Secondary Hypertension: Discovering the Underlying Cause

 

Most patients with hypertension have no clear etiology and are classified as having primary hypertension. However, 5% to 10% of these patients may have secondary hypertension, which indicates an underlying and potentially reversible cause. The prevalence and potential etiologies of secondary hypertension vary by age. The most common causes in children are renal parenchymal disease and coarctation of the aorta. In adults 65 years and older, atherosclerotic renal artery stenosis, renal failure, and hypothyroidism are common causes. 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. Additionally, renovascular hypertension should be considered in patients with an increase in serum creatinine of at least 50% occurring within one week of initiating angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy; severe hypertension and a unilateral smaller kidney or difference in kidney size greater than 1.5 cm; or recurrent flash pulmonary edema. Other underlying causes of secondary hypertension include hyperaldosteronism, obstructive sleep apnea, pheochromocytoma, Cushing syndrome, thyroid disease, coarctation of the aorta, and use of certain medications.

Hypertension is common, affecting nearly 30% of U.S. adults and increasing to 65% of persons 60 to 69 years of age.1 The annual cost of treatment for hypertension in the United States is $47.5 billion.2

Secondary hypertension is a type of hypertension with an underlying and potentially reversible cause. It makes up only a small fraction (5% to 10%) of hypertensive cases.35 The prevalence of secondary hypertension varies by age and is more common in younger persons, with a prevalence close to 30% in those 18 to 40 years of age with hypertension.3 Extensive testing for secondary hypertension is not warranted in all patients with hypertension because of cost, low yield, and the potential for false-positive results; however, testing is recommended in patients younger than 30 years.6,7

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

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.

C

3

Preadolescent children with hypertension should be evaluated for possible secondary causes.

C

16

Young adults thought to have secondary hypertension should be assessed for fibromuscular dysplasia of the renal artery with magnetic resonance angiography or computed tomography angiography.

C

43

The aldosterone-to-renin ratio is the best initial test to determine whether a patient with hypertension should have further evaluation for hyperaldosteronism.

C

24

Patients who are obese and who have signs or symptoms of obstructive sleep apnea and hypertension should be assessed with polysomnography.

C

51


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

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.

C

3

Preadolescent children with hypertension should be evaluated for possible secondary causes.

C

16

Young adults thought to have secondary hypertension should be assessed for fibromuscular dysplasia of the renal artery with magnetic resonance angiography or computed tomography angiography.

C

43

The aldosterone-to-renin ratio is the best initial test to determine whether a patient with hypertension should have further evaluation for hyperaldosteronism.

C

24

Patients who are obese and who have signs or symptoms of obstructive sleep apnea and hypertension should be assessed with polysomnography.

C

51


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

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BEST PRACTICES IN CARDIOLOGY: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not screen for renal artery stenosis in patients without resistant

The Authors

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LESLEY CHARLES, MD, is an associate professor in the Department of Family Medicine and program director of the Division of Care of the Elderly at the University of Alberta, Edmonton, Alberta, Canada....

JEAN TRISCOTT, MD, is a professor in the Department of Family Medicine and division director of the Division of Care of the Elderly at the University of Alberta.

BONNIE DOBBS, PhD, is a professor in the Department of Family Medicine, director of the Medically At-Risk Driver Centre, and director of research in the Division of Care of the Elderly at the University of Alberta.

Author disclosure: No relevant financial affiliations.

Address correspondence to Lesley Charles, MD, University of Alberta, Room 1259, 10230 111 Ave., Edmonton, AB, Canada T5G 0B7 (e-mail: Lesley.charles@albertahealthservices.ca). Reprints are not available from the authors.

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