From the Guidelines
To investigate secondary causes of hypertension, start with a comprehensive clinical assessment and basic laboratory tests, and proceed with targeted investigations based on suggestive signs, symptoms, or medical history, as recommended by the 2024 ESC guidelines 1. When evaluating patients with hypertension, it is essential to consider secondary causes, as identifying the underlying cause can lead to specific treatments or even cure, rather than lifelong antihypertensive therapy.
Initial Assessment
The initial assessment should include a detailed history, physical examination, and basic laboratory tests, such as urinalysis, blood chemistry (sodium, potassium, creatinine, glucose), lipid profile, and 12-lead ECG.
Targeted Investigations
For patients with features suggesting secondary hypertension, such as young age, sudden onset, resistant hypertension, or specific symptoms, proceed with targeted investigations.
- For primary aldosteronism, measure aldosterone-to-renin ratio 1;
- For renal artery stenosis, use duplex ultrasound followed by CT or MR angiography 1;
- For pheochromocytoma, measure plasma or urinary metanephrines 1;
- For Cushing's syndrome, perform overnight dexamethasone suppression test 1;
- For obstructive sleep apnea, use screening questionnaires and sleep studies 1;
- For renal parenchymal disease, check renal function, urinalysis, and renal ultrasound 1. Thyroid function tests should be performed when clinically indicated 1.
Recent Guidelines
The 2024 ESC guidelines recommend screening for secondary hypertension in patients with suggestive signs, symptoms, or medical history, and also advise considering screening for primary aldosteronism by renin and aldosterone measurements in all adults with confirmed hypertension 1.
Patient-Specific Approach
A patient-specific approach is essential, taking into account the individual's medical history, symptoms, and physical examination findings to guide targeted investigations. By following these recommendations and guidelines, clinicians can effectively investigate secondary causes of hypertension and provide personalized care to their patients, ultimately improving morbidity, mortality, and quality of life outcomes.
From the Research
Investigating Secondary Causes of Hypertension
To investigate secondary causes of hypertension as per ESC guidelines, the following steps can be taken:
- Identify patients with resistant hypertension, hypokalemia, or onset of hypertension at a young age 2, 3, 4, 5
- Perform a thorough medical history and physical examination to look for signs and symptoms of secondary hypertension 2, 3, 4
- Conduct laboratory tests such as plasma aldosterone concentration (PAC) to plasma renin activity (PRA) ratio, fractionated metanephrines, and catecholamines to diagnose primary aldosteronism and pheochromocytoma 6, 5
- Use imaging studies such as abdominal CT and 18F-FDOPA PET-CT to localize adrenal lesions 6
- Consider referral to a specialist for further evaluation and management if secondary hypertension is suspected 4
Common Causes of Secondary Hypertension
Some common causes of secondary hypertension include:
- Primary aldosteronism 6, 2, 3, 5
- Pheochromocytoma 6, 5
- Renovascular hypertension 2, 3
- Obstructive sleep apnea 2, 3
- Drug-induced hypertension 2, 3
Diagnostic Strategies
Diagnostic strategies for secondary hypertension may involve: