.physiology.org/doi/full/10....

#WorldHypertensionDay

Spironolactone vs Amiloride for Resistant Hypertension This randomized trial assesses whether amiloride is noninferior to spironolactone in reducing home-measured systolic blood pressure among patients with resistant hypertension.

the amiloride - spironolactone RCT
jamanetwork.com/journals/jam...

PATHWAY-2 trial www.thelancet.com/article/S014...

Lorundrostat RCT www.nejm.org/doi/full/10.... (coming on #NephJC soon)

#WorldHypertensionDay

💬 Today we discuss lorundrostat in the Advanced-HTM @nejm.org article
No excuse to not read it #NephJC #NephSky #MedSky
www.nejm.org/doi/10....

Note that aldosterone escape refers to escape from the effects of aldosterone under some conditions

And aldosterone breakthrough is the term for continued aldosterone production despite renin-angiotensin blockade

Advance-HTN: Return of the systolic order – Lorundrostat’s role in restoring balance — NephJC This week, we will discuss a NEJM trial on uncontrolled hypertension: lorundrostat, an aldosterone synthase inhibitor, aims at the hormonal dark side driving resistance.

Is (hypertensive) resistance really futile?
#NephSky Join us today 5/27/25 9pm EST only on #Bluesky to discuss Lorundrostat, a new Aldosterone Synthase Inhibitor. #NephJC
Learn about it you must! Don't give in to the dark side of uncontrolled HTN.
www.nephjc.com/news/advance-htn-lorundrostat