Evaluation of Secondary Hypertension
Evaluation of Secondary Hypertension
This Harvard Medical School Continuing Education video examines these key questions: Why is understanding secondary hypertension important? What underlying medical conditions, medications, or substances cause secondary hypertension? How do you evaluate patients for secondary hypertension?
Dr. Michael Honigberg, MD, a cardiologist at Massachusetts General Hospital, explains how recognizing causes of and contributors to secondary hypertension is helpful for comprehensively evaluating and managing patients. Common medications that can raise blood pressure are identified as are other common causes of secondary hypertension. Diagnostic tests and tools are reviewed and appropriate management for secondary hypertension is identified depending on its cause.
This video was peer reviewed by Dr. Jonathan Salik, TMD, MHPEd, Instructor of Medicine, Massachusetts General Hospital; and Dr. Sugantha Sundar, MD, Assistant Professor of Anesthesia, Beth Israel Deaconess Medical Center, to validate the quality and accuracy of the content.
00:00 | Introduction
00:33 | Distinguishing between primary and secondary hypertension
01:41 | Medication classes that can raise blood pressure
01:41 | Common medication classes that can raise blood pressure
02:20 | Other secondary causes of hypertension
04:42 | Patient evaluation
07:09 | Management of secondary hypertension
Management of secondary hypertension References:
Vitarello JA, Fitzgerald CJ, Cluett JL, Juraschek SP, Anderson TS. Prevalence of Medications That May Raise Blood Pressure Among Adults With Hypertension in the United States. JAMA Intern Med. 2022;182(1):90-93. doi:10.1001/jamainternmed.2021.6819.
Brown JM, Siddiqui M, Calhoun DA, et al. The Unrecognized Prevalence of Primary Aldosteronism: A Cross-sectional Study. Ann Intern Med. 2020;173(1):10-20. doi:10.7326/M20-0065
Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018;71(6):e136-e139.
Notice: At this time, the content in this video is not accredited.
Content
0 -> [MUSIC PLAYING]
3.234 ->
5.544 -> MICHAEL HONIGBERG: Hi.
6.61 -> I'm Dr. Michael Honigberg.
7.93 -> I'm a cardiologist at the
Massachusetts General Hospital
10.63 -> in Boston, Massachusetts.
12.37 -> Today we'll be talking
about the evaluation
15.13 -> of secondary hypertension.
17.68 -> Key takeaways from
today's video are
19.81 -> to review key secondary
causes of and contributors
22.63 -> to hypertension, to be able
to recognize medication
25.96 -> classes that can
raise blood pressure,
28.6 -> and to perform appropriate
evaluation for causes
31.36 -> of secondary hypertension.
33.49 -> The term primary
hypertension typically,
36.64 -> refers to hypertension
not caused
38.71 -> by an underlying
medical condition.
41.06 -> This may be driven by age,
other cardiometabolic traits,
45.16 -> such as elevated body weight,
and lifestyle factors,
48.25 -> such as a high-salt diet,
high sedentary time,
52 -> lack of physical activity.
54.28 -> Secondary hypertension,
by contrast,
56.35 -> has some distinguishing
features.
58.21 -> It is classically abrupt in
onset and/or unusually severe.
63.49 -> Typically, it is driven by an
underlying medical condition
66.61 -> or by medications
or substance use.
69.8 -> A specific remediable
secondary cause of hypertension
73.31 -> may be identified in up
to 10% of individuals
76.25 -> with a diagnosis
of hypertension.
78.53 -> It bears emphasizing
that this primary
80.51 -> versus secondary
distinction is not perfect.
83.33 -> Not all cases of
secondary hypertension
85.58 -> are dramatic in
their presentation.
87.44 -> And some secondary
causes may contribute to
90.2 -> or worsen pre-existing
primary hypertension.
93.78 -> However, remembering
secondary causes
96.14 -> is helpful for comprehensively
evaluating and managing
98.99 -> patients, and to guide
additional evaluation
102.17 -> when appropriate.
105.09 -> A recent study found
that 18.5% of US adults
108.78 -> with a diagnosis
of hypertension,
110.76 -> we're using medications
that raise blood pressure.
113.7 -> Some commonly used medications
with blood pressure-raising
116.76 -> effects, include oral
contraceptives, particularly
120.27 -> those with high
estrogen content,
122.67 -> nonsteroidal anti-inflammatory
drugs or NSAIDs, amphetamines,
127.26 -> certain antidepressant
classes, decongestants,
130.979 -> and corticosteroids.
132.6 -> Also certain weight
loss medications
134.85 -> and some cancer therapies,
such as bevacizumab
137.55 -> may also raise blood pressure.
139.54 -> There is a relatively long
list of other secondary causes
142.74 -> of hypertension.
143.83 -> These are some of
the more common ones.
145.95 -> And I will review them
in order of generally
148.14 -> more common to
generally less common.
151.11 -> Obstructive sleep apnea is
a relatively common cause
153.99 -> or contributor to
elevated blood pressure.
156.45 -> This would be
suggested clinically
158.25 -> by a history of snoring, daytime
hypersomnolence, or morning
162.09 -> headaches.
162.99 -> Primary
hyperaldosteronism refers
165.69 -> to excess production of
the hormone aldosterone
168.42 -> by the adrenal glands.
170.1 -> This would be suggested
by elevated serum sodium
173.31 -> levels, decreased
potassium levels,
176.13 -> and metabolic alkalosis.
178.02 -> Recent data suggests that
primary hyperaldosteronism
181.29 -> is substantially more prevalent
than we previously appreciated,
185.46 -> with reasonable prevalence even
among individuals with only
188.25 -> a mildly elevated
blood pressures
190.02 -> or even seemingly
normal blood pressures.
192.21 -> Renovascular hypertension
refers to abnormalities
196.35 -> of the renal arteries that lead
to elevated blood pressure.
199.72 -> This can take the form of
atherosclerotic disease
202.47 -> causing renal artery
stenosis, or a condition
206.04 -> called fibromuscular dysplasia,
a vascular abnormality more
209.73 -> typically seen in
young individuals.
211.62 -> Historical clues
to these conditions
213.33 -> might include abrupt onset
and/or label hypertension
216.69 -> after age 55, which would
specifically raise suspicion
220.23 -> for an atherosclerotic
renal artery stenosis
222.42 -> process, pulmonary edema,
complicating hypertension,
225.99 -> and a decrease in
kidney function.
228.15 -> Primary kidney disease,
including nephrotic syndrome,
231.21 -> may also lead to hypertension.
233.497 -> And in the case of
nephrotic syndrome,
235.08 -> this may be accompanied
with new onset edema.
237.72 -> Hypothyroidism may manifest
clinically with weight
240.99 -> loss that's unintended,
palpitations, hypertension,
244.71 -> and elevated heart rate.
246.27 -> Cushing syndrome is
an endocrine disorder
248.37 -> characterized by excess
production of the hormone
250.62 -> cortisol.
251.64 -> This causes excess weight gain,
increased central adiposity,
255.63 -> and striae of the skin.
257.35 -> Pheochromocytoma is a
rare neuroendocrine tumor
261.45 -> secreting catecholamines.
263.34 -> This manifests clinically
with labille blood pressures,
266.34 -> palpitations, headache,
and classically orthostasis
269.85 -> or positional blood
pressure changes.
271.59 -> Coarctation of the aorta is a
congenital aortic abnormality,
276.01 -> which may recur later in life.
278.02 -> So knowing history
of coarctation repair
280.5 -> is important.
281.82 -> Evaluation of the patient with
newly diagnosed hypertension
285.24 -> includes a careful history,
along with medication review,
288.93 -> and a thorough
physical examination.
291.7 -> A complete physical
exam should include
293.79 -> assessment of postural vital
signs, evidence of tremor,
297.81 -> evaluation of the pulses, and
auscultation for a renal artery
301.44 -> bruit.
302.85 -> Standard initial
laboratory testing
305.1 -> includes serum
electrolytes, and creatinine
308.22 -> for estimation of kidney
function, assessment
311.37 -> of glycemia, either with fasting
glucose or a hemoglobin A1c
315.36 -> level, a lipid panel,
thyroid-stimulating hormone,
319.41 -> and a urinalysis with or without
a urinary albumin-to-creatinine
323.49 -> ratio.
324.75 -> Secondary hypertension
should be considered whenever
327.27 -> there is suggestive
history, and particularly
330.12 -> in certain conditions
or situations.
332.49 -> One of those is
resistant hypertension,
334.54 -> which is defined as persistent
or refractory hypertension
338.13 -> despite the use of three
distinct antihypertensive
340.86 -> medication classes,
including a diuretic.
344.4 -> Other situations include
onset before age 30 years,
347.91 -> abrupt onset in a
patient with previously
350.31 -> normal or well-controlled
blood pressure,
352.89 -> deterioration of kidney function
with introduction of an ACE
356.01 -> inhibitor or ARB
would specifically
358.35 -> suggest the possibility of
renal vascular hypertension,
362.1 -> and excessive hyperkalemia
would suggest the possibility
365.49 -> of hyper aldosteronism.
368.92 -> How do we evaluate these
different possibilities?
371.65 -> The evaluation, the
diagnostic workup,
374.17 -> should be guided by clinical
history and clinician judgment.
378.07 -> Obstructive sleep apnea would
be diagnosed with a sleep study
381.04 -> and treated with
continuous positive airway
382.84 -> pressure at nighttime.
385.088 -> Hyperaldosteronism would
be diagnosed with plasma
387.13 -> aldosterone and renin levels.
389.56 -> Renovascular hypertension would
be diagnosed with renal artery
392.71 -> duplex Doppler
ultrasonography, and possibly
396.19 -> with cross-sectional
abdominal imaging.
399.08 -> Primary kidney disease
would be diagnosed
401.24 -> with a renal ultrasound to rule
out an obstructive process,
404.78 -> and laboratory tests to
discern an underlying cause.
408.87 -> Hypothyroidism would be
diagnosed with thyroid function
411.51 -> tests.
412.35 -> Cushing syndrome, with a
dexamethasone suppression test.
416.01 -> Pheochromocytoma, typically
with 24-hour urine metanephrines
420.03 -> and abdominal
cross-sectional imaging.
422.61 -> And coarctation of the
aorta, with echocardiography
425.76 -> with or without
cross-sectional aortic imaging.
430.27 -> The management of
secondary hypertension
431.98 -> depends very much on any
identifiable underlying causes.
436.09 -> For patients using blood
pressure-raising medications,
439.27 -> ideally these medications
should be withdrawn and replaced
441.94 -> with alternatives that do
not raise blood pressure.
444.91 -> Management of endocrine
causes typically
446.86 -> requires specialist involvement
to properly diagnose and treat
450.49 -> the underlying condition.
452.53 -> In cases of renal
artery stenosis,
454.48 -> evaluation for revascularization
of the renal artery
457.72 -> should be considered, if medical
management is unsuccessful,
460.9 -> or there is underlying
fibromuscular dysplasia.
464.79 -> It is worth emphasizing, and the
guidelines note this as well,
468.06 -> antihypertensive
therapy will frequently
470.04 -> be required even if
irremediable cause is identified
473.58 -> and addressed, such as in the
cases of renal artery stenosis
476.82 -> or obstructive sleep apnea.
480.12 -> So to summarize this
video, we reviewed
482.27 -> key secondary causes of and
contributors to hypertension.
485.57 -> You've learned to recognize
medication classes that
487.88 -> can raise blood pressure.
489.2 -> And you've learned to perform
appropriate targeted evaluation
492.11 -> for causes of
secondary hypertension.
494.39 -> Thank you for watching today.
495.96 -> I hope you found this
video educational.
497.63 -> [MUSIC PLAYING]
500.98 ->
Source: https://www.youtube.com/watch?v=-a4z_siFBv0