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DEFINITION

Chronic elevation in blood pressure (bp), as defined by 2017 Hypertension Guidelines (Table 119-1). Hypertension is major contributor to cardiovascular diseases and complications; etiology is unknown in 80–95% of pts (“essential hypertension”). Always consider a secondary correctable form of hypertension, especially in pts aged ≤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.

TABLE 119-1Definition of Hypertension

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; 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 (including 35% of pts with Turner syndrome); constriction is usually present in aorta at origin of left subclavian artery. Examination shows diminished, delayed femoral pulsations; systolic murmur loudest at left infrascapular region. CXR shows indentation of the aorta at the level of the coarctation and rib notching (due to development of collateral arterial flow). Doppler echocardiography identifies region of constriction and measures associated pressure gradient.

Pheochromocytoma

A catecholamine-secreting tumor, typically of the adrenal medulla or extraadrenal paraganglion tissue. 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 next); the tumor is then localized by CT or MRI.

Hyperaldosteronism

Usually due to aldosterone-secreting adenoma or bilateral adrenal hyperplasia; a cause of refractory hypertension that should be suspected when hypokalemia is present in a hypertensive pt off diuretics (Chap. 174).

Other Causes

Oral contraceptive usage, obstructive sleep apnea (Chap. 140), Cushing’s and adrenogenital syndromes (Chap. 174), thyroid disease (Chap. 173), hypercalcemia (e.g., hyperparathyroidism), and acromegaly (...

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