Materiały źródłowe

• #1 Practice Recommendations for Diagnosis and Treatment of the Most Common Forms of Secondary Hypertension | High Blood Pressure & Cardiovascular Prevention

  https://link.springer.com/article/10.1007/s40292-020-00415-9

  The vast majority of hypertensive patients are never sought for a cause of their high blood pressure, i.e. for a ‘secondary’ form of arterial hypertension. […] The early detection of a secondary form is crucial, because if diagnosed in a timely manner, these forms can be cured at long-term, and even when cure cannot be achieved, their diagnosis provides a better control of high blood pressure, and allows prevention of hypertension-mediated organ damage, and related cardiovascular complications. […] The European Societies of Cardiology and Hypertension (ESC/ESH) guidelines suggest that the screening for SH should be restricted to patients with certain features, such as younger age (i.e. < 40 years), acute worsening of HT in patients with previously documented chronically stable normotension, severe (grade 3) or drug-resistant HT, presence of extensive hypertension-mediated organ damage (HMOD).

• #1 Biochemical investigation of secondary hypertension – Manchester University NHS Foundation Trust

  https://mft.nhs.uk/the-trust/other-departments/laboratory-medicine/information-for-gps/laboratory-medicines-newsletter-for-gps/biochemical-investigation-of-secondary-hypertension/

  It is estimated that 26-30% of adults in the UK have hypertension, equating to around 13.2 million people in the UK. Up to 10% of the hypertensive population have a secondary cause of their hypertension, affecting around 1.3 million patients. Identification of affected patients will allow optimal clinical response to be achieved with the specific therapy. […] The following groups of patients should be screened for secondary causes of hypertension: Young onset hypertension (before the age of 40), Drug resistant hypertension, Sudden deterioration in blood pressure control, Hypertensive emergency, Clinical clues such as Muscle weakness/tetany, cramps, or arrhythmias (Primary hyperaldosteronism), Rapid onset acute pulmonary oedema (renal artery stenosis), Sweating, palpitations, or frequent headaches (phaeochromocytoma/paraganglioma), Snoring or daytime sleepiness (obstructive sleep apnoea).

• #1 Secondary hypertension – Diagnosis & treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/secondary-hypertension/diagnosis-treatment/drc-20350684

  To diagnose secondary hypertension, a health care provider will take a blood pressure reading using an inflatable cuff. […] A care provider might not diagnose secondary hypertension based on a single high blood pressure reading. It may take 3 to 6 high blood pressure measurements at separate appointments to diagnose secondary hypertension. […] Other tests to help pinpoint the cause of the high blood pressure might include: […] A urine test (urinalysis). A urine sample can contain markers that could point to medical conditions that cause high blood pressure. […] Ultrasound of the kidneys. Many kidney conditions are linked to secondary hypertension. […] Electrocardiogram (ECG or EKG). This painless noninvasive test records the electrical signals in the heart. This test can help determine whether a heart problem might be causing secondary hypertension.

• #1 Diagnosing Secondary Hypertension | AAFP

  https://www.aafp.org/pubs/afp/issues/2003/0101/p67.html

  Secondary hypertension is elevated blood pressure that results from an underlying, identifiable, often correctable cause. Only about 5 to 10 percent of hypertension cases are thought to result from secondary causes. Routine urinalysis, complete blood cell count, blood chemistry profile (potassium, sodium, creatinine, fasting glucose, fasting lipid levels), and a 12-lead electrocardiogram are recommended for all patients with hypertension. […] The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI) defines four goals for the evaluation of the patient with elevated blood pressure: detection and confirmation of hypertension; detection of target organ disease (e.g., renal damage, congestive heart failure); identification of other risk factors for cardiovascular disorders (e.g., diabetes mellitus, hyperlipidemia); and detection of secondary causes of hypertension.

• #1 Approach to the diagnosis of secondary hypertension in adults

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8542481/

  Presentations that should raise suspicion of secondary hypertension include early-onset, severe or resistant hypertension. A suggestive family history or clinical clues can point to a specific secondary cause. […] The assessment of patients begins with history taking and examination, to look for clinical clues. Laboratory tests include electrolytes, urea, creatinine and the aldosterone:renin ratio, urinalysis and the urine albumin:creatinine ratio. Abnormal results should prompt further investigation. […] Secondary hypertension occurs in approximately 10% of adults with hypertension. Identifying and treating the cause can potentially cure or markedly improve hypertension and reduce the associated cardiovascular risk. […] All patients suspected of having secondary hypertension should be screened for the common causes and associations. These include renal disease (parenchymal or renovascular), primary aldosteronism, medicines, illicit substances, alcohol and obstructive sleep apnoea.

• #1 Diagnosis of Secondary Hypertension: An Age-Based Approach | AAFP

  https://www.aafp.org/pubs/afp/issues/2010/1215/p1471.html

  Secondary hypertension is a type of hypertension with an underlying, potentially correctable cause. A secondary etiology may be suggested by symptoms (e.g., flushing and sweating suggestive of pheochromocytoma), examination findings (e.g., a renal bruit suggestive of renal artery stenosis), or laboratory abnormalities (e.g., hypokalemia suggestive of aldosteronism). […] Secondary hypertension also should be considered in patients with resistant hypertension, and early or late onset of hypertension. […] Approximately 5 to 10 percent of adults with hypertension have a secondary cause. […] In young adults, particularly women, renal artery stenosis caused by fibromuscular dysplasia is one of the most common secondary etiologies. […] In middle-aged adults, aldosteronism is the most common secondary cause of hypertension, and the recommended initial diagnostic test is an aldosterone/renin ratio.

• #1 Secondary Hypertension – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK544305/

  The initial screening tests for renal parenchymal diseases include serum creatinine with estimated glomerular filtration rate (eGFR), urine detailed report, urinary protein/protein to creatinine ratio, and renal ultrasound. […] The plasma aldosterone/renin ratio is the preferred screening test for primary aldosteronism and it should be done at least four weeks after the withdrawal of aldosterone antagonists and after the correction of hypokalemia. […] Screening for pheochromocytoma/paraganglioma is recommended in the presence of episodic hypertension, along with palpitations, headache, postural hypotension, and stigmata of neurofibromatosis. […] The management of secondary hypertension requires a multidisciplinary approach. […] The differential diagnosis of secondary hypertension as stated above are chronic kidney disease, autosomal dominant polycystic kidney disease, renal artery stenosis, fibromuscular dysplasia, primary aldosteronism, Cushing syndrome/disease, hyperthyroidism, hypothyroidism, hyperparathyroidism, pheochromocytoma, acromegaly, congenital adrenal hyperplasia, coarctation of the aorta, obstructive sleep apnea, drug-induced hypertension, pregnancy, scleroderma. […] Secondary hypertension is usually resistant to antihypertensive drugs if the underlying mechanism is not identified and treated appropriately.

• #1 Secondary Hypertension | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/28819

  It accounts for 70 to 85 percent of hypertension cases in children less than 12 years of age, and approximately 17 percent of cases in adults aged 65 and older. […] The prevalence of secondary hypertension is lowest amongst hypertensive patients who are 19 to 39 years of age while its prevalence in adolescents (12 to 18 years) is 10 to 15%. […] The initial screening tests for renal parenchymal diseases include serum creatinine with estimated glomerular filtration rate (eGFR), urine detailed report, urinary protein/protein to creatinine ratio, and renal ultrasound. […] A renal biopsy followed by histopathology is a gold-standard investigation, recommended for the diagnosis of specific conditions and pathophysiology of renal parenchymal diseases. […] Hypertension with hypokalemia is one of the characteristic features of primary aldosteronism, especially in those individuals with a family history of hypertension and cerebrovascular accidents at a young age.

• #1 Secondary Hypertension, Differential diagnosis | Time of Care

  https://www.timeofcare.com/causes-of-secondary-hypertension/

  DDx […] Causes of Secondary Hypertension: ABCDEF […] Accuracy of diagnosis. […] Moderate to severe HTN in a patient with diffuse atherosclerosis, a unilateral small kidney, or asymmetry in renal size of more than 1.5 cm that cannot be explained by another reason. […] An onset of stage II HTN after age 55 yrs. […] For the initial testing start with either: 1) U/S (duplex Doppler U/S), 2) CTA, 3) MRA depending on local availability, expertise, and the presence or absence of renal insufficiency. […] Because of the potential for harm from invasive procedures, test only patients who have a high likelihood of benefiting from the procedure. […] If there is a low index of suspicion for pheochromocytoma, get a 24-hour urinary fractionated catecholamines and metanephrines; if there is a high index of suspicion, get plasma fractionated metanephrines.

• #1 Ruling out secondary causes of hypertension | EuroIntervention

  https://eurointervention.pcronline.com/article/ruling-out-secondary-causes-of-hypertension

  The gold standard for diagnosing renal vascular disease is renal angiography. […] The presence of relevant ARAS should be considered particularly in patients with rapidly deteriorating renal function, those with a reduction in their estimated glomerular filtration rate of 25% after administration of a renin-angiotensin system-inhibitor or angiotensin receptor blocker, onset of hypertension after 50 years of age, and those with a history of flash pulmonary oedema. […] The prevalence of primary aldosteronism (PA) is greater than previously thought. […] The aldosterone-renin ratio (ARR) is the most reliable test for screening purposes. […] If the ARR is positive, biochemical evidence of PA has to be confirmed, e.g., with the oral sodium loading. […] Even in the general population, and particularly in men, obstructive sleep apnoea (OSA) is a common finding.

• #1 Ruling out secondary causes of hypertension | EuroIntervention

  https://eurointervention.pcronline.com/article/ruling-out-secondary-causes-of-hypertension

  Approximately 30% of adults with hypertension have OSA. […] Specific questionnaires may be helpful in the routine assessment of the clinical features of OSA, but their diagnostic sensitivity and specificity are low. […] Drug-induced hypertension is one of the most common causes of secondary hypertension and is often found in clinical practice. […] The elimination of the responsible agent is not always possible in some cases, but a dose reduction or an alternative treatment option should be considered. […] Although the prevalence of pheochromocytoma in the general hypertensive population is very low, diagnosis and treatment are extremely important in view of the possibility of precipitating hypertensive crisis if the tumour is stimulated. […] Hypertension is one of the most distinguishing features of endogenous Cushings syndrome, and can be found in about 80% of adult patients. […] Coarctation of the aorta is a common cause of secondary hypertension in children, milder cases may first be detected as a rare cause of arterial hypertension in adults.

• #1 Secondary Hypertension, Differential diagnosis | Time of Care

  https://www.timeofcare.com/causes-of-secondary-hypertension/

  Start with: Peripheral aldosterone concentration (PAC) and peripheral renin activity (PRA), preferably after being up for 2 hours, are the preferred screening tests for hyperaldosteronism. […] The clinical dx of coarctation of the aorta is based upon the characteristic findings of systolic hypertension in the upper extremities, diminished or delayed femoral pulses (brachial-femoral delay), and low or unobtainable arterial blood pressure in the lower extremities. […] The diagnosis is confirmed by noninvasive imaging methods, particularly echocardiography. […] MRA or CTA clearly defines the location and severity of coarctation of the aorta, as well as collateral vessels.

• #1 Practice Recommendations for Diagnosis and Treatment of the Most Common Forms of Secondary Hypertension | High Blood Pressure & Cardiovascular Prevention

  https://link.springer.com/article/10.1007/s40292-020-00415-9

  Given the unprecedented progress made in the last decades in the understanding, screening, work-up, and management of SH, the purpose of this mini-review is to furnish concise updated information on the diagnosis and treatment of the most common forms of SH. […] The main feature of patients with bilateral PA is multiple aldosterone-producing cell clusters (APCCs) or micro-aldosterone-producing adenomas, rather than bilateral adrenal hyperplasia (BAH). […] The use of confirmatory tests, such as the oral sodium loading test, the saline infusion test, the captopril challenge test, and the fludrocortisone plus salt loading test, remains controversial. […] Unilateral laparoscopic adrenalectomy is the best treatment that can be offered to PA patients with proven unilateral disease. […] The first-choice treatment for FMD-RVH is renal artery angioplasty without stenting.

• #1 Secondary Hypertension | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/28819

  The plasma aldosterone/renin ratio is the preferred screening test for primary aldosteronism and it should be done at least four weeks after the withdrawal of aldosterone antagonists and after the correction of hypokalemia. […] Measurement of 24-hour urine aldosterone level after oral sodium loading and plasma aldosterone level after intravenous saline infusion are the diagnostic tests for primary aldosteronism, while renal vein sampling can be done for selected patients. […] Screening for pheochromocytoma/paraganglioma is recommended in the presence of episodic hypertension, along with palpitations, headache, postural hypotension, and stigmata of neurofibromatosis. […] The management of secondary hypertension requires a multidisciplinary approach. […] The diagnosis and management of secondary hypertension require a multidisciplinary team and collaborative efforts.

• #1 Diagnosis of Secondary Hypertension: An Age-Based Approach | AAFP

  https://www.aafp.org/pubs/afp/issues/2010/1215/p1471.html

  Testing can be done by measuring metanephrines in a 24-hour urine sample, but measurement of plasma free metanephrines is easier for the patient and has a negative likelihood ratio close to zero, making it a good test to rule out the disorder. […] Given the low frequency of Cushing syndrome, testing should be done only if there are suggestive features or after other possible causes have been ruled out. […] Renal artery stenosis secondary to atherosclerotic disease affects older adults. […] It should be suspected in those who develop hypertension after 50 years of age, have known atherosclerosis elsewhere, have unexplained renal insufficiency, or have a rapid deterioration in kidney function. […] Evaluation for possible chronic renal failure should include calculating the estimated glomerular filtration rate and obtaining a urinalysis to assess for albuminuria.

• #1 Biochemical investigation of secondary hypertension – Manchester University NHS Foundation Trust

  https://mft.nhs.uk/the-trust/other-departments/laboratory-medicine/information-for-gps/laboratory-medicines-newsletter-for-gps/biochemical-investigation-of-secondary-hypertension/

  Renal disorders such as CKD, diabetic nephropathy or polycystic kidney disease are the most common cause of secondary hypertension. Other causes include vascular disorders such as renal artery stenosis, drugs and medications, obstructive sleep apnoea, pregnancy and endocrine disorders. Clinical examinations and routine biochemical tests can indicate which are the most likely secondary causes and signpost which further investigations could be helpful. […] Initial investigations for CKD should include eGFR and urine albumin:creatinine ratio. Early morning urine samples are recommended for the albumin:creatinine ratio. […] Aldosterone:renin ratio (ARR) is the first line test for the diagnosis of primary hyperaldosteronism. […] Plasma metanephrines are more sensitive than urine metanephrines for PPGL diagnosis (97% for plasma vs 90% for urine) which is why plasma metanephrines is the test offered for the investigation of PPGL in this Trust. […] If Cushings syndrome is clinically suspected, there are several tests that can be performed to identify if the patient has hypercortisolism; however random serum cortisol is not useful for this. […] Thyroid function tests (TSH and fT4) should be requested to investigate thyroid disorders.

• #1 Diagnosis of Secondary Hypertension: An Age-Based Approach | AAFP

  https://www.aafp.org/pubs/afp/issues/2010/1215/p1471.html

  Young adults thought to have secondary hypertension should be assessed for fibromuscular dysplasia of the renal artery. […] The aldosterone/renin ratio is the best initial test to determine whether a patient with hypertension should have further evaluation for aldosteronism. […] Obstructive sleep apnea can be a secondary cause of or contribute to hypertension. […] The most common etiologies in children, in whom 70 to 85 percent of cases of hypertension have a secondary cause, are different from those in older persons; therefore, an age-based approach to the differential diagnosis is recommended. […] Testing for thyroid dysfunction should be considered if there are any suggestive symptoms. […] The best initial test for aldosteronism is measurement of the aldosterone/renin ratio. […] Obstructive sleep apnea is a notable cause of secondary hypertension, particularly in 40- to 59-year-olds.

• #1 Practice Recommendations for Diagnosis and Treatment of the Most Common Forms of Secondary Hypertension | High Blood Pressure & Cardiovascular Prevention

  https://link.springer.com/article/10.1007/s40292-020-00415-9

  The gold-standard therapy for PPGLs is surgery for solitary or multiple tumors clustered in one area. […] Controlling cortisol hypersecretion by surgery or by cortisol lowering drugs or glucocorticoid receptor antagonists, can effectively lower BP in most hypertensive CS patients and normalize it in ~ 50% of cases. […] The proper work-up of OSA patients varies according to individual features. […] The detection of SH can be simplified and made cost-effective by estimating the patient’s prior (pre-test) probability of the disease, which can be established by knowing the prevalence of the most common forms and by following few rules, as herein presented.

• #1 Approach to the diagnosis of secondary hypertension in adults

  https://australianprescriber.tg.org.au/articles/approach-to-the-diagnosis-of-secondary-hypertension-in-adults.html

  Presentations that should raise suspicion of secondary hypertension include early-onset, severe or resistant hypertension. A suggestive family history or clinical clues can point to a specific secondary cause. […] The assessment of patients begins with history taking and examination, to look for clinical clues. Laboratory tests include electrolytes, urea, creatinine and the aldosterone:renin ratio, urinalysis and the urine albumin:creatinine ratio. Abnormal results should prompt further investigation. […] Secondary hypertension occurs in approximately 10% of adults with hypertension. Identifying and treating the cause can potentially cure or markedly improve hypertension and reduce the associated cardiovascular risk. […] The history and examination may raise suspicion of secondary hypertension. It is important to remember that drugs can cause hypertension. Laboratory tests can help to identify other causes.

• #1 Secondary Hypertension: Causes & Symptoms

  https://my.clevelandclinic.org/health/diseases/21128-secondary-hypertension

  Secondary hypertension is high blood pressure with an identifiable cause. Often, the cause is a medical condition or a medication you’re taking. […] Secondary hypertension is high blood pressure that has a known cause. The cause might be another medical condition, or certain medicines or substances you’re using. Often, treating this underlying cause can reduce your blood pressure to healthier levels. […] If your provider suspects you have secondary hypertension, they’ll start by: Doing a physical exam, reviewing your medical history, including any medications or supplements you’re taking, talking with you about what you eat and drink, including things like sodium and alcohol, doing some basic tests like an electrocardiogram (EKG/ECG), blood tests and urine tests. […] Treatment depends on the cause. Since many different conditions can cause secondary hypertension, there are many possible treatments. Your healthcare provider will tailor a plan to your needs. […] Secondary hypertension has a positive outlook with treatment. Early detection and treatment can lower the risk of damage to your blood vessels and heart from ongoing high blood pressure.

• #1 Secondary Hypertension: Differential Diagnosis and Basic…

  https://sciendo.com/article/10.1515/sjecr-2015-0056

  Secondary hypertension occurs in 5-10% of cases in the patient population with primary hypertension. The most common forms of secondary hypertension are as follows: parenchymal renal disease (renoparenchymal hypertension), renal artery stenosis (renovascular hypertension), adrenal gland adenoma (primary hyperaldosteronism), a tumour of the adrenal gland marrow (pheochromocytoma) and adenoma of adrenal and pituitary glands (Cushings syndrome). […] In patients with a typical clinical picture of secondary hypertension, the appropriate diagnostic tests should be conducted based on the suspected form of secondary hypertension. Determining a diagnosis of secondary hypertension is gradual. First, the appropriate screening tests are performed. If the screening test is positive, then additional tests to confirm the forms of secondary hypertension are conducted. Once a diagnosis of the appropriate form of secondary hypertension is confirmed, tests to distinguish causes and laterality tests to determine the precise localisation of the pathological process are applied to evaluate the response to therapy. Analysing the results of endocrine diagnostic tests provides an accurate diagnosis and selection of optimal therapeutic procedures.

• #1 Improved identification of secondary hypertension: use of a systematic protocol

  https://atm.amegroups.org/article/view/20388/html

  This tool may be used by healthcare providers to ensure the appropriate recognition of secondary causes of hypertension in a wider range of patients with high blood pressure beyond resistant hypertension, changing the diagnostic paradigm of this condition. […] Utilizing the methods developed in the Center, this approach, known as the CHIC Protocol, could constitute a valuable tool for early recognition and accurate diagnosis of SH in clinical practice. […] Although secondary causes of hypertension are common in patients with resistant hypertension, a higher prevalence of SH persisted independent of the measured severity of BP values and SH was also identified in patients with moderate hypertension. […] By analyzing the causes and distribution of SH, we found that hyperaldosteronism is the most frequent endocrine etiology.

• #1 Diagnosis of Secondary Hypertension: An Age-Based Approach | AAFP

  https://www.aafp.org/pubs/afp/issues/2010/1215/p1471.html

  Therefore, all children with confirmed hypertension should have an evaluation for an underlying etiology that includes renal ultrasonography. […] Whenever a patient is diagnosed with hypertension, one purpose of the initial assessment (i.e., history, physical examination, and basic laboratory testing) is to exclude possible secondary causes. […] Indications for further investigation into a possible secondary etiology in the absence of suggestive signs and symptoms include resistant hypertension, early or late onset of hypertension, a severe or accelerated course, or specific drug intolerances. […] In the absence of clinical signs to suggest possible secondary hypertension in adults, indications for further evaluation include resistant hypertension and early, late, or rapid onset of high blood pressure.

• #1 Approach to the diagnosis of secondary hypertension in adults

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8542481/

  Identifying secondary hypertension presents an opportunity to modify a patients cardiovascular risk profile beyond what is achievable by antihypertensive therapy alone. Renal disease and primary aldosteronism are common causes. […] A methodical approach to identifying the cause is necessary and must take into account the drugs being used by the patient. Advice on test selection and patient preparation to optimise the value of initial investigations can be provided by a chemical pathologist or hypertension specialist. Patients who have abnormal results will require further investigations to confirm the cause.

• #1 Improved identification of secondary hypertension: use of a systematic protocol

  https://atm.amegroups.org/article/view/20388/html

  The accurate identification and diagnosis of secondary hypertension is critical, especially while atherosclerotic cardiovascular heart disease continues to be the leading cause of death in the industrialized world. […] This study demonstrates the results of using a systematic and protocolled approach to improve recognition of the presence of secondary hypertension. […] The confirmation of secondary hypertension was subsequently confirmed by diagnostic laboratory and imaging techniques in a hospital setting. […] Physicians used confirmatory laboratory testing and imaging of patients who were identified as having a cause for their secondary hypertension, with no significant differences in sex, age and body mass index (BMI) among study groups. […] These results illustrate the prevalence and distribution of the causes of secondary hypertension using a systematic, protocolled approach, which revealed a higher percentage of secondary hypertension than previously reported.

• #1 Diagnosis and Treatment of Secondary Hypertension

  https://www.ekjm.org/journal/view.php?number=25799

  Secondary hypertension, which refers to arterial hypertension caused by an identifiable medical condition, accounts for 5-10% of all hypertensive diagnoses; however, this is thought to be an underestimate. […] If diagnosed promptly, secondary hypertension can be treated, and proper blood pressure restored. […] This review focuses on the screening, diagnosis, and management of the most common forms of secondary hypertension, including primary aldosteronism, renovascular hypertension, pheochromocytoma, Cushings syndrome, and renal parenchymal disease. […] Practice recommendations for diagnosis and treatment of the most common forms of secondary hypertension.

• #1 Evaluation of secondary hypertension – UpToDate

  https://www.uptodate.com/contents/evaluation-of-secondary-hypertension

  Evaluation of secondary hypertension. The evaluation of a patient with hypertension depends upon the likely cause and the degree of difficulty in achieving acceptable blood pressure control since many forms of secondary hypertension lead to „treatment-resistant” hypertension. By contrast, patients who have clinical clues suggesting the possible presence of secondary hypertension should undergo a more extensive evaluation. If secondary hypertension is present, the most effective treatment strategy often is one that is focused upon the specific mechanism underlying the hypertension. In addition, some of these disorders can be cured, leading to partial or complete normalization of the blood pressure. Because it is not cost effective to perform a complete evaluation for secondary hypertension in every hypertensive patient, it is important to be aware of the clinical clues that suggest secondary hypertension. The identification of patients who should undergo an evaluation for secondary hypertension will be reviewed here. […] Testing methods for renovascular hypertension and treatment of unilateral and bilateral atherosclerotic renal artery stenosis are discussed separately.

• #2 Diagnosing Secondary Hypertension | AAFP

  https://www.aafp.org/pubs/afp/issues/2003/0101/p67.html

  Secondary hypertension is elevated blood pressure that results from an underlying, identifiable, often correctable cause. Only about 5 to 10 percent of hypertension cases are thought to result from secondary causes. Routine urinalysis, complete blood cell count, blood chemistry profile (potassium, sodium, creatinine, fasting glucose, fasting lipid levels), and a 12-lead electrocardiogram are recommended for all patients with hypertension. […] The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI) defines four goals for the evaluation of the patient with elevated blood pressure: detection and confirmation of hypertension; detection of target organ disease (e.g., renal damage, congestive heart failure); identification of other risk factors for cardiovascular disorders (e.g., diabetes mellitus, hyperlipidemia); and detection of secondary causes of hypertension.

• #2 Secondary Hypertension – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK544305/

  Secondary hypertension is defined as elevated blood pressure (BP) secondary to an identifiable cause. […] This activity outlines the etiology of secondary hypertension and discusses the history, physical examination findings, diagnostic tests, and management of secondary hypertension. […] Identification of the etiology and pathophysiology of secondary hypertension is essential in selected groups of patients. […] It is important for healthcare professionals treating hypertension, to be aware of clinical clues that could suggest a secondary cause of hypertension. […] The common clinical signs which warrant investigations for a secondary cause of hypertension may include; Resistant hypertension, i.e., persistent blood pressure greater than 140/90 mm Hg despite using optimal doses of at least three anti-hypertensive from different classes, that includes a diuretic.

• #2 The Diagnosis of Essential and Secondary Hypertension in Adults | MDedge

  https://mdedge.com/jfponline/article/60601/diagnosis-essential-and-secondary-hypertension-adults

  Hypertension is arbitrarily defined as a diastolic blood pressure (DBP) of 90 mm Hg or higher, a systolic blood pressure (SBP) equal to or higher than 140 mm Hg, or both, on 3 separate occasions. […] The more common identifiable causes of hypertension include chronic renal disease (2%-5%), renovascular disease—including renal artery atherosclerosis and fibromuscular dysplasia—(0.2%-0.7%), Cushing syndrome (0.1%-0.6%), pheochromocytoma (0.04%-0.1%), and primary hyperaldosteronism (0.01%-0.3%). […] The presence of hypertension must be confirmed by blood pressure measurements obtained with proper technique. […] Hypertension is present when an accurately measured blood pressure is high on 3 separate occasions. […] A complete history, physical examination, and limited diagnostic testing (urinalysis, complete blood count, potassium, sodium, fasting glucose, creatinine, total cholesterol, high-density cholesterol, and electrocardiogram) are recommended once the presence of hypertension has been confirmed.

• #2 Approach to the diagnosis of secondary hypertension in adults

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8542481/

  Presentations that should raise suspicion of secondary hypertension include early-onset, severe or resistant hypertension. A suggestive family history or clinical clues can point to a specific secondary cause. […] The assessment of patients begins with history taking and examination, to look for clinical clues. Laboratory tests include electrolytes, urea, creatinine and the aldosterone:renin ratio, urinalysis and the urine albumin:creatinine ratio. Abnormal results should prompt further investigation. […] Secondary hypertension occurs in approximately 10% of adults with hypertension. Identifying and treating the cause can potentially cure or markedly improve hypertension and reduce the associated cardiovascular risk. […] All patients suspected of having secondary hypertension should be screened for the common causes and associations. These include renal disease (parenchymal or renovascular), primary aldosteronism, medicines, illicit substances, alcohol and obstructive sleep apnoea.

• #2 Secondary Hypertension: Causes & Symptoms

  https://my.clevelandclinic.org/health/diseases/21128-secondary-hypertension

  Secondary hypertension is high blood pressure with an identifiable cause. Often, the cause is a medical condition or a medication you’re taking. […] Secondary hypertension is high blood pressure that has a known cause. The cause might be another medical condition, or certain medicines or substances you’re using. Often, treating this underlying cause can reduce your blood pressure to healthier levels. […] If your provider suspects you have secondary hypertension, they’ll start by: Doing a physical exam, reviewing your medical history, including any medications or supplements you’re taking, talking with you about what you eat and drink, including things like sodium and alcohol, doing some basic tests like an electrocardiogram (EKG/ECG), blood tests and urine tests. […] Treatment depends on the cause. Since many different conditions can cause secondary hypertension, there are many possible treatments. Your healthcare provider will tailor a plan to your needs. […] Secondary hypertension has a positive outlook with treatment. Early detection and treatment can lower the risk of damage to your blood vessels and heart from ongoing high blood pressure.

• #2 Biochemical investigation of secondary hypertension – Manchester University NHS Foundation Trust

  https://mft.nhs.uk/the-trust/other-departments/laboratory-medicine/information-for-gps/laboratory-medicines-newsletter-for-gps/biochemical-investigation-of-secondary-hypertension/

  Renal disorders such as CKD, diabetic nephropathy or polycystic kidney disease are the most common cause of secondary hypertension. Other causes include vascular disorders such as renal artery stenosis, drugs and medications, obstructive sleep apnoea, pregnancy and endocrine disorders. Clinical examinations and routine biochemical tests can indicate which are the most likely secondary causes and signpost which further investigations could be helpful. […] Initial investigations for CKD should include eGFR and urine albumin:creatinine ratio. Early morning urine samples are recommended for the albumin:creatinine ratio. […] Aldosterone:renin ratio (ARR) is the first line test for the diagnosis of primary hyperaldosteronism. […] Plasma metanephrines are more sensitive than urine metanephrines for PPGL diagnosis (97% for plasma vs 90% for urine) which is why plasma metanephrines is the test offered for the investigation of PPGL in this Trust. […] If Cushings syndrome is clinically suspected, there are several tests that can be performed to identify if the patient has hypercortisolism; however random serum cortisol is not useful for this. […] Thyroid function tests (TSH and fT4) should be requested to investigate thyroid disorders.

• #2 Approach to the diagnosis of secondary hypertension in adults

  https://australianprescriber.tg.org.au/articles/approach-to-the-diagnosis-of-secondary-hypertension-in-adults.html

  Presentations that should raise suspicion of secondary hypertension include early-onset, severe or resistant hypertension. A suggestive family history or clinical clues can point to a specific secondary cause. […] The assessment of patients begins with history taking and examination, to look for clinical clues. Laboratory tests include electrolytes, urea, creatinine and the aldosterone:renin ratio, urinalysis and the urine albumin:creatinine ratio. Abnormal results should prompt further investigation. […] Secondary hypertension occurs in approximately 10% of adults with hypertension. Identifying and treating the cause can potentially cure or markedly improve hypertension and reduce the associated cardiovascular risk. […] The history and examination may raise suspicion of secondary hypertension. It is important to remember that drugs can cause hypertension. Laboratory tests can help to identify other causes.

• #2 Diagnosing Secondary Hypertension | AAFP

  https://www.aafp.org/pubs/afp/issues/2003/0101/p67.html

  Diagnosis is based on loss of renal cortical function (demonstrated by elevated serum creatinine levels and decreased creatinine clearance), although it may be impossible to tell if the renal dysfunction is primary or secondary to the hypertension. […] A more aggressive evaluation for secondary causes of hypertension should be considered in certain clinical situations.

• #2 Hypertension – Knowledge @ AMBOSS

  https://www.amboss.com/us/knowledge/hypertension/

  Most common causes in adults include thyroid dysfunction, fibromuscular dysplasia, and renal parenchymal disease. […] Young adults (especially women of age) with suspected secondary hypertension should be assessed for renal artery stenosis caused by fibromuscular dysplasia. […] Management of secondary hypertension depends on the suspected cause; involve specialists (e.g., endocrinologist or nephrologist) early. […] Diagnosis of hypertension in older adults is similar to younger adults. […] Some experts recommend that all individuals with hypertension be tested for primary hyperaldosteronism at least once because of its relatively high prevalence in patients with hypertension.

• #2 Ruling out secondary causes of hypertension | EuroIntervention

  https://eurointervention.pcronline.com/article/ruling-out-secondary-causes-of-hypertension

  The gold standard for diagnosing renal vascular disease is renal angiography. […] The presence of relevant ARAS should be considered particularly in patients with rapidly deteriorating renal function, those with a reduction in their estimated glomerular filtration rate of 25% after administration of a renin-angiotensin system-inhibitor or angiotensin receptor blocker, onset of hypertension after 50 years of age, and those with a history of flash pulmonary oedema. […] The prevalence of primary aldosteronism (PA) is greater than previously thought. […] The aldosterone-renin ratio (ARR) is the most reliable test for screening purposes. […] If the ARR is positive, biochemical evidence of PA has to be confirmed, e.g., with the oral sodium loading. […] Even in the general population, and particularly in men, obstructive sleep apnoea (OSA) is a common finding.

• #2 Secondary hypertension in adults | SMJ

  http://www.smj.org.sg/article/secondary-hypertension-adults

  It is important to diagnose these patients, as they often have increased cardiovascular morbidity and mortality than age-, sex- and BP-matched patients with essential hypertension, and treatment can lead to reversal of end-organ damage. […] The Endocrine Society observed that the current greatest problem is that the screening test is often not performed, leading to an underdiagnosis of this condition. […] Clinical situations that alert a physician to RAS are 30% rise in serum creatinine level after initiation of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB), discrepancy in kidney sizes of more than 1.5 cm or recurrent flash pulmonary oedema in a patient with normal left ventricular ejection fraction. […] Referral should be considered when a secondary cause of hypertension is suspected, and the choice of specialist should be based on the likely underlying cause.

• #2 Improved identification of secondary hypertension: use of a systematic protocol

  https://atm.amegroups.org/article/view/20388/html

  This tool may be used by healthcare providers to ensure the appropriate recognition of secondary causes of hypertension in a wider range of patients with high blood pressure beyond resistant hypertension, changing the diagnostic paradigm of this condition. […] Utilizing the methods developed in the Center, this approach, known as the CHIC Protocol, could constitute a valuable tool for early recognition and accurate diagnosis of SH in clinical practice. […] Although secondary causes of hypertension are common in patients with resistant hypertension, a higher prevalence of SH persisted independent of the measured severity of BP values and SH was also identified in patients with moderate hypertension. […] By analyzing the causes and distribution of SH, we found that hyperaldosteronism is the most frequent endocrine etiology.

• #2 Hypertension Workup: Approach Considerations, Baseline Laboratory Evaluation, Radiologic Studies

  https://emedicine.medscape.com/article/241381-workup

  Measurement of the ratio of aldosterone to plasma renin activity (PRA) is performed to detect evidence of primary hyperaldosteronism. A ratio of more than 20-30 is suggestive of this condition. […] If pheochromocytoma is suspected, urinary catecholamines and fractionated metanephrines are the tests of choice. Plasma fractionated metanephrine levels have specificity, but their sensitivity is too low for screening purposes.

• #2 Diagnosis of Secondary Hypertension: An Age-Based Approach | AAFP

  https://www.aafp.org/pubs/afp/issues/2010/1215/p1471.html

  Testing can be done by measuring metanephrines in a 24-hour urine sample, but measurement of plasma free metanephrines is easier for the patient and has a negative likelihood ratio close to zero, making it a good test to rule out the disorder. […] Given the low frequency of Cushing syndrome, testing should be done only if there are suggestive features or after other possible causes have been ruled out. […] Renal artery stenosis secondary to atherosclerotic disease affects older adults. […] It should be suspected in those who develop hypertension after 50 years of age, have known atherosclerosis elsewhere, have unexplained renal insufficiency, or have a rapid deterioration in kidney function. […] Evaluation for possible chronic renal failure should include calculating the estimated glomerular filtration rate and obtaining a urinalysis to assess for albuminuria.

• #2 Secondary Hypertension, Differential diagnosis | Time of Care

  https://www.timeofcare.com/causes-of-secondary-hypertension/

  DDx […] Causes of Secondary Hypertension: ABCDEF […] Accuracy of diagnosis. […] Moderate to severe HTN in a patient with diffuse atherosclerosis, a unilateral small kidney, or asymmetry in renal size of more than 1.5 cm that cannot be explained by another reason. […] An onset of stage II HTN after age 55 yrs. […] For the initial testing start with either: 1) U/S (duplex Doppler U/S), 2) CTA, 3) MRA depending on local availability, expertise, and the presence or absence of renal insufficiency. […] Because of the potential for harm from invasive procedures, test only patients who have a high likelihood of benefiting from the procedure. […] If there is a low index of suspicion for pheochromocytoma, get a 24-hour urinary fractionated catecholamines and metanephrines; if there is a high index of suspicion, get plasma fractionated metanephrines.

• #2 Ruling out secondary causes of hypertension | EuroIntervention

  https://eurointervention.pcronline.com/article/ruling-out-secondary-causes-of-hypertension

  Approximately 30% of adults with hypertension have OSA. […] Specific questionnaires may be helpful in the routine assessment of the clinical features of OSA, but their diagnostic sensitivity and specificity are low. […] Drug-induced hypertension is one of the most common causes of secondary hypertension and is often found in clinical practice. […] The elimination of the responsible agent is not always possible in some cases, but a dose reduction or an alternative treatment option should be considered. […] Although the prevalence of pheochromocytoma in the general hypertensive population is very low, diagnosis and treatment are extremely important in view of the possibility of precipitating hypertensive crisis if the tumour is stimulated. […] Hypertension is one of the most distinguishing features of endogenous Cushings syndrome, and can be found in about 80% of adult patients. […] Coarctation of the aorta is a common cause of secondary hypertension in children, milder cases may first be detected as a rare cause of arterial hypertension in adults.

• #2 Secondary hypertension – Wikipedia

  https://en.wikipedia.org/wiki/Secondary_hypertension

  Secondary hypertension (or, less commonly, inessential hypertension) is a type of hypertension which has a specific and identifiable underlying primary cause. […] The ABCDE mnemonic can be used to help determine a secondary cause of hypertension. […] The goal of treating patients with hypertension due to OSA is addressing the underlying cause. […] Hypertension is common in chronic kidney disease. […] Certain medications, including NSAIDs (ibuprofen aka Motrin) and steroids can cause hypertension. […] The increases in blood pressure may result in blood pressures greater than when the medication was initiated. […] The differential diagnosis of a renal tumor in a young patient with hypertension includes juxtaglomerular cell tumor, Wilms’ tumor, and renal cell carcinoma, all of which may produce renin. […] Neuroendocrine tumors are also a well known cause of secondary hypertension.

• #2 Approach to the diagnosis of secondary hypertension in adults

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8542481/

  Identifying secondary hypertension presents an opportunity to modify a patients cardiovascular risk profile beyond what is achievable by antihypertensive therapy alone. Renal disease and primary aldosteronism are common causes. […] A methodical approach to identifying the cause is necessary and must take into account the drugs being used by the patient. Advice on test selection and patient preparation to optimise the value of initial investigations can be provided by a chemical pathologist or hypertension specialist. Patients who have abnormal results will require further investigations to confirm the cause.

• #2

  https://link.springer.com/article/10.1007/s00467-025-06716-2

  The findings from the comparison of our short diagnostic work-up with the AAP and ESH guidelines are particularly noteworthy. […] Both AAP and ESH protocols are less expensive than our short diagnostic work-up, with the AAP being the least costly. […] However, the AAP protocol failed to identify several cases of secondary hypertension. […] This study reinforces the recent trend indicating that primary hypertension is more prevalent than secondary hypertension in children, with kidney parenchymal disease being the most common cause of secondary hypertension.

• #2 Secondary Hypertension | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/28819

  It accounts for 70 to 85 percent of hypertension cases in children less than 12 years of age, and approximately 17 percent of cases in adults aged 65 and older. […] The prevalence of secondary hypertension is lowest amongst hypertensive patients who are 19 to 39 years of age while its prevalence in adolescents (12 to 18 years) is 10 to 15%. […] The initial screening tests for renal parenchymal diseases include serum creatinine with estimated glomerular filtration rate (eGFR), urine detailed report, urinary protein/protein to creatinine ratio, and renal ultrasound. […] A renal biopsy followed by histopathology is a gold-standard investigation, recommended for the diagnosis of specific conditions and pathophysiology of renal parenchymal diseases. […] Hypertension with hypokalemia is one of the characteristic features of primary aldosteronism, especially in those individuals with a family history of hypertension and cerebrovascular accidents at a young age.

• #2 Diagnosis of Secondary Hypertension: An Age-Based Approach | AAFP

  https://www.aafp.org/pubs/afp/issues/2010/1215/p1471.html

  Young adults thought to have secondary hypertension should be assessed for fibromuscular dysplasia of the renal artery. […] The aldosterone/renin ratio is the best initial test to determine whether a patient with hypertension should have further evaluation for aldosteronism. […] Obstructive sleep apnea can be a secondary cause of or contribute to hypertension. […] The most common etiologies in children, in whom 70 to 85 percent of cases of hypertension have a secondary cause, are different from those in older persons; therefore, an age-based approach to the differential diagnosis is recommended. […] Testing for thyroid dysfunction should be considered if there are any suggestive symptoms. […] The best initial test for aldosteronism is measurement of the aldosterone/renin ratio. […] Obstructive sleep apnea is a notable cause of secondary hypertension, particularly in 40- to 59-year-olds.

• #2 Secondary Hypertension | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/28819

  The plasma aldosterone/renin ratio is the preferred screening test for primary aldosteronism and it should be done at least four weeks after the withdrawal of aldosterone antagonists and after the correction of hypokalemia. […] Measurement of 24-hour urine aldosterone level after oral sodium loading and plasma aldosterone level after intravenous saline infusion are the diagnostic tests for primary aldosteronism, while renal vein sampling can be done for selected patients. […] Screening for pheochromocytoma/paraganglioma is recommended in the presence of episodic hypertension, along with palpitations, headache, postural hypotension, and stigmata of neurofibromatosis. […] The management of secondary hypertension requires a multidisciplinary approach. […] The diagnosis and management of secondary hypertension require a multidisciplinary team and collaborative efforts.

• #2 (PDF) Secondary hypertension: Current diagnosis and treatment

  https://www.academia.edu/13566499/Secondary_hypertension_Current_diagnosis_and_treatment

  Secondary hypertension affects a small but significant number of the hypertensive population and, unlike primary hypertension, is a potentially curable condition. […] Specific testing is available and must be balanced depending on the risk and cost of the workup and treatment with the benefits obtained if the secondary cause is eliminated. […] Secondary hypertension should be considered in the presence of suggestive symptoms and signs, such as severe or resistant hypertension, age of onset younger than 30 years (especially before puberty), malignant or accelerated hypertension, and an acute rise in blood pressure from previously stable readings. […] The accurate identification and diagnosis of secondary hypertension is critical, especially while atherosclerotic cardiovascular heart disease continues to be the leading cause of death in the industrialized world.

• #2 Evaluation of secondary hypertension – UpToDate

  https://www.uptodate.com/contents/evaluation-of-secondary-hypertension/print

  Evaluation of secondary hypertension. […] The evaluation of a patient with hypertension depends upon the likely cause and the degree of difficulty in achieving acceptable blood pressure control since many forms of secondary hypertension lead to „treatment-resistant” hypertension. […] By contrast, patients who have clinical clues suggesting the possible presence of secondary hypertension should undergo a more extensive evaluation. […] If secondary hypertension is present, the most effective treatment strategy often is one that is focused upon the specific mechanism underlying the hypertension. […] Because it is not cost effective to perform a complete evaluation for secondary hypertension in every hypertensive patient, it is important to be aware of the clinical clues that suggest secondary hypertension. […] The identification of patients who should undergo an evaluation for secondary hypertension will be reviewed here.

• #2 Improved identification of secondary hypertension: use of a systematic protocol

  https://atm.amegroups.org/article/view/20388/html

  The diagnosis of hyperaldosteronism in our population was based upon increased aldosterone-to-renin ratio, in efforts to avoid over-diagnosis of incidentaloma, according to guideline recommendations. […] While the CHIC Protocol reflects a methodology to identify the risk of SH, physicians were encouraged to use confirmatory laboratory and imaging techniques for the diagnosis of the causes of SH. […] Overall, we have not revealed any novel diagnostic laboratory tests for the detection of SH, but have described the usefulness of applying what has been already shown to be beneficial: a systematic protocol that can be utilized in a broad range of hypertensive patients.

• #3 Practice Recommendations for Diagnosis and Treatment of the Most Common Forms of Secondary Hypertension | High Blood Pressure & Cardiovascular Prevention

  https://link.springer.com/article/10.1007/s40292-020-00415-9

  The vast majority of hypertensive patients are never sought for a cause of their high blood pressure, i.e. for a ‘secondary’ form of arterial hypertension. […] The early detection of a secondary form is crucial, because if diagnosed in a timely manner, these forms can be cured at long-term, and even when cure cannot be achieved, their diagnosis provides a better control of high blood pressure, and allows prevention of hypertension-mediated organ damage, and related cardiovascular complications. […] The European Societies of Cardiology and Hypertension (ESC/ESH) guidelines suggest that the screening for SH should be restricted to patients with certain features, such as younger age (i.e. < 40 years), acute worsening of HT in patients with previously documented chronically stable normotension, severe (grade 3) or drug-resistant HT, presence of extensive hypertension-mediated organ damage (HMOD).

• #3 Secondary Hypertension | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/28819

  Secondary hypertension is defined as elevated blood pressure (BP), secondary to an identifiable cause. […] Identification of the etiology and pathophysiology of secondary hypertension is essential in selected groups of patients. […] It is important for healthcare professionals treating hypertension, to be aware of clinical clues that could suggest a secondary cause of hypertension. […] The common clinical signs which warrant investigations for a secondary cause of hypertension may include; Resistant hypertension, i.e., persistent blood pressure greater than 140/90 mm Hg despite using optimal doses of at least three anti-hypertensive from different classes, that includes a diuretic. […] An acute rise in blood pressure in a patient who had previously stable pressures. […] Hypertension develops in non-black patients before the age of 30 years, who do not have any other risk factors for hypertension, e.g., obesity, family history, etc.

• #3 Secondary Hypertension | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/28819

  It accounts for 70 to 85 percent of hypertension cases in children less than 12 years of age, and approximately 17 percent of cases in adults aged 65 and older. […] The prevalence of secondary hypertension is lowest amongst hypertensive patients who are 19 to 39 years of age while its prevalence in adolescents (12 to 18 years) is 10 to 15%. […] The initial screening tests for renal parenchymal diseases include serum creatinine with estimated glomerular filtration rate (eGFR), urine detailed report, urinary protein/protein to creatinine ratio, and renal ultrasound. […] A renal biopsy followed by histopathology is a gold-standard investigation, recommended for the diagnosis of specific conditions and pathophysiology of renal parenchymal diseases. […] Hypertension with hypokalemia is one of the characteristic features of primary aldosteronism, especially in those individuals with a family history of hypertension and cerebrovascular accidents at a young age.

• #3 Hypertension Workup: Approach Considerations, Baseline Laboratory Evaluation, Radiologic Studies

  https://emedicine.medscape.com/article/241381-workup

  In general, the evaluation of hypertension primarily involves accurately measuring the patients blood pressure (BP), performing a focused medical history and physical examination, and obtaining the results of routine laboratory studies. A 12-lead electrocardiogram should also be obtained. These steps can help determine the following: […] Other studies may be obtained on the basis of clinical findings or in individuals with suspected secondary hypertension and/or evidence of target-organ disease, such as complete blood cell (CBC) count, chest radiography, uric acid level, and urine microalbumin. […] Secondary causes of hypertension should be considered in patients with severely elevated BP hypertension resistant to medication or recurrence of elevated BP that was previously well-controlled on a medication regimen acute onset, diastolic hypertension and end-organ damage that is out of proportion to the length of disease.

• #3 Ruling out secondary causes of hypertension | EuroIntervention

  https://eurointervention.pcronline.com/article/ruling-out-secondary-causes-of-hypertension

  Approximately 30% of adults with hypertension have OSA. […] Specific questionnaires may be helpful in the routine assessment of the clinical features of OSA, but their diagnostic sensitivity and specificity are low. […] Drug-induced hypertension is one of the most common causes of secondary hypertension and is often found in clinical practice. […] The elimination of the responsible agent is not always possible in some cases, but a dose reduction or an alternative treatment option should be considered. […] Although the prevalence of pheochromocytoma in the general hypertensive population is very low, diagnosis and treatment are extremely important in view of the possibility of precipitating hypertensive crisis if the tumour is stimulated. […] Hypertension is one of the most distinguishing features of endogenous Cushings syndrome, and can be found in about 80% of adult patients. […] Coarctation of the aorta is a common cause of secondary hypertension in children, milder cases may first be detected as a rare cause of arterial hypertension in adults.

• #3 Ruling out secondary causes of hypertension | EuroIntervention

  https://eurointervention.pcronline.com/article/ruling-out-secondary-causes-of-hypertension

  The gold standard for diagnosing renal vascular disease is renal angiography. […] The presence of relevant ARAS should be considered particularly in patients with rapidly deteriorating renal function, those with a reduction in their estimated glomerular filtration rate of 25% after administration of a renin-angiotensin system-inhibitor or angiotensin receptor blocker, onset of hypertension after 50 years of age, and those with a history of flash pulmonary oedema. […] The prevalence of primary aldosteronism (PA) is greater than previously thought. […] The aldosterone-renin ratio (ARR) is the most reliable test for screening purposes. […] If the ARR is positive, biochemical evidence of PA has to be confirmed, e.g., with the oral sodium loading. […] Even in the general population, and particularly in men, obstructive sleep apnoea (OSA) is a common finding.

• #3 Secondary Hypertension | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/28819

  The plasma aldosterone/renin ratio is the preferred screening test for primary aldosteronism and it should be done at least four weeks after the withdrawal of aldosterone antagonists and after the correction of hypokalemia. […] Measurement of 24-hour urine aldosterone level after oral sodium loading and plasma aldosterone level after intravenous saline infusion are the diagnostic tests for primary aldosteronism, while renal vein sampling can be done for selected patients. […] Screening for pheochromocytoma/paraganglioma is recommended in the presence of episodic hypertension, along with palpitations, headache, postural hypotension, and stigmata of neurofibromatosis. […] The management of secondary hypertension requires a multidisciplinary approach. […] The diagnosis and management of secondary hypertension require a multidisciplinary team and collaborative efforts.

• #3 Biochemical investigation of secondary hypertension – Manchester University NHS Foundation Trust

  https://mft.nhs.uk/the-trust/other-departments/laboratory-medicine/information-for-gps/laboratory-medicines-newsletter-for-gps/biochemical-investigation-of-secondary-hypertension/

  Renal disorders such as CKD, diabetic nephropathy or polycystic kidney disease are the most common cause of secondary hypertension. Other causes include vascular disorders such as renal artery stenosis, drugs and medications, obstructive sleep apnoea, pregnancy and endocrine disorders. Clinical examinations and routine biochemical tests can indicate which are the most likely secondary causes and signpost which further investigations could be helpful. […] Initial investigations for CKD should include eGFR and urine albumin:creatinine ratio. Early morning urine samples are recommended for the albumin:creatinine ratio. […] Aldosterone:renin ratio (ARR) is the first line test for the diagnosis of primary hyperaldosteronism. […] Plasma metanephrines are more sensitive than urine metanephrines for PPGL diagnosis (97% for plasma vs 90% for urine) which is why plasma metanephrines is the test offered for the investigation of PPGL in this Trust. […] If Cushings syndrome is clinically suspected, there are several tests that can be performed to identify if the patient has hypercortisolism; however random serum cortisol is not useful for this. […] Thyroid function tests (TSH and fT4) should be requested to investigate thyroid disorders.

• #3 Secondary hypertension in adults | SMJ

  http://www.smj.org.sg/article/secondary-hypertension-adults

  Secondary hypertension is a common cause of hypertension in adults, occurring in about 10% of hypertensive patients. […] Failure to recognise secondary causes can lead to resistant hypertension, cardiovascular complications or complications of the underlying condition. […] In older adults, primary aldosteronism, RAS and OSA are common and often underdiagnosed. Screening tests, if available, should be performed to detect these conditions. […] Diagnosis and treatment of causes of secondary hypertension can lead to good clinical outcomes.

• #4 Approach to the diagnosis of secondary hypertension in adults

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8542481/

  Presentations that should raise suspicion of secondary hypertension include early-onset, severe or resistant hypertension. A suggestive family history or clinical clues can point to a specific secondary cause. […] The assessment of patients begins with history taking and examination, to look for clinical clues. Laboratory tests include electrolytes, urea, creatinine and the aldosterone:renin ratio, urinalysis and the urine albumin:creatinine ratio. Abnormal results should prompt further investigation. […] Secondary hypertension occurs in approximately 10% of adults with hypertension. Identifying and treating the cause can potentially cure or markedly improve hypertension and reduce the associated cardiovascular risk. […] All patients suspected of having secondary hypertension should be screened for the common causes and associations. These include renal disease (parenchymal or renovascular), primary aldosteronism, medicines, illicit substances, alcohol and obstructive sleep apnoea.

• #4 Diagnosis of Secondary Hypertension: An Age-Based Approach | AAFP

  https://www.aafp.org/pubs/afp/issues/2010/1215/p1471.html

  Therefore, all children with confirmed hypertension should have an evaluation for an underlying etiology that includes renal ultrasonography. […] Whenever a patient is diagnosed with hypertension, one purpose of the initial assessment (i.e., history, physical examination, and basic laboratory testing) is to exclude possible secondary causes. […] Indications for further investigation into a possible secondary etiology in the absence of suggestive signs and symptoms include resistant hypertension, early or late onset of hypertension, a severe or accelerated course, or specific drug intolerances. […] In the absence of clinical signs to suggest possible secondary hypertension in adults, indications for further evaluation include resistant hypertension and early, late, or rapid onset of high blood pressure.

• #4 Approach to the diagnosis of secondary hypertension in adults

  https://australianprescriber.tg.org.au/articles/approach-to-the-diagnosis-of-secondary-hypertension-in-adults.html

  Presentations that should raise suspicion of secondary hypertension include early-onset, severe or resistant hypertension. A suggestive family history or clinical clues can point to a specific secondary cause. […] The assessment of patients begins with history taking and examination, to look for clinical clues. Laboratory tests include electrolytes, urea, creatinine and the aldosterone:renin ratio, urinalysis and the urine albumin:creatinine ratio. Abnormal results should prompt further investigation. […] Secondary hypertension occurs in approximately 10% of adults with hypertension. Identifying and treating the cause can potentially cure or markedly improve hypertension and reduce the associated cardiovascular risk. […] The history and examination may raise suspicion of secondary hypertension. It is important to remember that drugs can cause hypertension. Laboratory tests can help to identify other causes.

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