How should I take a focused history for a patient with suspected secondary hypertension?

Secondary Hypertension History Taking

When evaluating a patient for suspected secondary hypertension, obtain a comprehensive medical history focused on age of onset, severity, response to treatment, and specific symptom clusters that point to underlying endocrine, renal, or vascular causes. 1, 2

Red-Flag Historical Features Requiring Investigation

Screen aggressively when any of the following are present:

• Age of onset <30 years (especially without family history of hypertension) or new-onset hypertension after age 50 2, 3, 4
• Resistant hypertension: BP >140/90 mmHg despite optimal doses of ≥3 antihypertensive drugs including a diuretic 2, 5, 6
• Sudden onset or rapid worsening of previously well-controlled blood pressure 2, 5, 6
• Severe hypertension (systolic >180 mmHg or diastolic >110 mmHg) or hypertensive emergency 2, 3, 6
• Target organ damage disproportionate to the duration or severity of hypertension 2, 5

Symptom-Based History by Etiology

Primary Aldosteronism (8-20% of Resistant Hypertension)

Ask specifically about: 2

• Muscle weakness, cramps, or tetany (hypokalemia-related)
• Palpitations or arrhythmias
• Polyuria and polydipsia (from hypokalemia-induced nephrogenic diabetes insipidus)
• Family history of early-onset hypertension or stroke <40 years

Renovascular Disease

Inquire about: 2, 4

• Flash pulmonary edema (recurrent episodes)
• Acute rise in creatinine ≥50% within one week of starting ACE inhibitor or ARB
• Abrupt onset of severe hypertension, especially in women <50 years (fibromuscular dysplasia)
• Atherosclerotic risk factors in patients >50 years

Pheochromocytoma

The classic triad includes: 2

• Episodic sweating
• Palpitations
• Frequent headaches
• Labile or paroxysmal hypertension (not sustained)

Obstructive Sleep Apnea (25-50% of Resistant Hypertension)

Document: 2

• Habitual loud snoring
• Witnessed apneas during sleep
• Excessive daytime sleepiness
• Obesity with neck circumference >40 cm
• Non-dipping or reverse-dipping pattern on ambulatory BP monitoring

Cushing Syndrome

Ask about: 2

• Easy bruising
• Proximal muscle weakness (difficulty rising from chair)
• Weight gain with central distribution
• Mood changes or depression
• Menstrual irregularities in women

Thyroid Disease

Screen for: 2

• Hypothyroidism: cold intolerance, constipation, weight gain, dry skin, fatigue
• Hyperthyroidism: heat intolerance, tremor, weight loss despite increased appetite, insomnia, palpitations

Renal Parenchymal Disease

Obtain history of: 2

• Recurrent urinary tract infections
• Hematuria
• Urinary frequency or nocturia
• Obstructive urinary symptoms
• Family history of polycystic kidney disease

Coarctation of the Aorta

In young patients, ask about: 2, 4

• Leg claudication or fatigue with exercise
• Headaches
• Epistaxis
• Cold feet

Medication and Substance History

Systematically review all medications and substances that can induce hypertension: 2

• NSAIDs (including over-the-counter ibuprofen, naproxen)
• Decongestants (pseudoephedrine, phenylephrine)
• Stimulants (amphetamines, methylphenidate, cocaine)
• Oral contraceptives and hormone replacement therapy
• Immunosuppressants (cyclosporine, tacrolimus)
• Erythropoietin
• Corticosteroids
• Herbal supplements (licorice, ephedra, ma huang)
• Alcohol consumption (quantity and frequency)

Family History

Obtain detailed family history of: 1, 2

• Early-onset hypertension (especially <40 years)
• Stroke at young age (<40 years)
• Polycystic kidney disease
• Endocrine disorders (thyroid disease, pheochromocytoma, multiple endocrine neoplasia syndromes)
• Premature cardiovascular disease

Lifestyle and Social History

Document: 2

• Sodium intake (processed foods, restaurant meals, added salt)
• Alcohol consumption (>2 drinks/day in men, >1 drink/day in women)
• Smoking history
• Physical activity level
• Occupational exposures (lead, cadmium)

Review of Systems Targeting Organ Damage

Assess for: 1

• Neurologic: transient ischemic attacks, stroke, visual changes, cognitive decline
• Cardiac: chest pain, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, palpitations
• Renal: changes in urine output, foamy urine (proteinuria), peripheral edema
• Vascular: claudication, cold extremities

Common Pitfalls to Avoid

• Medication non-adherence accounts for a large proportion of apparent resistant hypertension; ask explicitly about missed doses, side effects, and cost barriers 2
• White-coat hypertension occurs in 20-30% of patients with apparent resistant hypertension; confirm with ambulatory or home BP monitoring before extensive workup 2
• Failing to review over-the-counter medications and supplements that can elevate blood pressure 2
• Not asking about sleep symptoms in obese patients with resistant hypertension, missing the diagnosis of obstructive sleep apnea 2

When to Refer to Specialist

Refer when: 2, 5

• Positive screening tests require confirmatory evaluation (e.g., elevated aldosterone-to-renin ratio)
• Complex procedures are needed (e.g., adrenal vein sampling)
• Surgical intervention is being considered (e.g., unilateral adrenalectomy)
• BP remains uncontrolled after ≥6 months of optimal medical therapy