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Mr. U is a 48-year-old man with a BP of 165/90 mm Hg.

Image not available.What is the differential diagnosis of hypertension? How would you frame the differential?

First, what is normal BP, and when is a patient hypertensive? The first step is accurately measuring the BP. Table 20–1 summarizes guidelines for obtaining valid BP measurements.

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Table 20–1. Guidelines for Measuring BP. 

The most recent Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High BP (JNC 7) classifies BP as follows, based on the mean of 2 seated BP measurements on each of 2 or more office visits:


  1. Normal: systolic BP < 120 mm Hg and diastolic BP < 80 mm Hg.

  2. Prehypertension: systolic BP 120–139 mm Hg or diastolic BP 80–89 mm Hg.

  3. Stage 1 hypertension: systolic BP 140–159 mm Hg or diastolic BP 90–99 mm Hg.

  4. Stage 2 hypertension: systolic BP ≥ 160 mm Hg or diastolic BP ≥ 100 mm Hg.


Hypertension is either primary (essential) or secondary (resulting from a specific identifiable cause). Causes of secondary hypertension can be organized using an organ/system framework:


  1. Primary (essential) hypertension

  2. Secondary hypertension

    1. Endocrine

      1. Primary aldosteronism

      1. Pheochromocytoma

      1. Thyroid disease

      1. Hyperparathyroidism

      1. Cushing syndrome

    1. Renal

      1. Chronic kidney disease

      1. Acute renal failure

    1. Vascular

      1. Renovascular disease

      1. Coarctation of the aorta

    1. Pulmonary: sleep apnea

    1. GI: obesity

    1. Drug-induced or drug-related

      1. Prolonged corticosteroid therapy

      1. Nonselective nonsteroidal antiinflammatory drugs (NSAIDs)

      1. Cyclooxygenase (COX)-2 inhibitors

      1. Cocaine

      1. Alcohol

      1. Sympathomimetics (decongestants, anorectics)

      1. Oral contraceptives

      1. Cyclosporine and tacrolimus

      1. Erythropoietin

      1. Stimulants (modafinil, amphetamines)


An algorithm outlining the diagnostic approach ...

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