Causes of Secondary Hypertension

I am currently on my Ambulatory Medicine rotation at a hospital that sees a patient population primarily comprised of the homeless, imprisoned, and uninsured. The staff is incredibly nice and I'm loving my time there. Every week I am assigned a couple of topics to look up and present orally to the attending. I thought I would share my findings on each topic.

Ambulatory Topic #1: Causes of Secondary Hypertension

1.     Primary renal disease — Both acute and chronic kidney disease, particularly with glomerular or vascular disorders.

*You see elevated serum Cr concentration and/or an abnormal urinalysis.

2.     Oral contraceptives — Oral contraceptives typically raise the BP within the normal range but can also induce overt hypertension.

3.     Drug-induced — Long term use of NSAIDs + many antidepressants can induce HTN. Chronic ETOH intake and ETOH abuse can also raise blood pressure.

4.     Pheochromocytoma — About 1/2 of patients with a "pheo" have paroxysmal HTN, most of the rest have what appears to be primary HTN.

* You see:

-paroxysmal elevations in blood pressure (which may be superimposed upon stable chronic hypertension)

-triad of headache (usually pounding), palpitations, and sweating

-drug-resistant hypertension and those with an adrenal incidentaloma should be evaluated for pheochromocytoma. Patients identified with pheochromocytoma are rarely asymptomatic.

5.     Primary aldosteronism — The presence of primary mineralocorticoid excess, primarily aldosterone, should be suspected in any patient with the

*You see:

-triad of hypertension, unexplained hypokalemia, and metabolic alkalosis. However, some patients have a normal plasma K+ concentration.

-otherwise unexplained or easily provoked hypokalemia due to urinary potassium wasting.

->1/2 pts =normal serum K+ concentration.

-suspected in the presence of slight hypernatremia, drug-resistant hypertension, and/or hypertension with an adrenal incidentaloma

6.     Renovascular disease — Renovascular disease = common disorder, occurring primarily in patients with generalized atherosclerosis.

7.     Cushing's syndrome — HTN is a major cause of morbidity + death in pts with Cushing's syndrome.

-Cushing's syndrome (including that due to glucocorticoid administration) is usually suggested by the classic physical findings of cushingoid facies, central obesity, proximal muscle weakness, and ecchymoses.

-Cushing’s or subclinical Cushing’s syndrome should also be suspected in patients with drug-resistant hypertension and in those with an adrenal incidentaloma.

8.     Other endocrine disorders — Hypothyroidism, hyperthyroidism, and hyperparathyroidism

-HTN may be associated with both hypothyroidism, which may be suspected because of suggestive symptoms or an elevated serum TSH level, and primary hyperparathyroidism. The latter is most often suspected because of otherwise unexplained hypercalcemia, which may affect vascular reactivity, day-night blood pressure regulation, and renal function

9.     Obstructive sleep apnea — Disordered breathing during sleep appears to be an independent risk factor for systemic hypertension.

-sleep apnea syndrome is most commonly identified in obese men who snore loudly while asleep. These patients have repeated apneic episodes at night due to passive collapse of the pharyngeal muscles during inspiration, such that the airway becomes occluded from the apposition of the tongue and soft palate against the posterior oropharynx.

-A variety of other symptoms may be seen including headache, daytime somnolence and fatigue, morning confusion with difficulty in concentration, personality changes, depression, persistent systemic hypertension, and potentially life-threatening cardiac arrhythmias.

-Patients with obstructive sleep apnea often retain sodium and fail to respond optimally to antihypertensive drug therapy

  10.  Coarctation of the aorta — Coarctation of the aorta is one of the major causes of secondary hypertension in young children

               -Coarctation of the aorta is one of the major causes of secondary hypertension in young children but may first be detected in adulthood (picture 1A-B). The classic findings are HTN in the upper extremities, diminished or delayed femoral pulses ("brachial-femoral delay"), and low or unobtainable arterial blood pressure in the lower extremities. In addition, a prominent “to-and-fro machinery murmur” from the aorta may be heard over the posterior chest.

Source: uptodate.com

Pic:http://www.aakp.org/aakp-library/ped-hypertension/

Pic: http://www.angiologist.com/secondary-hypertension/