What could be the cause of hypertension in an otherwise healthy 27-year-old male?

Hypertension in a 27-Year-Old Male: Causes and Evaluation

In an otherwise healthy 27-year-old male with hypertension, you should strongly suspect secondary hypertension rather than primary hypertension, as early-onset hypertension before age 30—especially without obesity, metabolic syndrome, or family history—is a red flag for an identifiable underlying cause. 1

Why Secondary Hypertension is More Likely at This Age

While primary (essential) hypertension accounts for approximately 90% of all hypertension cases, this pattern shifts dramatically in young adults. 2, 3 The key distinguishing features that should raise your suspicion include:

• Age of onset <30 years, particularly in the absence of typical risk factors 1
• Absence of family history of hypertension 1
• Sudden onset or rapid progression rather than gradual increase 1
• Severe or resistant hypertension at presentation 1

Most Common Secondary Causes in Young Adults

Renal Parenchymal Disease

The most common secondary cause overall, including chronic glomerulonephritis and polycystic kidney disease. 1, 3 Look for:

• History of kidney disease or proteinuria/hematuria 1
• Palpable kidneys on examination 1
• Elevated serum creatinine or abnormal urinalysis 1

Renovascular Disease (Renal Artery Stenosis)

Particularly fibromuscular dysplasia in young patients (90% women, typically diagnosed in early 50s, but can present earlier). 1 Suspect when:

• Abdominal or flank bruit present 1, 3
• Onset before age 30 3
• Accelerated or malignant hypertension 3

Primary Aldosteronism

Prevalence reaches 20% in resistant hypertension populations. 1 Clinical clues:

• Unprovoked hypokalemia (not on diuretics) or excessive hypokalemia 1
• Muscle cramps and weakness 1, 3
• Screen with aldosterone-renin ratio 1

Obstructive Sleep Apnea

Prevalence of 25-50% in hypertensive patients. 4 Look for:

• Snoring and daytime hypersomnolence 1, 3
• Obesity (though patient described as "otherwise healthy") 4

Pheochromocytoma

Though rare, critical not to miss. 3 Suspect with:

• Blood pressure lability and episodic symptoms 1, 4
• Paroxysmal headache, palpitations, pallor, and perspiration 3
• Screen with plasma free metanephrines (96-100% sensitivity) 4

Drug/Substance-Induced Hypertension

Often overlooked but common. 1, 3 Specifically ask about:

• NSAIDs (most common) 1, 3
• Cocaine or amphetamines 1, 3
• Oral contraceptives, steroids 1
• Sympathomimetics in cold remedies 1

Coarctation of the Aorta

Must be excluded in young adults. 1 Check for:

• Radio-femoral pulse delay or weak femoral pulses 1
• Thigh blood pressure measurement is mandatory in adults ≤30 years with elevated brachial BP—if thigh pressure is lower than arm pressure, coarctation is likely 1

Primary Hypertension Considerations

If secondary causes are excluded, primary hypertension can still occur in young adults, particularly with: 2, 3

• Obesity (responsible for 40% of all hypertension, up to 78% in men) 2, 3
• Strong family history of hypertension 1, 2
• Lifestyle factors: high sodium intake, physical inactivity, excessive alcohol (≥3 drinks/day) 2, 3
• Gradual BP increase over time rather than sudden onset 1

Recommended Diagnostic Approach

Initial Evaluation (All Patients)

• Accurate BP measurement technique, including standing BP to assess for orthostatic changes 1
• Thigh BP measurement (mandatory at this age) 1
• Comprehensive medication/substance history 1
• Family history of hypertension and cardiovascular disease 1

Basic Laboratory Screening

• Serum creatinine with eGFR 1
• Serum electrolytes (particularly potassium) 1
• Fasting glucose and hemoglobin A1C 1
• Lipid profile 1
• Urinalysis with urine albumin-creatinine ratio 1
• TSH 1
• Electrocardiogram 1

Targeted Secondary Hypertension Screening (Based on Clinical Clues)

• Aldosterone-renin ratio if hypokalemia, muscle weakness, or resistant hypertension 1
• Plasma free metanephrines or 24-hour urinary fractionated metanephrines if episodic symptoms or labile BP 1, 4
• Renal ultrasound or renal artery imaging if abdominal bruit, asymmetric kidney size, or elevated creatinine 1
• Sleep study if snoring, daytime sleepiness, or obesity 1, 3

Critical Pitfalls to Avoid

• Never assume primary hypertension in a patient <30 years without thoroughly excluding secondary causes, especially if there's no obesity, metabolic syndrome, or family history 1
• Don't forget the thigh BP measurement—this is the only way to detect coarctation clinically 1
• Always review all medications and substances before extensive workup, as drug-induced hypertension is common and reversible 1, 3
• Don't initiate beta-blockers in suspected pheochromocytoma before alpha-blockade, as this precipitates hypertensive crisis 4
• Consider referral to a specialist center if secondary hypertension is suspected, as these patients require expertise and resources for proper diagnosis and management 1