What are the likely causes and management options for hypertension in a 38-year-old patient?

Causes of Hypertension at Age 38

In a 38-year-old patient, hypertension is most commonly primary (essential) hypertension related to lifestyle factors, but this age warrants careful evaluation for secondary causes, particularly if blood pressure is severe, resistant to treatment, or has sudden onset. 1

Primary (Essential) Hypertension

Primary hypertension is the most likely diagnosis if there is:

• Gradual increase in blood pressure with slow rate of rise 1
• Strong family history of hypertension 1
• Lifestyle risk factors including weight gain, high-sodium diet, decreased physical activity, excessive alcohol consumption (>2 drinks daily for men, >1 for women), or sedentary lifestyle 1, 2
• Obesity, which is one of the strongest risk factors for hypertension 3, 4

Secondary Causes to Evaluate

At age 38, secondary hypertension should be strongly considered, as onset before age 30-40 years is a key clinical clue requiring comprehensive screening. 1, 5

Most Common Secondary Causes in This Age Group:

Renal Parenchymal Disease (most common secondary cause overall):

• History of urinary tract infections, obstruction, hematuria, urinary frequency, nocturia, or family history of polycystic kidney disease 1, 5
• Screen with serum creatinine, eGFR, urinalysis, and urinary albumin-to-creatinine ratio 1, 5

Renovascular Disease (particularly fibromuscular dysplasia in young women):

• Abrupt onset or worsening hypertension, flash pulmonary edema, or early-onset hypertension 1, 5
• Screen with renal ultrasound with Doppler, followed by CT or MR renal angiography if suspicious 5

Primary Aldosteronism (affects 8-20% of resistant hypertension cases):

• Hypokalemia (spontaneous or diuretic-induced), muscle cramps/weakness, or family history of early-onset hypertension 1, 5
• The 2024 ESC guidelines now recommend measuring plasma aldosterone-to-renin ratio in ALL adults with confirmed hypertension (Class IIa recommendation) 5

Obstructive Sleep Apnea (present in 25-50% of resistant hypertension):

• Snoring, daytime sleepiness, obesity, non-dipping nocturnal blood pressure pattern 1, 5
• Screen with Berlin Questionnaire or Epworth Sleepiness Score, confirm with polysomnography 3

Drug-Induced Hypertension:

• NSAIDs (most common), oral contraceptives, decongestants (phenylephrine, pseudoephedrine), amphetamines, antidepressants (MAOIs, SNRIs, TCAs), atypical antipsychotics, immunosuppressants (cyclosporine), excessive caffeine (>300 mg/day), herbal supplements (ephedra, yohimbine), or illicit drugs (cocaine, amphetamines) 1

Less Common but Important Causes:

• Pheochromocytoma: episodic symptoms, labile hypertension, pallor, palpitations, headache 1, 5
• Cushing's syndrome: central obesity, facial rounding, easy bruisability 1
• Hyperthyroidism: weight loss, palpitations, heat intolerance 1
• Coarctation of the aorta: measure thigh blood pressure if brachial BP elevated; lower thigh pressure than arm suggests coarctation 1

Initial Diagnostic Approach

Basic laboratory screening should include: 1, 5

• Fasting blood glucose or HbA1c
• Complete blood count
• Lipid profile
• Serum creatinine with eGFR
• Serum sodium, potassium, calcium
• Thyroid-stimulating hormone
• Urinalysis with urinary albumin-to-creatinine ratio
• Electrocardiogram
• Plasma aldosterone-to-renin ratio (per 2024 ESC guidelines) 5

Physical examination should specifically assess for: 1

• Accurate blood pressure measurement in both arms (use higher reading if consistent difference)
• Orthostatic blood pressure (decline >20/10 mmHg after 1 minute is abnormal)
• Thigh blood pressure if age ≤30 years
• Acral features (acromegaly), cushingoid features, enlarged kidneys (polycystic disease), abdominal bruits (renovascular disease), diminished femoral pulses (coarctation)

Critical Clinical Clues Suggesting Secondary Hypertension

Immediate red flags requiring thorough secondary hypertension workup: 1, 5

• Age of onset <30 years (or <40 per 2024 ESC guidelines)
• Severe hypertension (≥160/100 mmHg) or resistant hypertension (≥140/90 mmHg despite 3+ medications including diuretic)
• Abrupt onset or sudden deterioration of previously controlled hypertension
• Hypertensive urgency or emergency
• Target organ damage disproportionate to duration or severity of hypertension
• Absence of family history of hypertension

Management Principles

For primary hypertension at age 38: 1, 2

• Initiate lifestyle modifications: sodium restriction (<1500-2400 mg/day), potassium supplementation (3500-5000 mg/day unless contraindicated), weight loss if overweight, regular physical activity, alcohol moderation
• Start pharmacologic therapy if blood pressure ≥140/90 mmHg with high cardiovascular risk OR if blood pressure remains ≥140/90 mmHg after 3-6 months of lifestyle intervention in low-moderate risk patients
• First-line medications: thiazide/thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide), ACE inhibitor or ARB, or long-acting dihydropyridine calcium channel blocker

For suspected secondary hypertension: 5, 3

• Treat the underlying cause when identified
• Continue antihypertensive therapy as needed, as some patients require ongoing treatment even after addressing secondary causes
• Consider referral to hypertension specialist if blood pressure remains uncontrolled despite optimal therapy

Common Pitfalls to Avoid

• Failing to screen for secondary causes in young patients (<40 years), as this represents a critical opportunity for potentially curative treatment 5, 3
• Overlooking medication-induced hypertension before pursuing expensive imaging studies 5
• Missing obstructive sleep apnea, which is highly prevalent but underrecognized in resistant hypertension 1, 5
• Not measuring aldosterone-to-renin ratio, particularly given the 2024 ESC recommendation to screen all hypertensive patients 5
• Assuming primary hypertension without proper evaluation when clinical clues suggest secondary causes 1