A new scan to detect and cure the commonest cause of high blood pressure | Hacker News Reader

A new scan to detect and cure the commonest cause of high blood pressure

qmul.ac.uk

173 pointsgmays88 comments

This is not a CT but a PET scan, it records passive radiation from a molecule injected into the body, and therefore a 10 min long scan. Then it is based on radioactive carbon (C-11), which is pretty uncommon and needs quick use after production, so not every PET(CT) can do that, it needs be in the vicinity of a production facility (i.e. close to a university/research hospital). This is the sense of the last sentence: it needs a replacement the carbon with another radioactive isotope (fluor for instance) to be doable at every PET/CT place. I don't blame the title here, because the article itself is very strangely written, it says as well "CT scan" but this is no "CT scan", this is a PET scan.

Right, but it's a weird terminology subject, because CT is just short for "Computerized Tomography", with the initial implied "X-ray" part being a convention -- but all of these 3D scan techniques are variant kinds of Tomography, with X-ray CT/CAT scans being the original kind.

Your comments about C-11 are well-taken and an important caveat.

That's interesting, thanks for sharing. I was aware of the more common "radioactive glucose" PET scan that helps pinpoint cancer...where fast reproducing cells consume glucose. Didn't know there were adjacent types of PET scans.

Journal article: Wu et al., "11C-metomidate PET CT versus Adrenal Vein Sampling for diagnosing surgically curable primary aldosteronism: prospective test validation, and impact of somatic genotype and ethnicity on outcomes"

https://assets.researchsquare.com/files/rs-1179128/v1_covere...

Metomidate is a molecule (C_13 H_14 N_2 O_2) that naturally collects in the adrenal glands, and 11C-metomidate is a version where some of the carbon atoms are carbon-11, a radioactive version that will show up on PET-CT scans.

https://en.wikipedia.org/wiki/Metomidate

For reference, a PET-CT scan costs $1k-$10k in the US. Not sure how much the radioactive tracer adds.

That tracer has to be made on site, since 11C has a halflife of 20 minutes. So there has to be a particle accelerator to make the 11C and a chemistry lab to quickly get the 11C into the drug.

Fun video of one such site: https://www.youtube.com/watch?v=eMTZvA8iFgI

I had my left adrenal gland taken out in September.

TL;DR - If you know someone that takes a lot of blood pressure medications and has for many years, have them see an endocrinologist and get them screened for hyperaldosteronism ( aka Conn's syndrome ).

Kind of a crazy story.

I've had blood pressure (BP) issues since my senior year of high school. 1996. Started taking my first medication then.

Since then, I've had one hospital stay, 3 ER visits, yearly checkups, all because my blood pressure is really hard to control.

I've seen 3 cardiologists and two nephrologists over these past 25 years to help me manage my BP.

I figured the high BP was because I was fat.

I think my highest bp reading ever was 210/130. I’d commonly see 170/110. Not good.

These past couple of years, my blood pressure had gotten and stayed really, really high. To the point where I was waking up with headaches. I even had a few headaches where I thought I was going to have a stroke.

Fast forward to my most recent blood pressure related ER visit ( in March ) - the cardiologist raises the dose on yet another medication. I'm like "WTF is going here? This is craziness. I can’t keep taking all of these medications.”

Really frustrated, I do my own research. I stumble upon a couple of studies citing Pheochromocytomas, a tumor on the adrenal that secretes excessive hormones which causes an elevation in blood pressure.

Then I read a Washington Post article talking about a guy on “a bucketload of blood pressure medications” that actually ends up having a tumor on his adrenal gland.

The general condition is called Hyperaldosteronism. This is the condition discussed in the parent article.

It's pretty rare - like 1/1000. You basically have an adrenal glad that secretes too much Aldosterone which drives the bodily retention of salt and water. Which in turn, chronically elevates blood pressure while abnormally dumping potassium.

At my next cardiologist appt, the Dr. basically tells me "I have nothing else for you". He wanted to increase my four blood pressure medications, again. He thought I should go back to see the nephrologist.

Given my research, I asked him for a referral to the endocrinologist. For which he annoyingly shrugs, "sure, why not. But they're usually booked way out." I get a call from the endocrinologist the following Monday. I get in right away. I mention Hyperaldosteronism. Tell them my long history with resistant hypertension. They totally agree. They setup an appointment for a blood screening.

Sure enough, the tests come back with really elevated levels of aldosterone, really low levels of renin, and really low potassium levels. All signatures of hyperaldosteronism.

They then do an AVS, a vascular sampling of the blood coming out of each adrenal. It showed overwhelmingly my left adrenal produces high volumes of aldosterone with low levels of renin. The left adrenal’s Aldosterone/renin ratio demonstrated that it was the dominant one.

Which is actually good, because then I could have my left adrenal taken out, and still live very normally with the right adrenal taking over.

So that’s how my surgery came about. My overactive adrenal has probably been a huge contributor of my elevated blood pressure, for many, many years.

The pathology report came back and they did find a nodule in my left adrenal gland, that was not visible from the initial CT scan.

https://www.washingtonpost.com/health/2022/04/23/high-blood-...

P.S. The Facebook group for Conn's Syndrome is a wealth of a knowledge and has a few really amazing members that can guide you on how to navigate getting tested (a lot of doctor's aren't necessarily aware of the condition). https://www.facebook.com/groups/652067311558303

Glad you got it figured out and solved! I hate it when doctors refuse to listen to you.

It's strange how much difference a year can make.

I went from taking four BP medications, feeling like I would have a stroke in the next year and would probably die.

To now - I'm on a single BP medication (lisinipril), I've lost 40 pounds (Mounjaro), and am optimistic about my long term health.

And what happened? Did your blood pressure return to normal? Did the years of medication have any permanent side effects?

I still take one BP medication - 40mg of Lisinopril. My blood pressure numbers are much more "normal" - usually around 135/85.

I seem to be caffeine sensitive in general. On days where I drink caffeine, my BP is ~15 points higher on the systolic side. It lasts the entire day. I may be a slow metabolizer.

I've had a ton of anxiety over the years that seems to have vanished with the adrenalectomy. I was always on edge - like I could jump out of my skin. And after the operation, that has vanished.

When I had the hyperaldosteronism, I started to experience these "thunderclap headaches" - where I would suddenly get a super-intense headache on the verge of a stroke. They were awful.

Those have gone away as well.

With the anxiety did you also have palpitations or arrhythmia? I'm having a similar problem.

Yes, lots of palpitations. To the point where I wore a monitor for a few days so that my cardiologist could evaluate.

With hyperaldosteronism, because your body retains elevated levels of sodium, it dumps potassium. The low potassiums is probably the main cause of the palpitations.

Low potassium is a marker for hyperaldosteronism.

That's interesting. I have figured that out on my own and self medicate by eating a lot of bananas which has helped a ton. I also found taking magnesium also helped. I should really check for hyperaldosteronism which I have always suspected but like you was always steered towards bp medication and got eye rolls if I tried to engage in a educated conversation about the topic.

My ex also had a cyst on her kidney, influencing hormones and anxiety.

Kudos on your quest. Let's hope medical field improves diagnosing.

Have they put you on any low dose anxiolytics like valium?

Is the caffeine effect reproducible with tea or just coffee/energy drinks?

Thanks for this, I should probably get these screens as well after reading this. My BP can shoot to the moon very easily and always seemed related to my adrenalin.

Just a PSA (and no pun intended): in most places in the US these days, blood screening can be done without a doctor’s order and often more cheaply than what insurance will pay. Particularly if you pay direct, skip the doctor referral and order (and own) your own blood work. NOTE: this assumes you are not a nincompoop and enough of a research hound to understand what you’re ordering, how to understand the results in context, and ultimately return to a specialist for expert opinion. GP’s aren’t the gatekeepers they once were for blood tests.

I find it absolutely incredible that at any time in the U.S, under its laws, requesting something as fundamental as blood tests about YOUR OWN body from a private lab needed doctor permission. How would such rules even be justified? A person wanting to have their blood tested is not the same as someone trying to self-dose with possibly deadly medications.

I think it was mostly a function of two things: regulatory capture by profit-incentivized doctors, and the labs not having (or wanting to have) consumer-oriented sales processes.

The internet has made the latter easier in a number of ways - making research easier for consumers to know what to order and interpret results, and offering COTS systems for commerce, document management, authentication, shopping carts, and inventory tracking.

I would bet that in most states, laws were less of an issue than the labs not wanting street-facing sales - same way some hardware companies only sell to distributors (i.e. street sales (and consumer support) are a pain in the ass vs curated partners).

Despite all of these reasons, it still strikes me as incredible, and that labs wouldn't try to create a customer-oriented sales process. Where I live, in my country, anyone at all can go and get any number of lab tests for any reason they please at very competitive prices that are widely advertised. Doctors also often prescribe tests, but you go get them yourself from a commercial provider and don't need to prove any doctor prescription for them. Overall, it's great simply because the pricing is low through competition and getting a professional lab test done is very quick and easy.

Wow, super happy for you. Just to add to this I will say that I was mis-diagnosed with an adrenal lesion which turned out to be incidentaloma. I had an adrenal gland removed however the treatment was non curative.

At the time I asked why they weren't suggesting adrenal venous sampling and was looked at like I was an idiot by the resident doctor. Turns out she was the idiot. A specialist later told me they were probably too unskilled to do the adrenal sampling.

Also the cyp11 b1/b2 PCR test has existed for ages and is in the literature. Years later I had some DNA testing and discovered I have an even rarer version of PA called Familial Type 1 caused by a non stop mutation on CYP11b1/b2, hence why the adrenalectomy did nothing.

While its rarer, the test is only a few hundred dollars. To others... a pro tip: get a pre-genetic screening test even if you aren't having kids, the cost is cheap and the result might be life changing to you TODAY.

I feel an order of magnitude better since silencing the over production of that hormone and my doctor tells me that anecdotally practitioners report patients coming out of curative surgery for nodules or on dexamethasone for type 1 often report feeling like a cloud is lifted from their mind.... I can confirm this is true.

Sadly you really do need to, push, research and be your own advocate to get the best outcomes.

What an amazing story - thank you for sharing.

Is there any specific type/brand of DNA testing you utilized?

Nature article: https://www.nature.com/articles/s41591-022-02114-5

I really hope that stuff like “the commonest” doesn’t become one of the most common mistakes in HN headlines…

I'm confused, do you have issue with the word "commonest"?

The American Heritage dictionary gives the positive, comparative, and superlative forms as common, commoner, and commonest.

What's the mistake?

I can only bring German school-level English to the table, but my instincts told me that someone played loose with what should be “the most common”.

Your instincts are incorrect, "commonest" is a valid word and it's being used correctly in the title of this article.

I hope this mistake of correcting things that aren't mistakes doesn't become one of the most common mistakes in HN comments...

I don’t understand your need to be rude after learning that someone is not a native speaker.

If you aren't a native speaker why did you try to correct the writer of the article?

You're allowed to be rude but I am not? I don't want this to be a flame war, I want you to actually reflect on why you think you're allowed to be rude but I am not.

I wasn’t rude, I was wrong, and any blame for this is totally accepted.

I wasn’t rude, because I wasn’t adressing anyone in particular — I wasn’t writing on qmul.ac.uk or in an email to the author.

You were communicating directly with me, and I found it unnecessarily rude.

Edit: oh and btw you are totally and absolutely “allowed” to be rude, it’s not something I find off-limits or the likes. Just know that I find it… well, rude.

Honestly, my apologies. I’m quitting nicotine after ten years of (ab)using it.

I should probably stay off the internet for a while.

Again, my apologies.

That’s great news actually and I wish you all the best to get off of it permanently!

Honestly, if venting off on the Internets helps you to go through with it — well I’m always here when you need me ;-)

“Commonest mistakes” - ftfy

I concur with GP. IME, “most common” or “most fun” is generally looked upon as better form than “commonest”, or “funnest”. The latter catches the eye and not in a good way, having as it does the ring of childishness to it. Legal, sure. Proper? Nope.

Even if commonest is a valid word I agree that 'the most common' would read better. English is my first language.

It's a verbatim copy of the original article, published by the Queen Mary University of London.

Reminds me of the scene in StarTrek #4 where McCoy sez something like 'Fundascopic examination is unrevealing in these cases.'

A scan that cures is therefore 'the future'.

I wonder if US healthcare with its profusion of CT scanners can drive down long term patient treatment costs faster with their greater installed base.

I don't know about that. I currently need an MRI and the earliest appointment I could get was 4 weeks out, and that's not at the closest facility (they are nearly two months out). Maybe CT scans are faster.

Radiologist.

Depending on the protocol, CT scans usually take anywhere from 5 seconds to 10 minutes (in the longer scans most of that is waiting after contrast injection).

MRI studies take a long time to acquire data, usually at least 20 minutes for very short/limited studies. More involved protocols can take hours. Patient throughput is slower.

Can someone who knows more about the field to comment on whether this is as revolutionary as it sounds?

- this only concerns 5 - 10% of all hypertension patients

- ~50% of adult Americans have hypertension

- scanning all medication-non-responders (= people suffering from "resistant hypertension") and operating on all of them to remove the causative nodules sounds like quite the tall order

- doctors won't just suddenly start sending all the resistant hypertension patients to CTs to diagnose this cause, instead they will continue to escalate their patients anti-hypertensive medication, i.e. adding an aldosterone antagonist to the three other maximum dosage blood pressure lowering medications the patient already takes.

- this might become an option for people suffering from resistant hypertension that are receiving expensive, excellent state of the art treatment

isn't a single CT scan and surgery cheaper than 40 years of medication?

That small question is so complex, it could probably be elucidated in a complete high quality bachelor thesis.

Many of those patients will continue to have high blood pressure for other reasons (obesity, fat intake, renal impairment, god knows what else) and will need to continue their medication, maybe they will downgrade (upgrade? (-; ) from treatment resistant hypertension to normal hypertension. A significant amount of the patients receiving surgery will suffer from mild to severe bacterial infections that also need treatment.

At the top of my head I would still say yes, it would be cheaper.

ALSO and BUT: Please do not expect a treatment that is both cheaper and better for the quality of life of the patient to be chosen by default. Hospitals and doctors don't work that way.

Probably not. The sticker price of my blood pressure medicine comes out to like $60/yr. The scan alone would probably cost more than 40 years of medication (and the #s are potentially much worse if you consider time value of money and all that)

Cost to you, or combined cost for you / insurer ? Honest question.

Most blood pressure medication is dirt cheap, effective pills have been generic for decades now -- you can get a 3-month supply of the largest dose of lisinopril for under $10 cash (no insurance).

https://costplusdrugs.com/medications/lisinopril-2_5mg-table...

It depends on the type. ARB's are fairly cheap. Alpha 2 receptor agonists are a bit more. When I was on those I paid cash and almost always received a coupon on the spot for some reason but my total price out of pocket was $28 for the agonist and about $12 for the ARB. Some people are on more then 2 types. Happy to be off those things.

If I went to Costco and paid cash without invoking my insurance it would be $16 for a 90 day supply (so actually closer to $65/year, oops).

When I go through my insurance with their preferred pharmacy, I don't pay anything. But according to CVS my insurance company pays $1.87 for 90 pills, so about $7/year

It really depends on the surgery. Heart surgery isn't exactly minor and doctors do tend to prefer non-invasive treatment.

I like to minimize on my needed medications though. I would probably opt for this if it were available.

Isn't the described remedial procedure to take a radioactive substance that will burn out the nodules ?) That's not that expensive or invasive.

I understand something similar is done for Morbus Basedow / Grave's disease with the thyroid gland.

The linked article references "surgically curable primary aldosteronism".

You are probably referencing "radioiodine therapy" which is highly specific to thyroid issues.

My bad, I was misreading. They use the radioactive stuff just like a contrast fluid.

The article/headline is confusing; the real comparison is between a non-invasive PET-CT scan using metomidate as an imaging medium, and invasive and specialized adrenal vein sampling (AVS), both as diagnostic tools.

AVS is correlated using a non-metomidate adrenal CT scan anyway, so a CT-only option would be less expensive and could be performed in more facilities, making it more accessible:

> Until now, 99% are never diagnosed because of the difficulty and unavailability of tests.

And since AVS has such a low predictive success rate (63% per the study), the CT-scan-only alternative doesn't even have to be good, it just has to be about as bad as AVS.

The results of either could very well be "keep taking meds for 40 years" or "surgery helps immensely", but the real cost savings are in avoiding AVS and also potentially diagnosing and treating more people sooner.

(Also mind that the study's done in the UK, where CT scans cost patients about £800/US$1,000 even when done privately, and in Scotland/Wales/N. Ireland the meds are free to the patient. In the US, a CT scan averages about $5,000, $12,000 isn't unheard of, and the meds cost $7,000-$20,000 for 40 years.)

That sounds terrible. Are you advocating for that or just saying that is just what will happen.

Saying it will happen. Ideally everyone with treatment resistant blood pressure should now get the CT scan. But this would require a great deal of awareness, training and trust for the blood pressure treating MD/GP, the radiologist and the potential surgeon. Then there is the insurance aspect: Does the insurance in question even allow for this kind of CT scan & urine test for high blood pressure?

Integrating new techniques like this into commonly available treatment is HARD.

Radiologist.

It’s cool, it’s a nice study. The article definitely over hypes the “common cause of hypertension”. These lesions are rare. Most people with high blood pressure have it because of metabolic disease/chronic stress/lifestyle, and it can be managed with changes to diet exercise and meds.

It is true that doing adrenal vein sampling is hard and not always successful. Having a protocol that can non-invasively detect these lesions may save some people a procedure.

Thanks for this. Metabolic/stress/lifestyle problems were exactly my story. I had hypertension, anxiety, and was prediabetic. Using low carb and intermittent fasting, I lost 91 pounds, was no longer prediabetic, and went completely off bp meds. Anxiety is managed much better (no meds). My doc was amazed.

> Most people with high blood pressure have it because of metabolic disease/chronic stress/lifestyle, and it can be managed with changes to diet exercise and meds.

Do we know this though? If, as the article claims, the lesions were previously hard to detect, I would guess that most people with them never get diagnosed. I have high blood pressure and I've never been examined for those lesions.

Yeah there are other ways to tell if someone has aldosterone driven hypertension through blood work and urine tests. These other tests are to determine if surgery could fix the problem (tumor or unilateral vs bilateral abnormal aldosterone production).

Edited for clarity

I hope they make a lot of money. That’s a pretty fantastic system.

The work was funded by the NIHR (i.e. the UK taxpayer); the primary purpose is patient benefit to users of the NHS, not profit. If they're making a disproportionate "lot of money", there should be a signed revenue-sharing agreement in place given the benefit of the public funds provided.

I figure—but what, the doctors that developed this just take home NHS salary? It is going to save the NHS billions.

HBP costs over 100 billion $ in the US. https://www.cdc.gov/policy/polaris/healthtopics/highbloodpre....

1 in 20 is "most"? What about the other 19 in 20?

I was under the impression that the most common cause was being fat.

"Most common cause", singular.

Was looking for this comment, thank you.

The vast majority of arterial hypertension is “essential hypertension,” meaning no identifiable cause. I assume this is (misleadingly) saying that of the secondary (non-essential) hypertension cases, the condition that this scan detects is the most common.

Interesting. I thought "idiopathic" was the only medical term for "I don't know why."

From TFA:

" The scan found that in two thirds of patients with elevated aldosterone secretion, this is coming from a benign nodule in just one of the adrenal glands, which can then be safely removed."

So it seems that 2/3 of the cause of HBP is elevated aldosterone, but 1/20 of cases this can be fixed with a not-so-invasive procedure.

This headline goes beyond clickbait and into the realm of pure fantasy. Maybe the author asked ChatGPT to write it.

Looks like the cure is surgery, and with the sorry state of the US healthcare, that's hardly a solution.

I completely agree. Running the numbers in my head that would be up to 10 million patients this surgery would be relevant for in the US.

Tangent: "Commonest" is listed in the dictionary as an acceptable alternative to "most common", but I can't recall ever hearing it before. According to Ngram the latter is 20 times more common (or commoner, heh) but I would still have expected to remembering hearing it. Is this a UK vs. US thing?

It seems you have identified the second commonest cause of high blood pressure.

Yes, somewhat. https://bridgingtheunbridgeable.com/2016/04/14/commonest-com...

Hilariously, I think the HN anti-clickbait filter made this title more clickbaity: The original title was "Ten-minute scan enables detection and cure of the commonest cause of high blood pressure", which HN helpfully removed the number from... leading to "Minute scan detects and cures of most common cause of high blood pressure". And a one minute scan would be even more impressive, but that's not what it is...

They should still have some time to edit the description. If that time is exceeded they could email dang and ask to edit. The filter only happens on submission but not on edit.

I interpreted it as a minute scan (i.e. very small, of small importance). But it's a CT-scan which very much is not a minute scan.

I was picturing someone with an electron microscope, scanning the most minute of things...

But the rest of the shortened title is straight-up hashbrowns. You are fixing a common problem with a scan? That's not how medicine works.

Yes, that happens sometimes.

I've changed it to clearer language from the first paragraph.

The current title is also wrong: it's not a CT scan, but rather a PET/CT scan (with the emphasis on the PET, which requires injection with a radiotracer).

Ok, maybe it's safest to just drop the CT. Thanks!

For those who may not have access to this treatment, an alternative is to add the following to /etc/hosts:

  127.0.0.1      facebook.com
  127.0.0.1      www.facebook.com
  127.0.0.1      twitter.com
  127.0.0.1      www.twitter.com

Better to use 0.0.0.0 and have it immediately return an error than try to connect to localhost.

Bad joke. Social media can not cause chronic hypertension. It's physiological.

I guess you've never seen the streams of pictures of unhealthy food.

Um, no actually

I don't have fb or twitter accounts either, but I have been exposed to it regardless.

People will post whatever crap they eat. It tends to be very unhealthy food, and too much of it. Which normalizes eating non-food. Which affects health quite negatively.

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