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INTRODUCTION

Definition

Chronic elevation in bp (systolic ≥140 mmHg or diastolic ≥90 mmHg); etiology unknown in 80–95% of pts (“essential hypertension”). Always consider a secondary correctable form of hypertension, especially in pts under age 30 or those who become hypertensive after 55. Isolated systolic hypertension (systolic ≥140, diastolic <90) most common in elderly pts, due to reduced vascular compliance.

SECONDARY HYPERTENSION

Renal Artery Stenosis (Renovascular Hypertension)

Due to either atherosclerosis (older men) or fibromuscular dysplasia (young women). Presents with recent onset of hypertension, refractory to usual antihypertensive therapy. Abdominal bruit is present in 50% of cases; often audible; mild hypokalemia due to activation of the renin-angiotensin-aldosterone system may be present.

Renal Parenchymal Disease

Elevated serum creatinine and/or abnormal urinalysis, containing protein, cells, or casts.

Coarctation of Aorta

Presents in children or young adults; constriction is usually present in aorta at origin of left subclavian artery. Exam shows diminished, delayed femoral pulsations; late systolic murmur loudest over the midback. CXR shows indentation of the aorta at the level of the coarctation and rib notching (due to development of collateral arterial flow).

Pheochromocytoma

A catecholamine-secreting tumor, typically of the adrenal medulla or extraadrenal paraganglion tissue, that presents as paroxysmal or sustained hypertension in young to middle-aged pts. Sudden episodes of headache, palpitations, and profuse diaphoresis are common. Associated findings include chronic weight loss, orthostatic hypotension, and impaired glucose tolerance. Pheochromocytomas may be localized to the bladder wall and may present with micturition-associated symptoms of catecholamine excess. Diagnosis is suggested by elevated plasma metanephrine level or urinary catecholamine metabolites in a 24-h urine collection (see below); the tumor is then localized by CT scan or MRI.

Hyperaldosteronism

Usually due to aldosterone-secreting adenoma or bilateral adrenal hyperplasia. Should be suspected when hypokalemia is present in a hypertensive pt off diuretics (Chap. 182).

Other Causes

Oral contraceptive usage, obstructive sleep apnea (Chap. 146), Cushing's and adrenogenital syndromes (Chap. 182), thyroid disease (Chap. 181), hyperparathyroidism, and acromegaly (Chap. 179). In pts with systolic hypertension and wide pulse pressure, consider thyrotoxicosis, aortic regurgitation (Chap. 123), and systemic AV fistula.

APPROACH TO THE PATIENT Hypertension

History: Most pts are asymptomatic. Severe hypertension may lead to headache, dizziness, or blurred vision.

Clues to specific forms of secondary hypertension: Use of medications (e.g., birth control pills, glucocorticoids, decongestants, erythropoietin, NSAIDs, cyclosporine); paroxysms of headache, sweating, or tachycardia (pheochromocytoma); history of renal disease or abdominal trauma (renal hypertension); daytime somnolence and snoring (sleep apnea).

Physical examination: Measure bp with appropriate-sized cuff (large cuff for large arm). Measure bp in both arms as well as a leg (to evaluate for aortic coarctation). Signs of hypertension include retinal ...

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