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Secondary Hypertension Workup
Dec 23, 2010
•
Mark Morgan
categories:
Cardiovascular
Secondary Hypertension Workup
Some medicines that elevate blood pressure
no
YES
<-- oral contraceptives (estrogen)
no
YES
<-- ephedra, ginseng, ma huang (herbal)
no
YES
<-- amphetamines, cocaine (street drugs)
no
YES
<-- cox-2 inhibitors, ibuprofen, naproxen (NSAIDS)
no
YES
<-- buspirone, carbamazepine, clozapine, fluoxetine, lithium, tricyclic antidepressants (psychiatric)
no
YES
<-- methylprednisolone, prednisone (steroid)
no
YES
<-- decongestants, diet pills (sympathomimetic)
Clinical clues
no
YES
<-- Arm to leg systolic blood pressure difference > 20 mm Hg
no
YES
<-- Delayed or absent femoral pulses
no
YES
<-- Murmur
no
YES
<-- Increase in serum creatinine concentration (>= 0.5 to 1 mg/dL) after starting ACE inhibitor or ARB
no
YES
<-- Renal bruit
no
YES
<-- Bradycardia/tachycardia
no
YES
<-- Cold/heat intolerance
no
YES
<-- Constipation/diarrhea
no
YES
<-- Irregular, heavy, or absent menstrual cycle
no
YES
<-- Hypokalemia
no
YES
<-- Apneic events during sleep
no
YES
<-- Daytime sleepiness
no
YES
<-- Snoring
no
YES
<-- Flushing
no
YES
<-- Headaches
no
YES
<-- Labile blood pressures
no
YES
<-- Orthostatic hypotension
no
YES
<-- Palpitations
no
YES
<-- Sweating
no
YES
<-- Syncope
no
YES
<-- Buffalo hump
no
YES
<-- Central obesity
no
YES
<-- Moon facies
no
YES
<-- Striae
Age
Birth to 12 years
12 to 18 years
19 to 39 years
40 to 64 years
65 years and older
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concern: coarctation of the aorta
Arm to leg systolic blood pressure difference > 20 mm Hg; Delayed or absent femoral pulses; or Murmur are signs that could suggest coarctation of the aorta.
Suggested work up:
* transthoracic echocardiography for children
* MRI for adults.
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concern: renal artery stenosis
Increase in serum creatinine >= 0.5 to 1 mg/dL after starting ACE inhibitor or ARB; or renal bruit are signs that could suggest renal artery stenosis.
Suggested work up:
* CT angiography, doppler US of renal arteries, or MRI with gadolinium contrast medium.
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concern: thyroid disorders
Bradycardia/tachycardia; cold/heat intolerance; constipation/diarrhea; or irregular, heavy, or absent menstrual cycle are signs/symptoms which could suggest thyroid disorders.
Suggested work up:
* TSH level⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒⭒
concern: aldosteronism
Hypokalemia may suggest aldosteronism.
Suggested work up:
* renin and aldosterone levels to calculate the aldosterone/renin ratio
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concern: obstructive sleep apnea
Apneic events during sleep; daytime sleepiness; or snoring are signs/symptoms which may suggest obstructive sleep apnea.
Suggested work up:
* sleep study or Epworth Sleepiness Scale with nighttime pulse oximetry.
A web calculator for the Epworth Sleepiness Scale is here
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concern: pheochromocytoma
Flushing; headaches, labile blood pressures; orthostatic hypotension; palpitations; sweating; or syncope are signs/symptoms which could suggest pheochromocytoma.
Suggested work up:
* 24-hour urinary fractionated metanephrines or Plasma free metanephrines.
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concern: Cushing syndrome
Buffalo hump; central obesity; moon facies; or striae are signs/symptoms which could suggest Cushing syndrome.
Suggested work up:
* 24-hour urinary cortisol
* Late-night salivary cortisol
* Low-dose dexamethasone suppression
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In the absence of other clinical clues, an initial workup for hypertension for children/adolescents age birth to 18 years may include:
* urinalysis
* urine culture
* renal ultrasonography
* If this does not detect a cause and secondary hypertension is still suspected, echocardiography could be performed.
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In the absence of other clinical clues, an initial workup for hypertension for young adults age 19 to 39 years may include:
* MRI with gadolinium contrast media or CT renal artery
* TSH level.
* If this does not detect a cause and secondary hypertension is still suspected, echocardiography and 24-hour urine collection for cortisol and fractionated metanephrines could be performed.
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In the absence of other clinical clues, an initial workup for hypertension for middle-aged adults age 40-64 years may include:
* Renin and aldosterone levels
* TSH level
* If this does not detect a cause and secondary hypertension is still suspected, polysomnography could be performed.
* If this is unremarkable, a next step could be collecting 24-hour urine for cortisol and fractionated metanephrines.
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In the absence of other clinical clues, an initial workup for hypertension for older adults age 65 years and older may include:
* MRI with gadolinium contrast or CT renal artery
* TSH level
* urinalysis
* If this does not detect a cause and secondary hypertension is still suspected, 24-hour urine collection for cortisol and fractionated metanephrines could be performed.
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display/hide references
reference:
#1
Diagnosis of Secondary Hypertension: An Age-Based Approach Viera (2010) Am Fam Physician 82:1471-8
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