What is the treatment approach for secondary hypertension?

Treatment Approach for Secondary Hypertension

The treatment of secondary hypertension requires identification and targeted management of the underlying cause, which has the potential to cure hypertension in some patients or significantly improve blood pressure control in others. 1

Identification of Secondary Hypertension

• Screen for secondary hypertension in patients with early-onset hypertension (<30 years), resistant hypertension, sudden deterioration in BP control, hypertensive urgency/emergency, or strong clinical clues suggesting secondary causes 1, 2
• Basic screening should include thorough history, physical examination, basic blood biochemistry (sodium, potassium, eGFR, TSH), and urinalysis 1
• Further investigations should be based on clinical suspicion from initial evaluation 1
• Consider referral to specialist centers with expertise in diagnosing and managing secondary hypertension 1

Treatment Based on Specific Causes

Primary Aldosteronism

• Screen with plasma aldosterone-to-renin ratio in patients with resistant hypertension, hypokalemia, incidentally discovered adrenal mass, or family history of early-onset hypertension 1, 2
• For unilateral primary aldosteronism, surgical removal of the adrenal gland is typically considered 1
• For bilateral primary aldosteronism, medical treatment with mineralocorticoid receptor antagonists (MRAs) is recommended 1
• Spironolactone (50-100 mg daily, up to 300-400 mg if necessary) is the most widely used MRA 1, 3
• Eplerenone is an alternative with fewer side effects like gynaecomastia and erectile dysfunction 1

Renovascular Hypertension

• Medical therapy is recommended for atherosclerotic renal artery stenosis 1
• For fibromuscular dysplasia, percutaneous transluminal renal angioplasty without stenting is the treatment of choice 1
• Consider revascularization for patients with refractory hypertension, worsening renal function, or intractable heart failure despite medical management 1

Renal Parenchymal Disease

• Optimize antihypertensive therapy with RAS blockers (ACE inhibitors or ARBs) when appropriate 4
• Address the underlying renal disease with specific treatments 1
• Monitor renal function carefully when using RAS blockers 1

Obstructive Sleep Apnea

• Continuous positive airway pressure (CPAP) therapy for moderate-severe cases 1, 2
• Weight loss for obese patients 2
• Standard antihypertensive medications as needed 1

Management of Resistant Hypertension

• First exclude pseudoresistance (poor BP measurement technique, white coat effect, nonadherence) and substance-induced increases in BP 1
• Optimize current treatment regimen including lifestyle changes and diuretic-based treatment 1
• Use thiazide-like rather than thiazide diuretics, and consider loop diuretics for eGFR <30 ml/min/1.73m² 1
• Add spironolactone as fourth-line agent (if serum potassium <4.5 mmol/L and eGFR >45 ml/min/1.73m²) 1
• If spironolactone is contraindicated or not tolerated, consider eplerenone, amiloride, doxazosin, clonidine, or beta-blockers 1
• Renal denervation may be considered for resistant hypertension uncontrolled despite a three-drug combination, but only in medium-to-high volume centers after multidisciplinary assessment 1

Lifestyle Modifications

• Sodium restriction, weight loss, and limited alcohol consumption are recommended for all patients with secondary hypertension 2, 5
• Physical activity and healthy dietary patterns enhance the efficacy of pharmacologic therapy 5
• These modifications should be implemented alongside specific treatments for the underlying cause 1, 5

Follow-up and Monitoring

• Regular monitoring of blood pressure, renal function, and electrolytes is essential 1
• Assess for target organ damage 2, 6
• Evaluate treatment response and adjust therapy as needed 1
• Consider lifelong treatment if hypertension persists despite addressing the underlying cause 1

Pitfalls and Caveats

• Secondary hypertension is often underrecognized, affecting 5-10% of hypertensive patients 1, 7
• Delayed diagnosis can lead to vascular remodeling, affecting renal function and resulting in residual hypertension even after treating the underlying cause 1
• Combining two RAS blockers (ACE inhibitor and ARB) is not recommended 1
• Certain medications can worsen specific forms of secondary hypertension and should be avoided 2
• Even after treating the underlying cause, some patients may require ongoing antihypertensive therapy 1