Echo in Acute PE, Resistant Hypertension and Chlorthalidone in CKD | 2 New Trials

A new aldosterone synthase inhibitor just lowered stubborn blood pressure in kidney disease. Before you rewrite a prescription, here is the full pressure check: the RV in acute PE, true vs pseudo-resistant hypertension, and why thiazides still work in stage 4 CKD. Chapters 0:00 Breaking: aldosterone factory shut 0:23 Echo: the RV in acute PE 1:56 Cardiology: is it truly resistant hypertension? 3:01 Medicine: thiazides below eGFR 30 4:05 Trial: Launch-HTN CKD analysis (lorundrostat) 5:24 Trial: PRAGUE-26 6:30 Recap Key take-homes • Echo: RV/LV above 1, flat septum, TAPSE below 16 mm, McConnell and 60/60 signs; RV dysfunction plus raised troponin in a stable patient = intermediate-high risk. PASP well above 60 mmHg with a thick RV wall suggests chronic disease. • Cardiology: confirm resistance (3 drugs incl. a diuretic, max doses, out-of-office readings, adherence), screen for primary aldosteronism, then low-dose spironolactone (PATHWAY-2). Target systolic 120–129 if tolerated. • Medicine: chlorthalidone lowered 24-h systolic BP by 10.5 mmHg vs placebo in stage 4 CKD (CLICK); watch potassium, glucose, uric acid and creatinine. Trials • Launch-HTN CKD analysis (lorundrostat 50 mg): placebo-adjusted systolic fall 9.6 mmHg with CKD, 12.2 without, at week 12; albuminuria down 52%. Subgroup analysis, conference presentation, not yet peer reviewed. • PRAGUE-26: catheter-directed alteplase (max 20 mg) plus anticoagulation cut death, recurrent PE or collapse at 7 days from 6.8% to 0.7% (RR 0.10); 2 intracranial bleeds in the catheter arm. References • Launch-HTN CKD analysis, ASN Kidney Week 2026 (Vogt et al., doi:10.1681/ASN.2026fy6zb248) • Kroupa J et al. PRAGUE-26. N Engl J Med 2026. https://doi.org/10.1056/NEJMoa2608012 • Agarwal R et al. CLICK. N Engl J Med 2021;385:2507-19. https://doi.org/10.1056/NEJMoa2110730 • Williams B et al. PATHWAY-2. Lancet 2015 • 2019 ESC Guidelines for acute pulmonary embolism; 2024 ESC Guidelines for elevated blood pressure and hypertension • ECG strip: MIT-BIH Arrhythmia Database, PhysioNet (Open Data Commons Attribution License) Educational content for doctors and trainees. Not medical advice; apply to individual patients using your own clinical judgement and local guidance. All cases are illustrative. Reviewed by a practising cardiologist before publishing. #Cardiology #Hypertension #PulmonaryEmbolism