Sandbox/00022

Evaluation of secondary hypertension

Investigation should be limited for patients with clues suggestive of potentially correctable causes. ❑ Presence of clues for renovascular hypertension (most common potentially correctable cause)? ❑ Onset of hypertension before the age of 30 years ❑ Onset of severe hypertension (SBP ≥180 mm Hg and/or DBP ≥120 mm Hg) after the age of 55 years ❑ New azotemia or worsening renal function after administration of an ACE inhibitor or ARB agent ❑ Unexplained atrophic kidney or size discrepancy between kidneys of greater than 1.5 cm ❑ Sudden, unexplained pulmonary edema ❑ Accelerated hypertension (sudden and persistent worsening of previously controlled hypertension) ❑ Resistant hypertension (failure to achieve goal blood pressure in patients who are adhering to full doses of an appropriate 3-drug regimen that includes a diuretic) ❑ Malignant hypertension (hypertension with coexistent evidence of acute end-organ damage, i.e., acute renal failure, acutely decompensated congestive heart failure, new visual or neurological disturbance, and/or advanced [grade III to IV] retinopathy) ❑ Unexplained renal failure in the absence of proteinuria or an abnormal urine sediment ❑ Multivessel coronary artery disease ❑ Unexplained congestive heart failure ❑ Refractory angina

YES

NO

❑ Perform noninvasive diagnostic studies ❑ Duplex ultrasonography ❑ Gadolinium-enhanced magnetic resonance angiography ❑ Computed tomographic angiography (in individuals with normal renal function) ❑ Consider catheter angiography when noninvasive studies are inconclusive

Look for findings suggestive of other identifiable causes ❑ Pheochromocytoma ❑ Paroxysmal pounding headache ❑ Palpitations ❑ Profound perspiration ❑ Pallor ❑ Hand tremor ❑ Hyperaldosteronism ❑ Unexplained hypokalemia with urinary potassium wasting ❑ Obstructive sleep apnea ❑ Daytime somnolence ❑ Snoring ❑ Obesity ❑ Hyperparathyroidism ❑ Hypercalcemia ❑ Hypothyroidism ❑ Elevated TSH ❑ Puffy face ❑ Aortic coarctation ❑ Diminished or delayed femoral pulses and low or unobtainable blood pressures in the legs