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Clinical management of secondary hypertension

ESC Congress Report

Secondary forms of hypertension can be reversible through tailored disease-specific treatments.

  • A simple screening test that includes medical history, physical examination and routine exams should be done in every hypertensive patient.
  • Primary aldosteronism is present in at least 12% of the hypertensive population and possibly as much as 20% in resistant hypertension.
  • The diagnosis and treatment of pheochromocytoma.



The relevance of secondary hypertension was reviewed in this session and three forms of secondary hypertension primary aldosteronism, pheochromocytoma and renovascular hypertension were reviewed.

The first speaker Professor Stefano Taddei from (Pisa, IT) presented "when to suspect secondary hypertension". He started by recognising that the prevalence of secondary forms of hypertension is higher than previously thought. In fact, it consists of more than 25% of the total hypertension cases, considering the prevalence of primary aldosteronism, obstructive sleep apnea, renovascular hypertension and renal parenchymal disease, which are the most frequent forms of secondary hypertension observed in Hypertension Units.
The diagnosis of secondary hypertension has to be especially considered in young hypertensives, as well as in patients with resistant hypertension. Secondary forms of hypertension can be reversible through tailored disease-specific treatments, and at least a simple screening test has to be done in every hypertensive patient through the medical history, physical examination and routine exams. Eliminating substances with the capacity to increase blood pressure is the easiest way to distinguish, and in many cases control, a secondary hypertension. The characteristic of this simple screening that can increase the suspicion of secondary forms of hypertension are amply described in the recently published European Society of Cardiology/European Society of Hypertension Guidelines.

The second speaker, Professor Morris Brown from (Cambridge, UK) reviewed the diagnosis and treatment of primary aldosteronism. The presentation confirmed the high prevalence of this form of secondary hypertension; at least 12% of the hypertensive population and possibly as much as 20% in resistant hypertension, and it is frequently missed. 
It used to be widely believed that the presence of hypokalemia was a characteristic finding in this form of hypertension. It is known today that this is not seen in the majority of patients suffering from primary aldosteronism, although the development of hypokalemia when a patient is treated with and ACEi/ARB and a low dose of a thiazide diuretic increases the need to exclude primary aldosteronism. The diagnostic clues are found in a suppressed plasma renin level, particularly if treated with an ACEi/ARB.
A CT or MRI should be done to dismiss the presence of suprarenal nodules, and adrenal vein blood sampling or the performance of an 11C-matomidate PET CT should be completed to find lateralization of aldosterone secretion that indicates the need for intervention through laparotomy.

The third speaker Professor Gian Paolo Rossi from (Padua, IT) presented the diagnosis and treatment of pheochromocytoma. This form of hypertension appears in less than 1% of the hypertensive population and the majority of cases constitute an autopsy finding. The need to think about this form of hypertension is necessary when the classical signs and symptoms are present, and has to be followed with a determination of metanephrines in plasma or urine, followed by a CT or gadolinium-enhanced MRI. New data on genetic aspects of pheochromocytoma were presented that hopefully will help with the diagnosis in the future.

The last presentation by Professor Florian P Limbourg from (Hannover, DE) covered renovascular hypertension. Atherosclerotic renovascular hypertension has a relatively high prevalence that can be found in 6.8% of patients and in 30% of refractory hypertension patients. It is frequently accompanied by severe target organ damage in particular, left ventricular hypertrophy, chronic kidney disease and frequently elevated proteinuria. Stenosis above 70% are accompanied by relevant changes in renal hemodynamics. Renal function and proteinuria represent bad prognostic factors for the patient and, in fact, new ways to recognize the extent of renal ischemia are needed. In this sense, intrarenal vascular resistances could be of help in the prognosis. Stenosis above 70% are accompanied by relevant changes in renal hemodynamics, however, recent data have confirmed that intervention or the simple maintenance of medical therapy do not differ in their capacity to improve the prognosis of the patients.

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Clinical management of secondary hypertension

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.