From the Guidelines
The workup for secondary causes of hypertension in a 20-year-old male should be comprehensive, including a detailed history, physical examination, laboratory testing, and imaging studies, as outlined in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.
Initial Evaluation
The initial evaluation should include a detailed history focusing on medication use (including over-the-counter drugs, supplements, and illicit substances), family history of hypertension, and symptoms suggesting specific causes.
- Medication use, including over-the-counter drugs, supplements, and illicit substances
- Family history of hypertension
- Symptoms suggesting specific causes, such as endocrine disorders, renal disease, or vascular abnormalities
Physical Examination
Physical examination should assess for signs of endocrine disorders, renal disease, or vascular abnormalities.
- Signs of endocrine disorders, such as Cushing's syndrome or primary aldosteronism
- Signs of renal disease, such as abdominal mass or skin pallor
- Signs of vascular abnormalities, such as abdominal bruit or delayed ankle reflex
Laboratory Testing
Laboratory testing should include basic metabolic panel, urinalysis, and complete blood count.
- Basic metabolic panel to evaluate for electrolyte imbalances and renal function
- Urinalysis to evaluate for proteinuria, hematuria, or other abnormalities
- Complete blood count to evaluate for anemia or other hematologic abnormalities
Specific Tests
Specific tests should include plasma renin activity and aldosterone levels to evaluate for primary aldosteronism; 24-hour urine collection for metanephrines, catecholamines, and cortisol to screen for pheochromocytoma and Cushing's syndrome; and thyroid function tests.
- Plasma renin activity and aldosterone levels to evaluate for primary aldosteronism 1
- 24-hour urine collection for metanephrines, catecholamines, and cortisol to screen for pheochromocytoma and Cushing's syndrome
- Thyroid function tests to evaluate for hypothyroidism or hyperthyroidism
Imaging Studies
Imaging studies should include renal ultrasound to assess kidney size and structure, and renal artery duplex ultrasound or CT angiography to evaluate for renal artery stenosis.
- Renal ultrasound to assess kidney size and structure
- Renal artery duplex ultrasound or CT angiography to evaluate for renal artery stenosis 1
- Echocardiogram to assess for coarctation of the aorta
- Sleep study to evaluate for obstructive sleep apnea, if suspected
These investigations are crucial because identifying a secondary cause can lead to targeted treatment that may cure or significantly improve hypertension, avoiding lifelong antihypertensive therapy in a young patient, as recommended by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.
From the Research
Workup for Secondary Causes of Hypertension
The workup for secondary causes of hypertension in a 20-year-old male involves a comprehensive approach to identify the underlying cause of hypertension. The following steps can be taken:
- Take a thorough history to look for clinical clues, such as early-onset, severe or resistant hypertension, and a suggestive family history 2
- Perform a physical examination to look for signs of secondary hypertension, such as abdominal bruits or delayed femoral pulses 3
- Order laboratory tests, including:
- Electrolytes, urea, creatinine, and the aldosterone:renin ratio to screen for primary aldosteronism 2
- Urinalysis and the urine albumin:creatinine ratio to assess for renal disease 2
- 24-hour ambulatory blood pressure monitoring to assess for obstructive sleep apnea and other causes of secondary hypertension 4
- Consider further investigation based on abnormal results, such as imaging studies or specialty referrals 2, 5
- Evaluate for common causes of secondary hypertension, including:
- Renal disease, such as chronic kidney disease or renal artery stenosis 5, 4
- Primary aldosteronism, which can be screened for using the aldosterone:renin ratio 6, 2
- Obstructive sleep apnea, which can be diagnosed using polysomnography or other tests 2, 4
- Pheochromocytoma, which can be diagnosed using biochemical tests and imaging studies 6
- Other causes, such as Cushing syndrome, thyroid disease, or coarctation of the aorta 3
Special Considerations
In a 20-year-old male, it is essential to consider the potential for secondary hypertension due to underlying conditions such as:
- Renal parenchymal disease or coarctation of the aorta, which are more common in younger patients 3
- Primary aldosteronism, which can cause hypertension in young adults 6
- Pheochromocytoma, which is a rare but potentially curable cause of hypertension 6
- Obstructive sleep apnea, which can be a common cause of secondary hypertension in young adults 4