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Secondary hypertension

Checked: 23-08-2020 by Vicky Ryan Next Review: 23-08-2022

Overview

These guidelines have been provided by the Endocrinology Team at NBT so pathways might be slightly different at UHBW

Definition

Hypertension caused by an identifiable underlying primary cause

Important points

Overall only accounts for 5% of cases of hypertension but in young adults <40 years, the prevalence of secondary hypertension is about 30%

Generally divided into Renal and Endocrine causes

Consider screening for Endocrine causes in the following cases:

Hypertension <30 years of age
Sustained BP ≥150/100mmHg OR BP >140/90mmHg resistant to 3 conventional antihypertensives including a diuretic OR hypertension on ≥4 anti-hypertensives
Hypertension and spontaneous hypokalaemia
Hypertension and an adrenal incidentaloma
Hypertension and early onset (<40 years) family history of hypertension or cerebrovascular disease
All first degree relatives of patients with primary hyperaldosteronism/Conn’s Syndrome
Hypertension and obstructive sleep apnoea
Symptoms suggestive of a phaeochromacytoma – hypertension, palpitations, sweating, episodic headaches and chest pain
Signs and symptoms suggestive of Cushing’s syndrome - central adiposity, proximal myopathy, striae, easy bruising

Renal causes may be suggested by the following – accelerated hypertension, deteriorating renal function, deteriorating renal function after commencing an ACEi or A2RB, asymmetrical kidneys on ultrasound

Who to refer

Routine Endocrine clinic referral for possible Endocrine causes of hypertension as outlined above. Please list all current anti-hypertensive medications in the referral to facilitate further investigation e.g. plasma renin/aldosterone ratio measurement

Consider Renal referral if a Renal cause is suspected

Red Flags

Urgent referral via the Endocrine SpR mobile if clinical or biochemical suggestion of a phaeochromacytoma or Cushing’s disease

Before referral

Further investigations

24 hour collection for urinary metanephrines

Plasma aldosterone/renin ratio – often difficult to obtain in primary care but may be able to be arranged prior to clinic appointment – email Phlebotomygprequest@nbt.nhs.uk

Echocardiogram

If suspicion for renal hypertension – renal CTA or MRA

Urinary free cortisol – if signs and symptoms suggestive of Cushing’s syndrome

Services

Endocrinology NBT

Endocrinology UHBW

Resources

References:

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