What key elements should be included in the history when evaluating a patient with young‑onset hypertension diagnosed before age 40?

History Taking for Young-Onset Hypertension (Age <40)

When evaluating a patient with young-onset hypertension, obtain a comprehensive history focused on identifying secondary causes, assessing target organ damage risk, and documenting lifestyle factors that distinguish primary from secondary hypertension.

Essential Historical Components

Duration and Pattern of Blood Pressure Elevation

• Document the duration of hypertension, previous BP levels, and any prior antihypertensive medications including reasons for discontinuation or intolerance 1
• Ask about the rate of BP rise: a gradual increase with slow progression suggests primary hypertension, while abrupt onset or sudden worsening of previously controlled BP suggests secondary causes 1, 2
• Age of onset <30 years is a red flag for secondary hypertension, particularly renal parenchymal disease, renovascular disease, or coarctation of the aorta 1, 2

Medication and Substance History

• Inquire about current medications and over-the-counter drugs that can elevate BP, including NSAIDs, decongestants, oral contraceptives, and corticosteroids 1
• Document alcohol consumption, caffeine intake, and nicotine use (smoking or vaping), as these substances can influence BP 2
• Ask about illicit drug use, particularly cocaine and amphetamines, which can cause severe hypertension in young adults 3

Family History

• Obtain family history of early-onset hypertension or stroke at age <40 years, which may suggest genetic causes including primary aldosteronism or monogenic hypertension 4
• Document family history of renal disease, pheochromocytoma, or other endocrine disorders 5, 1
• A positive family history of hypertension in an overweight/obese patient suggests primary hypertension and may not require extensive secondary workup 5

Perinatal and Developmental History

• Obtain perinatal information including maternal hypertension during pregnancy, gestational age, birth weight, and neonatal complications, as low birth weight is associated with later hypertension 1
• This is particularly important in patients diagnosed before age 30 5

Lifestyle and Dietary Factors

• Assess dietary sodium intake, recent weight changes, and physical activity level 1
• Document job changes with increased stress or decreased physical activity, as these lifestyle factors favor primary hypertension 1
• The presence of weight gain, high-sodium diet, and decreased physical activity supports essential hypertension rather than secondary causes 1

Psychosocial History

• Document stress, depression, anxiety, and adverse childhood experiences, as these are associated with hypertension development 1
• This is particularly relevant in the 20-40 age group where psychosocial factors play a significant role 5

Red Flag Symptoms Suggesting Secondary Hypertension

Renal Disease Indicators

• Ask about hematuria, nocturia, history of urinary tract infections, or flash pulmonary edema, which suggest renal artery stenosis or renal parenchymal disease 1, 6
• Document any history of recurrent UTIs or known kidney disease, as renal parenchymal disease accounts for 34-79% of secondary hypertension in young patients 2

Endocrine Disorder Symptoms

• Inquire about muscle weakness, tetany, cramps, or arrhythmias, which may suggest hypokalemia from primary aldosteronism 1
• Ask about sweating, palpitations, and frequent headaches, which may indicate pheochromocytoma 1
• Document symptoms of Cushing syndrome: truncal obesity, purple striae, easy bruising, glucose intolerance 2

Sleep Apnea Screening

• Assess for snoring and daytime sleepiness, which may indicate obstructive sleep apnea—present in 25-50% of patients with resistant hypertension 2

Cardiovascular Symptoms

• Ask about claudication, leg fatigue with exercise, or cold extremities, which may suggest coarctation of the aorta 2, 6
• Document any history of chest pain, palpitations, or syncope 5

Comorbidity Assessment

Cardiovascular Risk Factors

• Assess personal history of myocardial infarction, heart failure, stroke, transient ischemic attacks, diabetes, dyslipidemia, chronic kidney disease, and smoking status 1
• This is critical because younger individuals with hypertension require focus on prevention of resistant hypertension, target organ injury, and treatment morbidity 5

Target Organ Damage History

• Document any known left ventricular hypertrophy, retinopathy, or proteinuria 1
• Target organ damage disproportionate to duration or severity of hypertension suggests secondary causes 1

Clinical Context for Distinguishing Primary vs. Secondary Hypertension

Features Favoring Primary Hypertension

• Gradual BP increase with slow rate of rise 1
• Positive family history of hypertension 5
• Overweight or obesity 5, 7
• Lifestyle factors favoring higher BP (weight gain, high-sodium diet, decreased physical activity, increased stress, excessive alcohol) 1

Features Favoring Secondary Hypertension

• Age of onset <30 years 1, 6
• Abrupt onset or sudden worsening of previously controlled BP 1
• Severe hypertension (>180/120 mmHg) or resistant hypertension (uncontrolled on ≥3 medications) 1, 6
• Absence of family history in a non-obese patient 3

Common Pitfalls to Avoid

• Do not assume all young hypertensive patients need extensive secondary workup: >90% will have primary hypertension, especially if overweight/obese with positive family history 3, 5
• Do not miss medication-induced hypertension: NSAIDs, oral contraceptives, and decongestants are frequently overlooked 1
• Do not forget to ask about substance use: young adults may be reluctant to disclose alcohol, cocaine, or amphetamine use 3
• Do not overlook sleep apnea: it is highly prevalent in resistant hypertension but often undiagnosed 2