Hypertension
9. What are the common causes of secondary hypertension in younger men and women?
In younger men, a common cause of secondary hypertension is excessive alcohol intake (get
the patient to quit!). In younger women, common and classic causes are birth control pills (stop
them!) and renal artery stenosis from fibromuscular dysplasia (which may cause a bruit and
should be treated with balloon angioplasty).
10. List less common causes of secondary hypertension.
Pheochromocytoma. Look for wild swings in blood pressure with diaphoresis and confu-
sion. As a screening test, order 24-hour urine collection to assess catecholamine products
(metanephrines, vanillylmandelic acid, homovanillic acid).
Renal artery stenosis (RAS). Unlike young patients with fibromuscular dysplasia, elderly
patients typically have RAS due to atherosclerosis. A renal artery bruit is classically present
(although not sensitive); magnetic resonance or conventional angiography makes the definitive
diagnosis. Giving ACE inhibitors to patients with RAS may precipitate acute renal failure (some-
times the first diagnostic clue to its presence).
Polycystic kidney disease. Look for flank mass, positive family history (autosomal domi-
nant pattern of inheritance), and elevations in creatinine and blood urea nitrogen.
Cushing's syndrome. Look for stigmata of Cushing's syndrome on exam. Order 24-urine
collection to assess free cortisol or dexamethasone suppression test
Conn's syndrome. The cause is an aldosterone-secreting adrenal neoplasm. Look for high
aldosterone levels, low renin levels, hypokalemia, metabolic alkalosis, and/or an adrenal mass on
computed tomography.
Coarctation of the aorta. Look for hypertension in the upper extremities only, with unequal
pulses, radiofemoral delay, and rib notching on chest radiograph; associated with Turner's syn-
drome. MRI or angiography makes a definitive diagnosis.
Renal failure from any cause. In children, watch for poststreptococcal glomerulonephritis
or hemolytic uremic syndrome.
Abdominal aortogram demonstrates
high-grade, proximal, left renal artery
stenosis (curved arrow). (From Katz DS,
Math KR, Groskin SA (eds): Radiology
Secrets. Philadelphia, Hanley & Belfus,
1998, p 185, with permission.)
11. What does lowering blood pressure accomplish?
Hypertension is the number-one modifiable risk factor for strokes. Lowering blood pressure
decreases heart disease, myocardial infarctions, atherosclerosis, renal failure, and dissecting
aortic aneurysms.
12. What is the most common cause of death among untreated patients with hypertension?
The same as for the general population—coronary artery disease.
Hypertension 111
13. Which three tests should be ordered for every patient with a diagnosis of hypertension?
Why?
1. Electrocardiogram: to determine whether the heart has been affected (e.g., left ventric-
ular hypertrophy).
2. Chemistry 7 panel (i.e., basic metabolic panel): clues to possible secondary cause of
hypertension (e.g., electrolyte disturbances in Conn's syndrome).
3. Urinalysis: clues to possible secondary cause of hypertension (e.g., red blood cell casts
in poststreptococcal glomerulonephritis) and to kidney damage (proteinuria).
