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Secondary arterial

hypertension: when, who,


and how to screen?
STEFANO F. RIMOLDI1, URS SCHERRER1,2, AND FRANZ H. MESSERLI3 *
EUROPEAN HEART JOURNAL, 2013
Introduction
• Secondary hypertension → ↑ Systemic Blood
pressure due to an identifiable cause
• Only 5-10% secondary form
• Rare and expensive screening
• Majority young patients (< 40 y.o.) respond to
specific treatment
• >35% elderly patients, not achieves target BP
Prevalence
• Depends mostly on age and clinical characteristics of the
screened population
• There remains some residue hypertension after the
pathogenetic cause of secondary hypertension has been
identified and removed
Who should be screened?
• Age
• Habitus
• Blood pressure
• Generalized Atherosclerosis
• Second diagnostic look after therapy
What to do before screening: exclude pseudo-hypertension
and pseudo-resistance

• Pseudo-hypertension ⇨ osler’s sign


• Pseudo-resistance
• Inadequate blood pressure measurement
techniques
• Poor treatment control
• White coat hypertension
• Drug related hypertension
Drugs Related Hypertension
• NSAIDs • Oral Contraceptive
• Glucocorticoids
• Antidepressants
• Diet pills
• Immunosuppresive agents
• Decongestants
• Stimulants • Chemotherapy (VEGFi and TKI)
Role of ambulatory 24 h blood pressure
monitoring
Best measurement
method
Common cause of Secondary Hypertension
1. Obstructive Sleep Apnea
•Exaggrated daytime sleepiness
•Snoring
•Morning headache
•Lack of concentration
•Irritability
•Obesity
•Large neck
•Marcoglossia
•BP nocturnal and daytime increase
2. Renal Perenchymal Disease
◦ Most common in adults
◦ If creatinin concentration and/or urine analysis are
pathologic, a renal ultrasound should be next step
3. Renal Artery Stenosis
• In children and young adults, fibromuscular dysplasia of the renal artery one
of the most common cause
• Excluded by imaging (screening with duplex USG, comfirmation by
angiography)
• Adults : atherosclerotic RAS (1-8%)
Atherosclerotic renal artery stenosis to screen or not to screen?
Several studies shown that renal events, major cardiovascular event, and death = similar
De Leeuw et al. Stenting of atherosclerotic – little benefit
Longstanding hypertension, eGFR of 30 mL/min, and contralateral nephrosclerosis is very
unlikely to benefit from revascularization.
Flash pulmonary edema ( Pickering syndrome) = urgent revascularization will prove to be life
saving
Renal denervation for treatment resistant hypertension dramatically increased the interest
evaluated RAS.
4. Primary Aldosteronism
• Inappropriately high aldosterone synthesis that is
independent of the renin angiotensin system
• Can’t be suppressed by sodium loading
Uncommon Causes of Secondary
Hypertension
1. Cushing’s Syndrome
• < 0,1 general population
• Syndrome : obesity, facial plethora,
buffalo hump, hirsutism, purple striae
• Hypertension = 80% patients
Cortisol Test
 Testing for excess cortisol production :
 24 hour urinary cortisol
 Overnight dexamethasone suppression test
 Collecting a salivary sample before retiring

 Dexamethasone suppression →
Analyzing a baseline sample for cortisol
Dexamethasone suppresses ACTH production and should decrease cortisol production
 ACTH stimulation →
Level of cortisol in a person's blood before and after an injection of synthetic ACTH.
Adrenal glands damaged/not functioning : low cortisol level
Reference range for serum cortisol
Morning - 7-28 μg/dL
Afternoon - 2-18 μg/dL
Stimulated* - ≥ 18 μg/dl
Suppressed** - < 2 μg/dl
*Low-dose ACTH stimulation test: before or after (anytime, but usually one hour) ACTH 250 μg
(one ampule) intravenous injection
**Overnight low-dose dexamethasone suppression test: 8 AM serum cortisol after oral
dexamethasone 1 mg taken in late evening (11 PM)
2. Hyper/hypothyroidism
• Associated with arterial hypertension
• Hypothroid = diastolic BP elevated since low CO
is compensated by peripheral vasocontriction
• Hyperthyroid = ⇧ CO and predominantly
systolic BP elevation
3. Phaechromocytoma
• 0,2% in unselected hypertensive patients.
• Clinical features : ↑ cathecolamines
• Paroxysmal hypertension
• Palpitation
• Perspiration
• Pallor
• Pounding headache
• Screening if
• Resistant hypertension and hyperadrenergic
spells
• Family history
• Genetic syndrome ( MEN 2; von Hippel Lindau,
neurofibromatosis)
• Adrenal mass ( size > 4cm, cystic and haemorrhagic
changes)
Two main screen test:
- 24 urine catecholamines and
metanephrine
- Plasma fractionated
metanephrines

_
+
Scintigraphiclocalization
Imaging with with 123I-
abdominal/adrenal MRI or metaiodobenzylguanidine
CT (MIBG) or additional
imaging
CATU ( Cathecolamines Urine Test)
– 24hrs
Help to diagnose pheochromocytoma
Preparation : avoid certain food and drinks
Collecting urine in 24 hours
- High value – adrenal gland tumor, sepsis, illness, major
stress
- Low value – diabetes or nervous system problems
4. Coarctation of the aorta
• Second most common cause of hypertension in
children and young adults
• Constriction of the lumen of the aorta near lig.
arteriosum ( makes 7% of all congenital heart
disease)
• Frequent symptoms : headache, cold feet, pain in leg
during exercise
• Clinical clues
• Arterial hypertension in the presence of weak
remoral pulses
• Systolic murmurs in the front and/or back of the
chest
• Notching of the posterior ribs (collateral circulation)
on chest x-ray
• Follow up at least every 2 years, echocardiography and
BP ( 24 h ABPM – right upper arm)
CONCLUSION
• Secondary hypertension affects 5-10% of the hypertensive patients
• Screening is expensive and time-consuming, only performed in high clinical
suspicion
• Despite having found and appropriately treated a secondary cause oh
hypertension, BP rarely ever returns to normal.
• Some patients with secondary hypertension also have concominant essential
hypertension or that vascular remodelling and progressed over time to no return
• In potentially reversible hypertension, early detection and treatment are
important to minimize/prevent irreversible changes in the systemic may give rise
to persistent hypertension
THANK YOU