Hypertension Differential Diagnosis

The differential diagnosis for hypertension can be organized into the following categories:

• Single Most Likely Diagnosis

  • Essential Hypertension: This is the most common cause of hypertension, accounting for approximately 90-95% of cases. It is a diagnosis of exclusion, made after ruling out secondary causes of hypertension. Essential hypertension is often associated with a family history, obesity, and lifestyle factors such as a high-sodium diet and physical inactivity.

• Other Likely Diagnoses

  • Renal Disease (e.g., Chronic Kidney Disease, Renal Artery Stenosis): Kidney problems can lead to hypertension due to fluid overload, electrolyte imbalances, or activation of the renin-angiotensin-aldosterone system. Conditions such as chronic kidney disease or renal artery stenosis are common causes of secondary hypertension.
  • Primary Aldosteronism: This condition, characterized by excessive production of aldosterone, leads to sodium retention, water retention, and potassium loss, resulting in hypertension.
  • Sleep Apnea: Obstructive sleep apnea is increasingly recognized as a cause of secondary hypertension, possibly due to intermittent hypoxia, sympathetic activation, and inflammation.
  • Thyroid Disease: Both hyperthyroidism and hypothyroidism can cause hypertension, although the mechanisms differ. Hyperthyroidism increases cardiac output, while hypothyroidism may lead to increased peripheral resistance.

• Do Not Miss Diagnoses

  • Pheochromocytoma: A rare tumor of the adrenal gland that secretes catecholamines, leading to episodic or sustained hypertension. Although rare, missing this diagnosis can be fatal due to the risk of hypertensive crises.
  • Aortic Coarctation: A congenital narrowing of the aortic isthmus, which can cause severe hypertension in the arms, with decreased or delayed pulses in the lower extremities. Untreated, it can lead to heart failure, aortic dissection, or cerebral hemorrhage.
  • Cushing's Syndrome: Caused by excess cortisol, this condition can lead to hypertension due to the mineralocorticoid effects of cortisol. Missing this diagnosis can result in significant morbidity and mortality.

• Rare Diagnoses

  • Hyperparathyroidism: Excess parathyroid hormone can lead to hypertension, possibly through its effects on calcium and phosphate metabolism, and renal function.
  • Acromegaly: Growth hormone excess can cause hypertension, likely due to its effects on cardiac output, vascular tone, and renal function.
  • Liddle's Syndrome: A rare genetic disorder characterized by excessive sodium absorption in the distal nephron, leading to hypertension and hypokalemia.
  • Apparent Mineralocorticoid Excess: A rare condition where the enzyme 11-beta hydroxysteroid dehydrogenase type 2 is deficient, leading to an excessive effect of cortisol on mineralocorticoid receptors, causing hypertension and hypokalemia.