Secondary hypertension is high blood pressure with a specific, often treatable cause such as primary aldosteronism, kidney or renal artery disease, sleep apnea or a medication. Suspect it when hypertension starts young, starts suddenly or stays high despite three drugs.
Key symptoms
- Often no symptoms; found on a routine blood pressure check
- Episodes of headache, sweating and palpitations (pheochromocytoma)
- Muscle weakness or cramps from low potassium
- Loud snoring and daytime sleepiness (sleep apnea)
What you find on exam
- Blood pressure in both arms and in a leg; lower leg pressure suggests coarctation
- Abdominal bruit over the renal arteries
- Cushing features: central obesity, purple stretch marks, rounded face
- Thyroid size and signs of thyroid disease
Tests
- Basic metabolic panel: potassium and creatinine; urinalysis
- Aldosterone to renin ratio to screen for primary aldosteronism
- Plasma free metanephrines if pheochromocytoma is suspected; TSH
- Renal artery duplex ultrasound or CT angiography; sleep study if snoring
Treatment basics
- Stop drugs that raise pressure: NSAIDs, decongestants, stimulants, some contraceptives
- Primary aldosteronism: spironolactone, or adrenal surgery if one gland is the source
- CPAP for sleep apnea; angioplasty for fibromuscular dysplasia
- Pheochromocytoma: alpha blockade before any beta blocker, then surgery
- Keep controlling blood pressure with standard drugs while the cause is treated
Red flags
- Pressure of 180/120 or higher with chest pain, confusion or vision change
- Rising creatinine after starting an ACE inhibitor (possible bilateral renal artery stenosis)
- Sudden spells of very high pressure with pounding headache
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AHA Scientific Statement, Measurement of Blood Pressure in Humans (Hypertension, 2019). Written by Making Synapses. Making Synapses is not affiliated with these organizations.