Secondary hypertension: primary health care approach
DOI:
https://doi.org/10.32385/rpmgf.v37i6.12722Keywords:
Hipertensão secundária, Cuidados de saúde primários, Síndrome da apneia obstrutiva do sono, Doenças do parênquima Renal, Estenose da artéria renal, Hiperaldosteronismo primárioAbstract
Objectives: Identify situations suggestive of secondary hypertension (SH). Review the pathophysiology, clinical and/or laboratory manifestations, diagnosis, and treatment of the main forms of secondary hypertension as well as establish the role of the family doctor in its approach based on the most recent evidence.
Data sources: MEDLINE/PubMed, The Cochrane Library, UpToDate, U.S. Preventive Services Task Force, and guidelines from Direção-Geral da Saúde.
Methods: Scientific articles were searched on evidence-based medicine online platforms using the keywords ‘Secondary Hypertension’ and ‘Primary Health Care’. The research was conducted in July 2019 and the selection of articles was based on the title, abstract, and publication date. Clinical guidelines were also consulted.
Results: SH should be suspected in situations of resistant hypertension, onset of hypertension before age 30 in a patient without risk factors, sudden increase or instability in basal blood pressure, malignant or accelerated hypertension, the onset of diastolic hypertension in the elderly, hypertension associated with hydro electrolytic disorders or hypertension with clinical features suggestive of a specific etiology. In children and adolescents, the main causes of SH are renal parenchymal diseases, whereas in adults the common causes are obstructive sleep apnea syndrome, renal parenchymal diseases, renal artery stenosis, primary hyperaldosteronism, and pheochromocytoma. Recognition of clinical and/or laboratory manifestations suggestive of the etiology of SH should guide screening tests for further treatment or referral.
Conclusion: Evaluating secondary causes in all hypertensive patients is not cost-effective, so only patients with characteristics suggestive of SH should be studied. Properly performing and interpreting screening tests is critical for the referral and treatment of patients with SH.
Downloads
References
Williams B, Mancia G, Spiering W, Rosei EA, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018;39(33):3021-104.
Rimoldi SF, Scherrer U, Messerli FH. Secondary arterial hypertension: when, who, and how to screen? Eur Heart J. 2014;35(19):1245-54.
Charles L, Triscott J, Dobbs B. Secondary hypertension: discovering the underlying cause. Am Fam Med. 2017;96(7):453-61.
Taler SJ. Secondary causes of hypertension. Prim Care. 2008;35(3):489-500.
Chiong JR, Aronow WS, Khan IA, Nair CK, Vijayaraghavan K, Dart RA, et al. Secondary hypertension: current diagnosis and treatment. Int J Cardiol. 2008;124(1):6-21.
Puar TH, Mok Y, Debajyoti R, Khoo J, How CH, Ng AK. Secondary hypertension in adults. Singapore Med J. 2016;57(5):228-32.
Direção-Geral da Saúde. Programa nacional de saúde infantil e juvenil: norma n.º 010/2013, de 31/05/2013. Lisboa: DGS; 2013.
U.S. Preventive Services Task Force. Screening for primary hypertension in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159(9):613-9.
Whelton PK, Carey RM, Aronow WS, Casey Jr DE, Collins KJ, Himmelfarb CD, 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: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71(19):e127-e248.
Textor S. Evaluation of secondary hypertension. UpToDate [Internet]; 2019 [updated 2021 Sep 8; cited 2019 Jul 27]. Available from: https://www.uptodate.com/contents/evaluation-of-secondary-hypertension
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo Jr JL, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206-52.
Iber C, Ancoli-Israel S, Chesson AL, Quan SF. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. Darien, IL: American Academy of Sleep Medicine; 2007. p. 15-49.
Maspero C, Giannini L, Galbiati G, Rosso G, Farronato G. Obstructive sleep apnea syndrome: a literature review. Minerva Stomatol. 2015;64(2):97-109.
Carey RM, Calhoun DA, Bakris GL, Brook RD, Daugherty SL, Dennison-Himmelfarb CR, et al. Resistant hypertension: detection, evaluation, and management: a scientific statement from the American Heart Association. Hypertension. 2018;72(5):e53-e90.
Floras JS. Hypertension and sleep apnea. Can J Cardiol. 2015;31(7):889-97.
Gonzaga C, Bertolami A, Bertolami M, Amodeo C, Calhoun D. Obstructive sleep apnea, hypertension and cardiovascular diseases. J Hum Hypertens. 2015;29(12):705-12.
DiBona GF. Physiology in perspective: the wisdom of the body. Neural control of the kidney. Am J Physiol Regul Integr Comp Physiol. 2005;289(3):R633-41.
Pedrosa RP, Drager LF, Gonzaga CC, Sousa MG, Paula LK, Amaro AC, et al. Obstructive sleep apnea: the most common secondary cause of hypertension associated with resistant hypertension. Hypertension. 2011;58(5):811-7.
Kasai T, Floras JS, Bradley TD. Sleep apnea and cardiovascular disease: a bidirectional relationship. Circulation. 2012;126(12):1495-510.
Arzt M, Young T, Finn L, Skatrud JB, Ryan CM, Newton GE, et al. Sleepiness and sleep in patients with both systolic heart failure and obstructive sleep apnea. Arch Intern Med. 2006;166(16):1716-22.
Somers VK, White DP, Amin R, Abraham WT, Costa F, Culebras A, et al. Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing. Circulation. 2008;118(10):1080-111.
Direção-Geral da Saúde. Cuidados respiratórios domiciliários – Prescrição de ventiloterapia e outros equipamentos: norma n.º 022/2011, de 28/09/2011, atualizada em 11/09/2015. Lisboa: DGS; 2015.
Townsend RR. Definition, risk factors, and evaluation of resistant hypertension. UpToDate [Internet]; 2019 [updated 2020 Apr 13; cited 2019 Sep 1]. Available from: https://www.uptodate.com/contents/definition-risk-factors-and-evaluation-of-resistant-hypertension
Levey AS, Atkins R, Coresh J, Cohen EP, Collins AJ, Eckardt KU, et al. Chronic kidney disease as a global public health problem: approaches and initiatives – a position statement from Kidney Disease Improving Global Outcomes. Kidney Int. 2007;72(3):247-59.
Grams ME, Sang Y, Levey AS, Matsushita K, Ballew S, Chang AR, et al. Kidney-failure risk projection for the living kidney-donor candidate. N Engl J Med. 2016;374(5):411-21.
Warady BA, Srivastava T, Weidemann DK. Chronic kidney disease in children: clinical manifestations and evaluation. UpToDate [Internet]; 2019 [updated 2021 Dec 2; cited 2019 Sep 04]. Available from: https://www.uptodate.com/contents/chronic-kidney-disease-in-children-clinical-manifestations-and-evaluation
Tönshoff B, Kiepe D, Ciarmatori S. Growth hormone/insulin-like growth factor system in children with chronic renal failure. Pediatr Nephrol. 2005;20(3):279-89.
Pullalarevu R, Akbar G, Teehan G. Secondary hypertension, issues in diagnosis and treatment. Prim Care. 2014;41(4):749-64.
Rosenberg M. Overview of the management of chronic kidney disease in adults. UpToDate [Internet]; 2019 [updated 2021 Nov 29; cited 2019 Sep 4]. Available from: https://www.uptodate.com/contents/overview-of-the-management-of-chronic-kidney-disease-in-adults
James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 Evidenced-based guideline for the management of high blood pressure in adults: report from the panel members are pointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-20.
Basile J, Bloch MJ. Overview of hypertension in adults. UpToDate [Internet]; 2019 [updated 2021 Aug 4; cited 2019 Aug 10]. Available from: https://www.uptodate.com/contents/overview-of-hypertension-in-adults
Textor SC, Lerman L. Renovascular hypertension and ischemic nephropathy. Am J Hypertens. 2010;23(11):1159-69.
Fava C, Minuz P, Patrignani P, Morganti A. Renal artery stenosis and accelerated atherosclerosis: which comes first? J Hypertens. 2006;24(9):1687-96.
Alyamani M, Thomas J, Shanks M, Oudit GY. Resistant hypertension from renal artery stenosis leading to heart failure with preserved ejection fraction. J Investig Med High Impact Case Rep. 2018;6:2324709618816501.
Williams GJ, Macaskill P, Chan SF, Karplus TE, Yung W, Hodson EM, et al. Comparative accuracy of renal duplex sonographic parameters in the diagnosis of renal artery stenosis: paired and unpaired analysis. AJR Am J Roentgenol. 2007;188(3):798-811.
Radermacher J, Haller H. The right diagnostic work-up: investigating renal and renovascular disorders. J Hypertens. 2003;21 Suppl 2:S19-S24.
Evans KL, Tuttle KR, Folt DA, Dawson T, Haller ST, Brewster PS, et al. Use of renin-angiotensin inhibitors in people with renal artery stenosis. Clin J Am Soc Nephrol. 2014;9(7):1199-206.
Ritchie J, Green D, Chrysochou C, Chalmers N, Foley RN, Kalra PA. High-risk clinical presentations in atherosclerotic renovascular disease: prognosis and response to renal artery revascularization. Am J Kidney Dis. 2014;63(2):186-97.
Trinquart L, Mounier-Vehier C, Sapoval M, Gagnon N, Plouin PF. Efficacy of revascularization for renal artery stenosis caused by fibromuscular dysplasia: a systematic review and meta-analysis. Hypertension. 2010;56(3):525-32.
Funder JW, Carey RM, Mantero F, Murad MH, Reincke M, Shibata H, et al. The management of primary aldosteronism: case detection, diagnosis, and treatment: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2016;101(5):1889-916.
Lee FT, Elaraj D. Evaluation and management of primary hyperaldosteronism. Surg Clin North Am. 2019;99(4):731-45.
Kline GA, Prebtani AP, Leung AA, Schiffrin EL. Primary aldosteronism: a common cause of resistant hypertension. Can Med Assoc J. 2017;189(22):E773-8.
Monticone S, Burrello J, Tizzani D, Bertello C, Viola A, Buffolo F, et al. Prevalence and clinical manifestations of primary aldosteronism encountered in primary care practice. J Am Coll Cardiol. 2017;69(14):1811-20.
Pappachan JM, Buch HN. Endocrine hypertension: a practical approach. Adv Exp Med Biol. 2017;956:215-37.
Yang J, Shen J, Fuller PJ. Diagnosing endocrine hypertension: a practical approach. Nephrology. 2017;22(9):663-77.
Berta E, Lengyel I, Halmi S, Zrínyi M, Erdei A, Harangi M, et al. Hypertension in thyroid disorders. Front Endocrinol. 2019;10:482.
Prisant LM, Gujral JS, Mulloy AL. Hyperthyroidism: a secondary cause of isolated systolic hypertension. J Clin Hypertens. 2006;8(8):596-9.
Beastall GH, Beckett GJ, Franklyn J, Fraser WD, Hickey J, John R, et al. UK guidelines for the use of thyroid function tests [Internet]. London: British Thyroid Foundation; 2006. Available from: https://www.british-thyroid-association.org/sandbox/bta2016/uk_guidelines_for_the_use_of_thyroid_function_tests.pdf
Rossi GP, Barisa M, Allolio B, Auchus RJ, Amar L, Cohen D, et al. The Adrenal Vein Sampling International Study (AVIS) for identifying the major subtypes of primary aldosteronism. J Clin Endocrinol Metab. 2012;97(5):1606-14.
Pivonello R, Isidori AM, De Martino MC, Newell-Price J, Biller BM, Colao A. Complications of Cushing’s syndrome: state of the art. Lancet Diabetes Endocrinol. 2016;4(7):611-29.
Buonacera A, Stancanelli B, Malatino L. Endocrine tumors causing arterial hypertension: pathophysiological mechanisms and clinical implications. High Blood Press Cardiovasc Prev. 2017;24(3):217-29.
Barbot M, Ceccato F, Scaroni C. The pathophysiology and treatment of hypertension in patients with Cushing’s syndrome. Front Endocrinol. 2019;10:321.
Alexandraki KI, Kaltsas GA, Isidori AM, Akker SA, Drake WM, Chew SL, et al. The prevalence and characteristic features of cyclicity and variability in Cushing’s disease. Eur J Endocrinol. 2009;160(6):1011-8.
Lacroix A, Feelders RA, Stratakis CA, Nieman LK. Cushing’s syndrome. Lancet. 2015;386(9996):913-27.
Nieman LK, Biller BM, Findling JW, Newell-Price J, Savage MO, Stewart PM, et al. The diagnosis of Cushing’s syndrome: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2008;93(5):1526-40.
Boscaro M, Arnaldi G. Approach to the patient with possible Cushing’s syndrome. J Clin Endocrinol Metab. 2009;94(9):3121-31.
Nieman LK, Biller BM, Findling JW, Murad MH, Newell-Price J, Savage MO, et al. Treatment of Cushing’s syndrome: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2015;100(8):2807-31.
Isidori AM, Graziadio C, Paragliola RM, Cozzolino A, Ambrogio AG, Colao A, et al. The hypertension of Cushing’s syndrome: controversies in the pathophysiology and focus on cardiovascular complications. J Hypertens. 2015;33(1):44-60.
Pappachan JM, Tun NN, Arunagirinathan G, Sodi R, Hanna FW. Pheochromocytomas and hypertension. Curr Hypertens Rep. 2018;20(1):3.
Lenders JW, Duh QY, Eisenhofer G, Gimenez-Roqueplo AP, Grebe SK, Murad MH, et al. Pheochromocytoma and paraganglioma: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2014;99(6):1915-42.
Canu L, Parenti G, De Filpo G, Mannelli M. Pheochromocytomas and paragangliomas as causes of endocrine hypertension. Front Endocrinol. 2019;10:333.
Young Jr WF. Clinical presentation and diagnosis of pheochromocytoma. UpToDate [Internet]; 2019 [updated 2021 Apr 13; cited 2019 Sep 15]. Available from: https://www.uptodate.com/contents/clinical-presentation-and-diagnosis-of-pheochromocytoma
Law MA, Tivakaran VS. Coarctation of the aorta [Internet]. Treasure Island: StatPearls Publishing; 2021 [updated 2021 Aug 11]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430913/
Vigneswaran TV, Sinha MD, Valverde I, Simpson JM, Charakida M. Hypertension in coarctation of the aorta: challenges in diagnosis in children. Pediatr Cardiol. 2018;39(1):1-10.
Pemberton J, Sahn DJ. Imaging of the aorta. Int J Cardiol. 2004;97 Suppl 1:53-60.
Bacha E, Hijazi ZM. Management of coarctation of the aorta. UpToDate [Internet]; 2019 [updated 2020 Nov 13; cited 2019 Sep 21]. Available from: https://www.uptodate.com/contents/management-of-coarctation-of-the-aorta
Weber HS, Cyran SE. Endovascular stenting for native coarctation of the aorta is an effective alternative to surgical intervention in older children. Congenit Heart Dis. 2008;3(1):54-9.
Moltzer E, Raso FU, Karamermer Y, Boersma E, Webb GD, Simoons ML, et al. Comparison of candesartan versus metoprolol for treatment of systemic hypertension after repaired aortic coarctation. Am J Cardiol. 2010;105(2):217-22.
Downloads
Published
Issue
Section
License
Copyright (c) 2021 Portuguese Journal of Family Medicine and General Practice
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
The authors will assign to the RPMGF the sole right to publish and distribute the content of the manuscript specified in this declaration via physical, electronic, broadcasting or any other medium that may come into existence. They also grant the RPMGF the right to use and exploit this manuscript, in particular by assigning, selling or licensing its content. This permission is permanent and takes effect from the moment the manuscript is submitted, has the maximum duration allowed by applicable Portuguese or international law and is of worldwide scope. The authors further declare that this assignment is made free of charge. If the RPMGF informs the authors that it is not going to publish their manuscript, the exclusive assignment of rights ceases forthwith.
The authors authorise the RPMGF (or any entity it may appoint) to act on their behalf when it believes that copyright may have been infringed.
