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Transcript of 7. HTA Endocrina Studenti 2014
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Corin Badiu, 2012
Hipertensiunea arteriala endocrinaHipertensiunea arteriala endocrina
Sindromul Cushing Sindromul Cushing Hiperaldosteronismul primar Hiperaldosteronismul primar
Feocromocitomul Feocromocitomul
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Blood Pressure Classification (JNC8)
BP Classification SBP mmHg DBP mmHg
James PA et al, !"# e$idence%&ased guideline for the management of high &lood
pressure in adults' report from the panel mem&ers appointed to the ighth Joint
National Committee (JNC 8) JA*A !"#+""(-)'-!.
Normal <120 and <80
Prehypertension 120–139 or 80
–89
HBP Stage1 140–19 or 90–99
HBP Stage 2 1!0"1#9 or 100"109
HBP Stage 3 $180 or $110
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FREQUENCY OF VARIOUS DIAGNOSES IN
HYPERTENSIVE PATIENTS
PRIMARY CARE REFERRAL
Essential 92-9! "9!
C#$%ni& 'i(ne) (isease *-+! ,!
Ren%as&.la$ (isease /02-10/! ,!
P#e%&#$%%&)t%a /01-/02! /02!
Al(%ste$%nis /01-/0*! /0!
C.s#in34s s)n($%e /01-/02! /02!
C%a$&tati%n /01-/02! 1!
O$al &%nt$a&e5ties /02-10/! 1!
H6P in &#il($en 7 a(%les&ents8 -!%8-/ is secondar0
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Protocol
%on&irmarea hipertensiunii
'denti&ica etiologia
(&ectarea peri&erica
'denti&ica riscul cardio)ascular
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*asurare
Metoda Descriere
'n ca+inet ,oua determinari- la minute inter)al- in“se.and”/ %on&irma )alorile crescute prin citiri la+ratul contralateral/
*onitori.aream+ulatorie
'ndicata pt e)aluarea H( de “halat"al+”/ (+senta scaderii cu 10–20 a ( in somn indicarisc % crescut/
(uto"determinare urni.ea.a in&ormatii asupra raspunsului laterapie/ Poate auta sa im+unatateascacomplianta la terapie/
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actori de 5isc pt Hipertensiune Secundara
6 5aspuns sla+ la terapie 7H( re.istenta la $ 3 medic din clase ≠
6 Pierderea controlului la pacienti sta+ili pe medicatie anti H(
6Hipertensiune stadiul 3 7SBP$180 sau ,BP$110
6 ,e+ut inainte de 20 ani sau peste 0 ani
6 (&ectare semni&icati)a a organelor tinta 7cord- ochi- rinichi
6 ipsa istoricului &amilial de hipertensiune
6 :lemente de H( secundara in anamne.a- e; clinic sau paraclinic
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Mineralocorticoid excess
Cushing’s syn.
Pheochromocytoma
Hipertensiunea endocrina secundaraHipertensiunea endocrina secundara
suprarenalasuprarenala
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Suprarenale
lucocorticoi.i 7%orti.ol
%orte; *ineralocorticoi.i 7(ldosteron
(ndrogeni (drenocortical
*edulla %atecolamine
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Histologie
Capsula=ona glomerulosa
=ona f asciculata
=ona r eticularis
*edulosuprarenala
ena central>
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HistologieHistologie
CGA
17 HOlaza
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Steroidogeneza specifică
lucocorticoi.i 7C21
*edulosuprarenala
*ineralocorticoi.i 7C21
(ndrogeni 7C19
ena central>
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Substratul steroidogenezei
18
19
2 CH 2!
CH"
H#
$ B
C D
CH" CH"
CH"
CH"
CH2
CH2 CH2
CH
2%
2& 2'2221
2"
12
'
%
89
1
12
1"
1&1!
1'
1%11
!"&
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Steroidogeneza
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Steroidogeneza
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%holesterol
P40%S%%
PregnenoloneP40%1#
1#?"hydro;y"pregnenolone
P40%1#,ehydroepiandrosterone
7DH($
3@HS, 3@HS,
ProgesteroneP40%1#
1#?"hydro;y"progesterone
P40%21 P40%21
,eo;ycorticosterone7D#C
11",eo;ycortisol
P40%11B1 P40%11B1
%orticosterone Cortisol
P40%11B2
$ldosterone
)*
)+
),
)*
)+
),
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Reglarea Axei CSR Reglarea Axei CSR
• CRH / VP
• ACTH
• Cortisol
• Leptina
• Citokine
• GR, CRHR, V1b, ACTH R,
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,itmul Circadian
-imp
Plasma
. cortisol /
0nmol3
Stres
00A00 12A00 00A0018A000!A00100
!00
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%ortisol%ortisol
H
HH
H
H
H
ortisol
!0" # CBG$ ∆4−%&eto
'" # albu(ina
'" #liber
T1/2 )0#120 (in
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Sindromul %ushing
*indro( lini si bio+i(i deter(inat de eesul seretiei autono(e
endo-ene de orti.ol (ineraloortioi.i si andro-eni din C*R
6 $C-H dependent 824 AC1H Hipofi2ar 33/
AC1H ctopic "/ AC1H cu sursa necunoscuta #/
6 $C-H independent 184 Adenom adrenal "!/ Carcinom adrenal ./
6 Hiperpla2ie macronodulara "/
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%ushing
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'storic C ta+lou clinic
• Crestere ponderala
• Te-u(entar$ piele subtire, anee, ,+irsutis(, e+i(o.e, er-eturi,+iperpi-(entare ACTH dependent
•3be.itate entrala, 4aies 5in luna plina6,adipo.itate intersapulo#ertebral si(obili.area tesutului adipos de pe (e(bre
• 7n4etii reurente
• A(enoree seundara, in4ertilitate
• *aderea 4ortei (usulare, ura -reusarile
• 8epresie, labilitate psi+o#a4etia
• HTA, 89, osteoporo.a$ seundare
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%ushing
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%ushing
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*reenin- in Cus+in-
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este screening pentru sindrom %ushingA6 %orti.ol urinar li+er 6 )ernight 7N 1"mg de;amethasone suppression test/
Confirmarea dg de sindrom Cus5ing6 5itm corti.ol6 ,D* 2;2 70/mg la ! ore- 2 .ile
(Normal 4-!nmol5l dupa #8 h)
Staili$ea :%$ei eti%5at%3eni&e6 6D* 2;8 72 mg la ! ore- 2 .ile
(Normal 4-!nmol5l dupa #8 h)6 6o2are AC1H6 Cateteri2are de sinus pietros
este dinamice in %ushing
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este dinamice in %ushing
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8ia-nosti in Cus+in- *:ndro(e
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Diagnostic Diferential
6 (%H " nedetecta+il in tumori adrenale
6 " &oarte mare in %ushing paraneopla.ic
6 HypoEaliemie 7Falcalo.a C posi+il ectopic sau GG adrenal
6 ,D* 2;8♦ # adenom hipo&i.ar 7+oala % corti.olul <0 din +a.a
10 ectopice pre.inta supresie semni&icati)a
6 Petrosal sinus sampling 7F" %5H
6 6ici un -(S- nu este 14 precis7
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7n4erior Petrosal *inus *a(plin-
V. femurala ... IPS
CRH 100 ug i.v.
Control - VCI
IPSIPS -!" 0" #" !" 10 min
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magistica
6 % a+dominal
6 *5'
6 Scintigra&ie cu scintandren 7%olesterol '131
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Boala %ushing
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Boala %ushing
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%ushing adrenal
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Nelson
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(natomie patologica
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(natomie patologica
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ratament
♦ ratamentul sd %ushing se adresea.a secretiei de corti.ol/♦ erapia primara pentru tumori adrenale este adrenalectomia/♦ 'n (%H ectopic- controlul hipercortisolismului se o+tine prin
medicatie/♦
'n +oala %ushingA chirurgia hipo&i.ei- adrenalectomie +ilaterala-radioterapie hipo&i.ara♦ Sd %ushing iatrogen " scaderea progresi)a a do.elor ♦ %and chirurgia nu se poate e&ectua- se poate controla
hipercortisolismul cu medicatie
7rmarirea postoperatorie'
ratament di&erit in S5 &ata de +oala %ushing
S5A su+stitutie 3 luni- apoi teste de stimulare
Boala %ushingA ree)aluare periodica la 3 " ! "12 luni
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%himioterapie
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Hiperaldosteronism primar
♦ Hipertensiune arteriala♦ HipoEaliemie
♦ (lcalo.a meta+olica♦ Poliurie
♦ %lasi&icare etiopatogenicaA♦ #0A sindrom %onn 7tumora %S5♦ 30A Hiperaldosteronism primar cu
hiperpla.ie adrenala +ilaterala 7iddle
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Hipertensiunea mineralocorticoida
,enin aldosterone s:stem
5enin su+strate
(ngiotensin ' (inacti$e)
(ngiotensin ''
$ldosterone
'ncreased per&usion pressure
5enal sodium I
Jater retention
asoconstriction hirst
oJ renal
Blood &loJ
G',N:KJutaglomerular
apparatus
,enin
High GF
oJ arterial
pressure
Carotid sinus
oJ sodium
intaEe
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,g de &orma etiopatogenica
6 Neoplasm 7in cca !0 din ca.uriL de o+icei adenom- rar
carcinom
6 Hiperpla.ie +ilaterala 7in 40
6 Sdr/ de e;ces mineralocorticoid includ de&iciente en.imatice
6 Hiperaldosteronism autosomal dominant corectat de
administrarea de glucocorticoi.i
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:)aluare paraclinica
este de rutin>- +iochimie iș hematologie (nali.a de urin>A inclusi) densitatea- al+uminurie-Potasiu seric- calciu- creatininaunctie tiroidiana-
%olesterol- :Gradioscopie torace%atecolamine:cocardiogra&ia
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orme etiopatogenice6
(denom %S5 cu productie de aldosteron 7(P(6 Hiperpla.ie +ilateral> idiopatic> 7'H(
6 Hiperpla.ie suprarenala primara 7unilateral>
6 %arcinom adrenocortical cu productie de (ldosteron
6 Hiperaldosteronism &amilial
6 Hiperaldosteronism remedia+il cu glucocorticoi.i 7H tip '
6 Hipertensiune arterial> prin deo;icorticosteron
6 :;ces aparent de mineralocorticoi.i
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(natomie patologica
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ratament
6 (drenalectomie laparoscopica
6 erapie medicala daca trat chg este contraindicat
6 Spironolactona 70"200mg- corectea.a hipertensiunea
6 5 (d)A e&ecte antiandrogenice care determina ,S si
ginecomastie/
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aparoscopic
6 e&t adrenal mass-
6 e&t laparoscopicadrenalectomy
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:)aluare postoperatorie
6 unctionalA secretie tumorala 7aldosteron renina-
corti.ol- ionograma
6 5e.er)a &unctionala %S5A test la Synacthen6 *or&ologicA 'magistica adrenala
6 %omplicatiiA :cogra&ie cord- &talmologie
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eocromocitom
6 0/01"0/1 din populatia H(6 0/ din cei )eri&icati pt secretie de catecolamine
6 * M
6 ,ecada de )iata 3 "
6 5ara- de in)estigat doar in suspiciune clinicaA6 Semne sau Simptome
6 H( se)era- cri.a H(
6 H( re&ractara 7$ 3 clase de medicamente
6 H( la < 20 sau $ 0 ani
6 e.iune adrenala la imagistica S5 7e;/ incidentalom
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5egula 10O
6 10 e;tra"adrenal 7cca 1
6 10 apar la copii
6 10 &amilial 7apro; 206 10 +ilateral sau multiplu 7$ in &amilial
6 10 recidi)ea.a 7$ cele e;tra"adrenale
6 10 maligne6 10 descoperite intamplator
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%linica
6 %inci PA6 Pressure 7H( 90
6 Pain 7Headache 80
6 Perspiration #1
6 Palpitation !4
6 Pallor 42 Paro;ysms 7the si;th PQ
6 riada clasicaA
6 Pain 7Headache- Perspiration- Palpitations6 acE o& all 3 )irtually e;cluded diagnosis o&
pheochromocytoma in a series o& $ 21-0000 patients
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:&ecte )egetati)e:&ecte )egetati)e
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5eceptori (drenergici
6 (l&a"(drenergici∀ 1; )asoconstrictie)asoconstrictie-- rela;are intestinala- contractie uterina-
dilatare pupilara
∀ 2; ↓ N: presinaptic 7clonidina- agregare plachetara-
)asoconstrictie- ↓ secretiei de insulina
6 Beta"(drenergici
∀
1; ↑ ( contractilitatii- ↑ lipoli.ei- ↑ secretiei de renina∀ 2; )asodilatatie)asodilatatie- +ronchodilatatie- ↑ glicogenoli.a
∀ "; ↑ lipoli.a- ↑ termogene.a in tesut adipos +run
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%ri.a
6 ,urata 10"!0 min
6 rec)entaA .ilnic """"" la cate)a luni
6 Spontan
6 Precipitata6 Proceduri diagnostice- contrast '/(/ 7'// nu determina cri.a
6 *edicatie 7opiode- β"+locante &ara α"+loc/ inductia
aneste.iei- histamina- (%H- glucagon- metoclopramida
6 :&&ort &i.ic- miscari care cresc presiunea intra"a+dominala
6 *ictiune 7paragangliom )e.ical
6 Nasterea
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Hipotensiune
6 Hipotensiune 7ortostaticaparo;istica
6 *ecanismeA6 %ontractia :%
6 Pierderea re≤elor posturale data de stimulare
adrenergica prelungita
6 Secretie tumorala de adrenomedulina7neuropeptid )asodilatator
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6 ,ureri a+dominale- constipatie se)era 7megacolon
6 ,ureri precordiale6 (n;ietate
6 (ngina'* cu artere coronare normaleA
%atecholamin" indusaA ↑ consumul de o;igen miocardic sau)asospasm coronarian
6 'nsu& cardiaca glo+ala6 H( cardiomiopatie hipertro&ica dis&unctie diastolica
6 %ardiomiopatie dilatati)a indusa de catecolamine dis&unctiesistolica
6 (ritmii cardiace I de&ecte de conducere
%linica
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enetica
Sindrom Anomaliegenetica
Anomalie fenotipica
*:N 2(- 2B 10 R11/2
75:
*%- HP5- :-
neuroame mucoase-ganglioneurom
Neuro"ectodermaleN"1
1#R11 7N"1
3p2"2! 7H
Neuro&i+romato.a
(ngioame retiniene- GG
renal- Hemang SNS,H B
S,H %-,
1p3!
1R21- 11R23
P- : malign
7n sfert din feocromocitoame% determinare genetica
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*:N2 screening
S 9adian, C Badiu et al, Acta ndocrinologica (Buc), $ol :::, no ", p " % , !!.
rom genes to clinical picture
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rom genes to clinical picture- 0 y- se)ere HBP- aEotsu+o cardiomyopathy
6 ! mutations 74 S,H%- 2 S,H(
Ma$iana D%$es&.; Si%na Ve$<ea; C%$in 6a(i. Acta ndocrinologica (Buc), $ol ;, no #, p-#, !!<
Preop
Postop
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yrosine ",opa ,opamine
Norepinephrine
:pinephrine
Catecolamine
Normetanephrine
*etaneprine
PN*
,BH
%*
%*
*eta&oliti
Homo)anillic acid
7H(
*(- %*
anillymandelic (cid7*(
*(
*(
H
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yrosine ",opa ,opamine
Norepinephrine
:pinephrine
Catecolamine
Normetanephrine
*etaneprine
PN*
,BH
%*
%*
*eta&oliti
Homo)anillic acid
7H(
*(- %*
anillymandelic (cid7*(
*(
*(
Secretia tumoralaA6 eo mareA $ meta+oliti
7meta+oli.are in tumora inainte de secretie
6 eo micA more catecholamines
6 eo Sporadic A N: $ :6 eo amilialA : $ N:6 ParagangliomA N:6 %hemodectom- glomus ugularA N:6 anglioneuromA N:6 eo malignA ,opamina- H(
6 Neuro+lastomA ,opamina- H(
H
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H( paro;istica
*esserli et al- (m %ardiol 200#L99A132C1329
9epetate cri2e de angor, cu documentarea => a 8 episoade de ?:*A
1S9 stg (feocromocitom), ",- cm
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*or&ologie
6 Small 7mg- circumscri+ed to large 7Eg masses
6 Small polygonal cells arranged in )ascular nests
6 :lectron microscopy " mem+rane +ound granules
7catecholamines
6 *alignancy is +ased on metastasis
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*eta+olism
6 Hypercalcaemia6 (ssociated *:N2 HP
6 PHrP secretion +y pheochromocytoma6 *ild glucose intolerance
6 ipolysis
6 Teight"loss6 Getosis $ , synthesis 7
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amilial
6 *:N 2a6 0 pheochromocytoma 7usually +ilateral- *%- HP
6 *:N 2+6 0 pheochromocytoma 7usually +ilateral- *%- mucosal
neuroma- mar&anoid ha+itus6 on Hippel"andau
6 0 pheochromocytoma 7usually +ilateral- retino+lastoma-cere+ellar haemangioma- nephroma- renalpancreas cysts
6 N1 7on 5ecElinghausenUs6 2 pheochromocytoma 70 i& N"1 and HN6 %a&V"au"lait spots- neuro&i+roma- optic glioma
6 amilial paraganglioma6 amilial pheochromocytoma I islet cell tumor 6 therA u+erous sclerosis- Sturge"Te+er- ata;ia"telangectgasia- %arneyWs
riad 7Pheochromocytoma- astric eiomyoma- Pulmonary chondroma
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*etane&rine plasmatice
6 Nu sunt dependente posturalA pot &i recoltate normal
6Secretate continuu de &eocromocitom
6 Sensi+ilitate 99- speci&icitate 89
6 als po.iti)A acetaminophen
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'nter&erente de do.are
6 *edicatie care creste &als po.iti) ni)elul metane&rinelorurinareA ricyclic antidepressants e)odopa a+etalol :thanol Sotalol (mphetamines Buspirone Ben.odia.epines *ethyldopa %hlorproma.ine
6 *edicatie care scade ni)elul metane&rinelor urinare A *ethyltyrosine- Jhich inhi+its tyrosine hydro;ylase- the rate"
limiting en.yme in catecholamine synthesis *ethylglucamine- Jhich is present in radiocontrast media 5eserpine
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este in urina
6 24hA %reatinina- catecolamine- metane&rine- normetane&rine
6 5e.ultate Po.iti)e 7$ 2"3 oriA6 24h Xcatechols $ 2 ori
6 24h Xtotal metanephrines $ 1/2 ugd 7!/ umold
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este sali)are
(/ */ Ste&anescu et al, (cta :ndocrinologica 7Buc- )ol/ ''- no/ 4- p/ 431"442- 2011
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ocali.are imagistica
6 Xltrasonogra&ia
6 % a+domen6 eocromocitom adrenal " sensi+ilitate 93"100
6 eocromocitom e;tra"adrenal " sensi+ilitate 90
6 *5'6 $ sensi+ilitate % pt &eocromocitom e;tra"adrenal
6 *'B Scan6 sensi+ilitate ##"90- speci&icitate 9"100
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:cogra&ia
6 ( &ost inlocuita de % si *5'L este limitata depregatirea tractului digesti)
6 aloare limitata in di&erentierea le.iunilor chistice decele solide in adrenala
6 *5' este pre&erata ca modalitate de in)estigare/
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:cogra&ia in eocromocitom
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% in eo
e.iuni adrenale $1 cm- e;tra"adrenale $2 cm- sensi+ilitate 9- speci&icitate #0
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%a)ogra&ie % in eo
6M6<1'81"& pgm- *NM231# pgm- 6M62& ore<2898 mcg- *N24 oreM9 mcg
Cromogranina $<'"8 ngm
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'5* in &eocromocitom
T1 weighted T2 weighted
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6 *'B
6 111'ndium"pentreotide6 Some pheochromocytomas ha)e somatostatin
receptors
6 P:6 18"&luorodeo;yglucose 7,
6 !"Y18Z"&luorodopamine
ocali.are imagistica nucleara
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'magistica nucleara
6 131'"*'B si 123'"*'B sunt concentrate in sistemul simpato"medular si pastrate in granule de neurosecretie
6 (pro;imati) 30 din patienti- au un uptaEe mai mic decat cel
hepatic/
6 'n &eocromocitom- 131'"*'B e)identia.a tumora ca o arie inglanda suprarenala cu captare crescuta/
6 123'"*'B permite o calitate mai +una a imaginii- poate &ie)aluat prin single photon emission computed tomography7SP:%- are e;punere mai mica la radiatii si re.ultate in timpmai scurt/
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*'B
:n feocromocitom, "":%*:B> e$identia2a tumora ca oarie in glanda suprarenala cu captare crescuta
*etastatic Pheo
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6 12=212; '131" *'B scanA tracer pathological uptaEe on+oth lungs- Jithout a+dominal or cer)ical uptaEe
6 1%=1=21"; '131" *'B therapy 10 m %i
6 %=212 present; asymptomatic- normotensi)e patient
*etastatic Pheo
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*:N2 screening
S/ 5adian- %/ Badiu et al- (cta :ndocrinologica 7Buc- )ol/ '''- no/ 1- p/ 13 " 22- 200#
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Macroscopic view of a malignant pheochromocytoma,
demonstrating capsular invasion, hemorrhage, necrosis,
and multinodularity
The characteristic small nests pattern was seen in allh h t h th b i li t A
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pheochromocytomas, whether benign or malignant. Agranular, basophilic cytoplasm was usually
identied surrounding slightly irregular nuclei (right)
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( large nest is seen u;taposed to small nests/ (n area o& central
comedonecrosis is also appreciated/
The characteristic chromogranin (left) immunoreactiity
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in the pheochromocytes is contrasted to the S!1""protein immunoreactiity of the supporting sustentacularsupporting cells (right) in this benign pheochromocytoma
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;ana-e(ent$ (edial si aneste.i
• Anta-onisti Al4a < 4enoiben.a(ina= >/# (etirosina=♦ 7nepe u 10(- /.i u restere pro-resia sub ontrol HTA
• Coretea.a depletia olu(ia
• Beta bloada doar dupa al4a bloada o(pleta, u propranolol, atenolol,labetalol
• ?ita eliberarea de +ista(ina
• ;onitori.are ina.ia arteriala 73p
• Aneste.ie si sedare pre#op@ *e eita +alotanul poate preipita arit(ii
• Control olu( intraasular si TA
• itroprusiat a i@ in per4u.ie lenta, sub (onitori.area ina.ia a TA• orartrinal i@ in per4u.ie lenta, sub (onitori.area ina.ia a TA
=ota$ tipi, sunt neesare 10#1 .ile de trata(ent pre#op
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%lase de erapie
6 asodilatatoare♦ Nitroprusiat- Nitroglicerina
6 Beta"+locante eg/ a+etalol6 (l&a"+locante eg/ entolamina
6 Blocante de %a eg/ Nicardipine
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5egim de pregatire preoperatorie
∀α F β +locada com+inata
eno;i+en.amina
6 Selecti)e α1"+locEer 7e;/ Pra.osin6 Propranolol
6 *etiro.ina
6 Blocante de %alciu 7%%B6 Nicardipina
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PreopA > +locEade
6 Start at least 10"14d preop6 (lloJ su&&icient time &or :%) re"e;pansion
6 Pheno;y+en.amine6 Special pharmacy access only 7no ,'N
6 ,rug o& choice
6 %o)alently +inds α"receptors 7α1 $ α2
6 Start 10 mg po +id increase R2d +y 10"20 mgd
6 'ncrease until BP cntrl and no more paro;ysms
6 *aintenance 40"80 mgd 7some need $ 200 mgd
6 Salt loadA Na%l !00 mg od"tid as tolerated
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PreopA > +locEade
∀ +locEade
6 Xsed to control re≤ tachycardia and prophyla;is
against arrhythmia during surgery
6 Start only a&ter e&&ecti)e α"+locEade 7may ppt
HN
6 '& suspect %Hdilated %*K start loJ dose
6 Propanolol most studied in pheo prep Start 10 mg po +id increase to cntrl H5
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;ana-e(ent$ re.etie +irur-iala
• ;idline or transerse abdo(inal inision
• Bilateral adrenal eploration alon- it+ eploration o4 para#aorti and paraaal retroperitoneu( diap+ra-(to pelis
• Laparosopi approa+ aeptable ia a 4lank,retroperitoneal, or transabdo(inal approa+♦ *+orter +ospital L3*
♦ Loer (orbidit: rate
♦ Hi-+er inidene o4 (issed para-an-lio(as/(ultipletu(ors
♦ Roboti sur-er:
D i li
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Deoro(oito( (ali-n
• Reidiele apar in ' #10 ani dupa re.etia le.iunii pri(are
• Pot 4i detetate 20 ani (ai tar.iu@
• *upraietuirea la ini ani$ %E # E0"@
• Trata(ent♦ Resetia (etasta.elor
♦ Controlul TA
♦
Radioterapia paliati pentru (etasta.e osoase@♦ Terapie ablatia u 7#;7BG # raspuns partial
♦ C+e(oterapie o(binata ilo4os4a(ida, inristina si
daarba.ina poate 4i e4iae@
C l ii
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Conlu.ii
• HTA endorina < HTA seundara
• C*R / ;*R
• Teste dia-nostie 4untionale in dina(ia
• Trata(ent +irur-ial