Secondary Hypertension

1
Secondary Hypertension

• Wang, Tzong-Luen, MD, PhD, FESC, FACC
• Emergency Department
• Shin-Kong Wu Ho-Su Memorial Hospital
• Date 01-28-2004

2
Hypertension

• Essential Hypertension
• Systemic hypertension of unknown cause
• 90-95
• Secondary Hypertension
• Hypertension that results from an underlying,
  identifiable, often correctable cause
• 5-10

3
Goals for Evaluation (JNC-VI)

• Detection and Confirmation of Hypertension
• Detection of Target Organ Disease
• Renal damage
• Congestive Heart Failure
• Identification of Other Risk Factors for
  Cardiovascular Diseases
• Detection of Secondary Hypertension

4
Diagnosis ABCDE

• A Accuracy, Apnea, Aldosteronism
• B Bruits, Bad Kidney
• C Catecholamines, Coarctation, Cushings
  Syndrome
• D Drugs, Diet
• E Erythropoietin, Endocrine Disorders

5
About A

• Accuracy
• Cuff width
• White coat hypertension
• Apnea
• Obstructive sleep apnea (OSA)
• Daytime somnolence, obesity, snoring,
  lower-extremity edema (RV failure), morning
  headaches, and nocturia COPD
• Sleep study
• Surgery, Nasal CPAP

6
About A

• Aldosteronism
• Primary aldosteronism
• Overproduction of aldosterone independent of the
  renin-angiotensin system
• Retention of salt and water?inhibit renin
• Hypokalemia/Increased urine potassium
• Plasma aldosterone/renin ratio
• Secondary aldosteronism

7
About B

• Bruits (Renovascular Disease)
• 65 renovascular hypertension secondary to
  atherosclerosis in the renal arteries
• Usually after age 50 at risk (smoking, DM,
  atherosclerotic disease)
• Remainder fibromuscular dysplasia
• 50 abdominal bruits
• Both systolic and diastolic bruits highly
  suggestive
• MRA 100 sensitivity, 70 specificity proximal
  renal stenosis (atherosclerosis)
• Conventional or CT angiography distal (FMD)
• Captopril radioisotopic renogram
• Duplex ultrasound
• Renal arteriography / PTA

8
About B

• Bruits (Renovascular Disease)
• Onset of hypertension occurring in patients
  younger than 30 years or older than 50 years (may
  be abrupt)
• Abrupt onset of hypertension
• Severe or resistant hypertension
• Symptoms of atherosclerotic disease elsewhere
• Negative family history for hypertension
• Smoking tobacco products
• Azotemia with ACE inhibition
• Recurrent pulmonary edema

9
About B

• Bruits (Renovascular Disease)
• Recurrent flash pulmonary edema or unexplained
  episodes of congestive heart failure
• Advanced funduscopic changes
• Abdominal bruit
• A clear abdominal bruit is heard in 46 of
  patients with RVHT.
• It also is heard in 9 of patients with essential
  hypertension however, innocent bruits are common
  in younger individuals.
• Systolic-diastolic bruits in combination with
  hypertension are suggestive of RVHT

10
About B

• Plasma renin activity
• The baseline plasma renin activity (PRA) is
  elevated in 50-80 of patients with RVHT. Renin
  levels may be increased or decreased by all
  antihypertensive agents. Nonsteroidal
  anti-inflammatory drugs (NSAIDs) decrease plasma
  renin levels. Measuring the rise in the PRA 1
  hour after administering 25-50 mg of captopril
  can increase the predictive value of PRA.
  Patients with RAS have an exaggerated increase in
  PRA, perhaps due to removal of the normal
  suppressive effect of high angiotensin II levels
  on renin secretion in the stenotic kidney.
• The sensitivity and specificity of studies of the
  captopril renin test are 75-100 and 60-95,
  respectively. Limitations include the need to
  discontinue antihypertensive medications that can
  affect the PRA (eg, ACE inhibitors,
  beta-blockers, diuretics), the low sensitivity,
  and the somewhat decreased predictive value when
  compared to a renogram after ACE inhibition.

11
About B

• Renal vein renin measurements
• Renal vein renin measurements compare renin
  release from each kidney and are used to predict
  the potential success of surgical
  revascularization. Increased renin secretion in
  the ischemic kidney as compared to the
  contralateral kidney, ie, a renal vein renin
  difference of 1.5-fold, constitutes a positive
  test result and suggests that revascularization
  will treat elevated blood pressure successfully.
  Renin secretion in the contralateral kidney is
  suppressed, as evidenced by the similar levels of
  renin measured in the renal artery (infrarenal
  inferior vena cava) and renal vein.
• Fewer than 10 of healthy patients have a ratio
  above 1.5 and fewer than 20 have a ratio below
  1.1. The accuracy of these measurements has been
  suggested to be enhanced by the prior
  administration of an ACE inhibitor, which will
  increase renin secretion on the affected side.
• False-negative and false-positive results are
  common.

12
About B

• Renogram and captopril renogram
• Because of its high false-negative rate (20-25),
  the nonstimulated renal scan has limited efficacy
  as a screening test. The predictive value of
  radioisotope scanning, however, can be enhanced
  by the administration of captopril orally (25-50
  mg) 1 hour before the isotope is injected.
  Removal of angiotensin mediated vasoconstriction
  by ACE inhibition induces a decline in the GFR of
  the stenotic kidney and often an equivalent
  increase in the GFR of the contralateral kidney.
  The difference in the GFR between the 2 kidneys
  is enhanced by radioisotope and is visible on the
  renogram.
• A marker of glomerular filtration (eg,
  diethylenetriamine pentaacetic acid DTPA) or
  compounds that are secreted by the proximal
  tubule (eg, hippurate, mercaptotriglycylglycine
  MAG-3) can be used to estimate total, as well
  as differential, kidney function, information
  that may be useful when assessing treatment
  options. The latter may be more reliable in
  patients with renal insufficiency.

13
About B

• Renogram and captopril renogram
• Positive results from ACE inhibitor renogram are
  determined by the following 2 criteria (1)
  decreased relative uptake of isotope, with 1
  kidney accounting for less than 40 of the total
  GFR and (2) delayed peak uptake of the isotope of
  more than 10-11 minutes (normal is 3-6 min).
• Note that a slower washout of the isotope may
  occur in the stenotic kidney, which is
  demonstrated in unilateral RAS by a delay of 5
  minutes or longer in washout on the involved
  side. This criterion may be evaluated best with a
  compound such as hippurate, which is secreted
  into the tubules rather than only being filtered.

14
About B

• Bad Kidney (Renal Parenchymal Disease)
• Mechanical and humoral effects of glomerular
  hypertension
• Decreased ability to excrete salt and excess
  water
• Low renin state
• Hyperparathyroidism and erythropoietin
• ACEI
• Early control of hypertension and diabetes
• Elevated serum creatinine and decreased
  creatinine clearance

15
About C

• Catecholamines
• White-coat hypertension, pheochromocytoma, OSA,
  pre- and post-operative hypertension
• Sympathethomimetics, weight-loss agents
  containing ephedrine
• Pheochromocytoma
• Headache
• Diaphoresis
• Paroxysmal hypertension

16
About C

• Coarctation of the Aorta
• Most often just distal to the origin of the left
  subclavian artery
• Young adulthood
• High incidence of premature death
• Decreased lower-extremity pulses with upper
  extremity hypertension
• Dyspnea on exertion
• Chest findings of notched ribs (from collateral
  vessels)
• Dilation of the aorta above and below the
  constriction (the 3 sign)

17
About C

• Coarctation of the Aorta

18
About C

• Coarctation of the Aorta with Dissection

19
About C

• Coarctation of the Aorta
• Early presentation Young patients may present in
  the first 3 weeks of life with poor feeding,
  tachypnea, and lethargy and progress to overt CHF
  and shock. These patients may have appeared well
  prior to hospital discharge, and deterioration
  coincides with closure of the patent ductus
  arteriosus (PDA). Presentation may be abrupt and
  acute with ductal closure. Development of
  symptoms often is accelerated by the presence of
  associated major cardiac anomalies, such as VSD.
  Historically, these infants have carried the
  highest risk of operation. Symptoms may be subtle
  at first, and patients may make repeated trips to
  the physician before finally presenting in
  extremis.
• Late presentation Patients often present after
  the neonatal period with hypertension or a
  murmur. These patients often have not developed
  overt CHF because of the presence of arterial
  collateral vessels. Diagnosis often may be made
  after hypertension is noted as an incidental
  finding during evaluation of other problems, such
  as trauma or more routine illness. Other
  presenting symptoms may include headaches, chest
  pain, fatigue, or even life-threatening
  intracranial hemorrhage. True claudication is
  rare. Many patients are asymptomatic except for
  the hypertension that is noted incidentally.

20
About C

• Coarctation of the Aorta
• Early presentation
• Neonates may present with tachypnea, tachycardia,
  and increased work of breathing and may even be
  moribund with shock. Keys to the diagnosis
  include BP discrepancies between the upper and
  lower extremities and reduced or absent lower
  extremity pulses to palpation.
• Differential cyanosis (pink upper extremities
  with cyanotic lower extremities) may occur when
  right-to-left flow across a PDA provides lowered
  rates of flow in the body. Although often not
  obvious to the eye, differential cyanosis may be
  documented by preductal and postductal pulse
  oximetry measurements and by inspection. However,
  in the presence of large lesions in the
  left-to-right shunt (eg, VSD), PA saturations may
  approximate aortic saturations with less obvious
  differential oximetric findings. Reversed
  differential cyanosis (upper body cyanosis with
  normal lower body saturation) may occur with
  transposition of the great arteries, PDA, and
  pulmonary hypertension resulting in right-to-left
  ductal shunting.
• In low cardiac output and ventricular
  dysfunction, pulses may be diminished diffusely,
  and BP gradients may seem minimal.
• The murmur associated with CoA may be
  nonspecific, yet usually is a systolic murmur in
  the left infraclavicular area and under the left
  scapula. Additional murmurs resulting from the
  presence of associated abnormalities, such as VSD
  or aortic valve stenosis, also may be detected.
  An ejection click may signify the presence of a
  bicuspid aortic valve, while a gallop rhythm may
  indicate ventricular dysfunction.

21
About C

• Coarctation of the Aorta
• Late presentation
• Older infants and children may be referred for
  evaluation of hypertension or murmur.
  Hypertension in a fussy infant may be attributed
  to agitation thus, comparing 4 extremity BP
  readings is important. Occasionally, left arm
  pressure may be lower than right arm pressure if
  the origin of the left subclavian artery is
  involved in the coarctation. Careful simultaneous
  palpation of upper and lower extremity pulses may
  help confirm suspected coarctation.
• A murmur in the left infraclavicular area and
  under the left scapula may be systolic, but the
  murmur also may sound continuous in the presence
  of multiple collateral vessels or, occasionally,
  severe coarctation. An ejection click may be
  audible when an associated bicuspid aortic valve
  and a murmur of aortic stenosis or insufficiency
  are present. Similarly, a murmur of mitral
  stenosis or LV outflow tract obstruction also may
  occur. A gallop rhythm may occur in the presence
  of a hypertrophic noncompliant LV.
• Other findings on physical examination may
  include abnormalities of blood vessels in the
  retina and a prominent suprasternal notch
  pulsation. A thrill may be present in the
  suprasternal notch or on the precordium in the
  presence of significant aortic valve stenosis. In
  the rare case of abdominal coarctation, an
  abdominal bruit may be noted.

22
About C

• Cushing syndrome
• Excess levels of exogenously administered
  glucocorticoids
• Endogenous overproduction of cortisol
• primary adrenocortical abnormality (ie, adenoma,
  carcinoma, nodular adrenal hyperplasia)
• excess adrenocorticotropic hormone (ACTH)
• ACTH-secreting neoplasms are either an anterior
  pituitary tumor (Cushing disease) or
• ectopic nonpituitary tumor (eg, oat cell, small
  cell lung carcinoma, carcinoid tumor)
• Mineralocorticosteroid effects of excess
  glucocortisoids
• Dexmethasone-suppression test

23
About C

• Cushing syndrome
• Additional thinkings
• Adrenal crisis
• Galactorrhea
• Hypothyroidism
• LH, FSH, GH, TSH

24
About C

• Cushing syndrome
• Determination of 24-hour urinary free cortisol is
  an excellent indicator of overall daily cortisol
  production. Values more than 4 times the upper
  limit of normal are very suggestive of Cushing
  syndrome, whereas values 1-4 times normal are
  consistent with either pseudo-Cushing or Cushing
  syndrome.
• With the overnight 1 mg dexamethasone suppression
  test, 1 mg of dexamethasone is ingested at 11 pm,
  and serum cortisol is measured at 8 am the next
  morning. In healthy individuals, serum cortisol
  should be less than 2 mcg/dL.

25
About C

• Cushing syndrome
• The 48-hour low-dose dexamethasone suppression
  test (0.5 mg dexamethasone PO q6h for 8 doses)
  has been used for many years. In healthy
  individuals, 24-hour urinary 17-hydroxycorticoster
  oids are suppressed to 4 mg or less during the
  second day of dexamethasone ingestion. A 24-hour
  urinary free cortisol higher than 20 mcg suggests
  Cushing Syndrome. Unfortunately, sensitivity and
  specificity of this test are only about 70.
• 48-hour low-dose dexamethasone suppression test
  plus CRH stimulation. Ovine CRH (1 mcg/kg IV) is
  given 2 hours after the eighth dose of 0.5 mg
  dexamethasone. Serum cortisol is measured 15
  minutes after ovine CRH administration. A
  cortisol of higher than 1.4 mg/dL is very
  suggestive of Cushing syndrome.

26
About C

• Cushing syndrome
• A logical first step involves determining if the
  syndrome is ACTH-dependent or ACTH-independent. A
  plasma ACTH, measured by an immunoradiometric
  assay of less than 5 pg/mL, is suggestive of a
  primary adrenal tumor. An ACTH level higher than
  10-20 pg/mL is consistent with ACTH-dependent
  Cushing syndrome.
• The 8 mg overnight dexamethasone suppression test
  and the 48-hour high-dose dexamethasone test may
  be useful when baseline ACTH levels are
  indeterminate. These studies also help in
  determining whether a patient has pituitary or
  ectopic ACTH production.
• In the overnight 8 mg dexamethasone suppression
  test, individuals receive dexamethasone 8 mg PO
  at 11 pm with measurement of cortisol at 8 am the
  next day. Suppression of serum cortisol to less
  than 50 of baseline is suggestive of a pituitary
  source of ACTH rather than ectopic ACTH or
  primary adrenal disease. Diagnostic accuracy,
  however, is only 70-80.
• With the 48-hour high-dose dexamethasone
  suppression test, patients ingest 2 mg
  dexamethasone q6h for 8 doses. A decrease in
  urinary free cortisol of more than 50 is
  suggestive of an anterior pituitary tumor rather
  than ectopic ACTH or a primary adrenal tumor.
  Unfortunately, sensitivity of this test is only
  80, with a specificity of 70-80. More stringent
  criteria of a 90 decrease in urinary free
  cortisol levels excludes the diagnosis of ectopic
  ACTH and has 100 specificity for anterior
  pituitary disease.

27
About D

• Drugs
• Immunosuppressive agents, NSAID, COX-2
  inhibitors, estrogen, nicortine, alcohol
• Diet
• Excessive salt
• Blacks, the elderly, patients with diabetes,
  patients with essential hypertension
• Low intake of potassium, calcium and magnesium
• Dietary patterns associated with obesity

28
Drugs that Raises Blood Pressure

• Immunosuppressive agents
• Cyclosporine, tacrolimus, corticosteroid
• NSAID
• Ibuprofen, naproxen, piroxicam
• COX-2 inhibitors
• Celecoxib, rofecoxib, valdecoxib
• Estrogens
• Weight-loss agents
• Sibutramine, phentermine, ephedrine
• Stimulants
• Nicotine, amphetamines
• Minerocorticosteroids
• Fludrocortisone
• Antiparkinsonian
• Bromocriptine
• Monoamine oxidase inhibitors
• Phenelzine
• Anabolic steroids
• Testosterone

29
About E

• Erythropoietin
• Endogenous
• COPD
• Exogenous
• Chronic renal failure
• Polycythemia/hyperviscosity mechanisms
• Direct pressor effects

30
About E

• Endocrine Disorders
• Hypothyroidism
• Decrease cardiac output
• Compensatory increase in vascular tone
• Prominent rise in DBP than in SBP
• Hyperthyroidism
• Increased cardiac output
• Compensatory decreased vascular tone
• Greater increase in SBP
• TSH levels

31
About E

• Endocrine Disorders
• Hyperparathyroidism
• Primary or secondary to renal insufficiency
• 30-40 have hypertension
• Unclear mechanisms
• Calcium?
• PTH?
• Parathyroidectomy does not reliably resolve
  hypertension

32
About E

• Endocrine Disorders
• Pregnancy-induced hypertension
• Pre-eclampsia
• Eclampsia
• HELLP syndrome

33
About E

• Endocrine Disorders
• Pre-eclampsia
• Seizure or postictal state (100)
• Headache (80)
• Generalized edema (50)
• Vision disturbance (40)
• Abdominal pain with nausea (20)
• Amnesia and other mental status changes

34
About E

• Endocrine Disorders
• Pre-eclampsia
• Sustained systolic BP greater than 160 mm Hg or
  diastolic BP greater than 110 mm Hg
• Tachycardia
• Tachypnea
• Rales
• Mental status changes
• Hyperreflexia
• Clonus
• Papilledema
• Oliguria or anuria
• Localizing neurologic deficits
• Right upper quadrant (RUQ) or epigastric
  abdominal tenderness
• Generalized edema
• Small fundal height for the estimated gestational
  age
• Apprehension

35
About E

• Endocrine Disorders
• Pre-eclampsia
• Risk factors may include the following
• Familial incidence
• Lower socioeconomic status
• Multiple fetuses
• Teenaged patient or patient older than 35 years
• Collagen disorders
• Primigravida
• Gestational diabetes
• Hydatid mole
• Fetal hydrops
• History of renal disease

36
About E

• Endocrine Disorders
• Pre-eclampsia
• Microangiopathic hemolytic anemia and dilution of
  pregnancy
• Thrombocytopenia (elevated liver enzyme levels, and low platelet
  count (HELLP) syndrome
• The serum creatinine level is elevated because of
  decreased intravascular volume and a decreased
  glomerular filtration rate (GFR).
• Rule out hypoglycemia as cause of seizure or
  result of seizure, and rule out hyperglycemia as
  cause of mental status changes.
• Liver function test results may reveal the
  following
• Aspartate aminotransferase (SGOT) level higher
  than 72 IU/L, total bilirubin levels higher than
  1.2 mg/dL, and LDH level higher than 600 IU/L
• Elevated levels due to hepatocellular injury and
  HELLP syndrome
• The coagulation profile may reveal normal
  prothrombin (PT) and activated partial
  thromboplastin (aPTT) times, fibrin split
  products, and fibrinogen levels Rule out
  associated disseminated intravascular coagulation
  (DIC).
• Urinalysis may reveal the following findings
• Proteinuria (300 mg/24h or 1 g/L)
• Positive human chorionic gonadotropin (HCG)
  result
• Uric acid levels may be increased mildly.
• Creatinine clearance (CrCl) may be less than 90
  mL/min/1.73 m2
• Increased T4 levels may be present

37
About E

• Endocrine Disorders
• Pre-eclampsia
• Supportive care for eclampsia consists of airway
  support, adequate oxygenation, anticonvulsant
  therapy, and BP control.
• Magnesium sulfate is the initial drug
  administered to terminate seizures. Seizures
  usually terminate after the loading dose of
  magnesium.
• Benzodiazepine or phenytoin (Dilantin) can be
  used for seizures that are not responsive to
  magnesium sulfate.
• If significant hypertension continues after the
  initial loading dose of magnesium, hydralazine or
  another antihypertensive agent is administered
  for BP control. Care must be taken not to
  decrease the BP too drastically a drastic
  decrease can cause inadequate uteroplacental
  perfusion and fetal distress.
• Maintaining a diastolic BP of 90 mm Hg is the
  goal of antihypertensive therapy.

38
About E

• Endocrine Disorders
• Pheochromcytoma
• Headache, diaphoresis, palpitations, paroxysmal
  hypertension
• Vary depending on the types of catecholamines,
  the amount and frequency of their release into
  the circulation and other factors
• Urinary measurement of catecholamine metabolites
  (vanillylmandelic acid, metahephrines,
  normetanephrines)
• Plasma metanephrines
• Acromegaly
• rare

39
About E

• Endocrine Disorders
• Pheochromcytoma
• MEN 2A (Sipple syndrome) is comprised of
  medullary thyroid carcinoma, hyperparathyroidism,
  pheochromocytoma, and Hirschsprung disease. Over
  95 of cases of MEN 2A are associated with
  mutations in the Ret proto-oncogene affecting 1
  of 5 codons in exons 10 (codons 609, 611, 618,
  620) or exon 11 (codon 634).
• Medullary thyroid carcinoma, pheochromocytoma,
  mucosal neurofibromatosis, intestinal
  ganglioneuromatosis, Hirschsprung disease, and a
  marfanoid body habitus characterize MEN 2B. A
  germline missense mutation in the tyrosine kinase
  domain of the Ret proto-oncogene (exon 16, codon
  918) has been reported to be present in 95 of
  patients with MEN 2B.

40
About E

• Endocrine Disorders
• Pheochromcytoma
• Pheochromocytoma, cerebellar hemangioblastoma,
  renal cell carcinoma, renal and pancreatic cysts,
  and epididymal cystadenomas are associated with
  VHL disease. One study found that this syndrome
  was present in close to 19 of patients with
  pheochromocytoma (Neumann, 1993). Over 75
  germline mutations in a VHL suppressor gene
  located on chromosome 3 have been identified.
• Congenital anomalies (often benign tumors) of the
  skin, nervous system, bones, and endocrine glands
  characterize neurofibromatosis, or von
  Recklinghausen disease. Only 1 of patients with
  neurofibromatosis have been found to have
  pheochromocytoma, but as many as 5 of patients
  with pheochromocytoma have been found to have
  neurofibromatosis.

41
About E

• Endocrine Disorders
• Pheochromcytoma
• Other neuroectodermal disorders associated with
  pheochromocytoma include tuberous sclerosis
  (Bourneville disease, Epiloia) and Sturge-Weber
  syndrome.
• Pheochromocytoma may produce calcitonin, opioid
  peptides, somatostatin, adrenocorticotropic
  hormone (ACTH), and vasoactive intestinal peptide
  (VIP). ACTH hypersecretion has caused Cushing
  syndrome, and VIP overproduction causes watery
  diarrhea.

42
About E

• Endocrine Disorders
• Pheochromcytoma
• Precipitants of a hypertensive crisis
• Anesthesia induction
• Opiates
• Dopamine antagonists
• Cold medications
• Radiographic contrast media
• Drugs that inhibit catecholamine reuptake, such
  as tricyclic antidepressants and cocaine
• Childbirth

43
About E

• Endocrine Disorders
• Pheochromcytoma
• Alcohol withdrawalLabile essential
  hypertensionHyperventilationOrthostatic
  hypotensionMultiple pharmacologic agents
  (monoamine oxidase inhibitors MAOIs,
  decongestants, sympathomimetics)Illegal drug use
  (phencyclidine PCP, lysergic acid diethylamide
  LSD, cocaine)Migraine headacheAutonomic
  neuropathyStrokeToxemia of pregnancyPolyneuropa
  thy, organomegaly, endocrinopathy, monoclonal
  gammopathy, and skin changes (POEMS) syndrome

44
About E

• Endocrine Disorders
• Pheochromcytoma
• Major physical stress and multiple drugs may
  interfere with the assay and cause false
  elevations of the metanephrines. These drugs
  include the following
• Tricyclic antidepressants
• Levodopa
• Labetalol
• Ethanol
• Sotalol
• Amphetamines
• Buspirone
• Benzodiazepines
• Methyldopa
• Chlorpromazine
• The following decrease 24-hour urine levels
• Methyltyrosine, which inhibits tyrosine
  hydroxylase, the rate-limiting enzyme in
  catecholamine synthesis
• Methylglucamine, which is present in
  radiocontrast media
• Reserpine

45
About E

• Endocrine Disorders
• Pheochromcytoma
• CT
• MRI
• I-131-MIBG scan
• In-111-somatostatin analog scan
• PET F-18-FDG

46
Risk Factors for Secondary Hypertension

• Poor response to therapy (resistant)
• Worsening of control in previously stable
  hypertensive patients
• Stage 3 hypertension (SBP180 or DBP110)
• Onset younger than age 20 or older than age 50
• Significant hypertensive target organ damage
• Lack of family history of hypertension
• Findings on history, physical examination, or
  laboratory testing suggesting a secondary
  hypertension

47
Findings Suggesting Secondary Hypertension
48
Findings Suggesting Secondary Hypertension
49
Findings Suggesting Secondary Hypertension
50
Routine Screening

• Urinalysis
• CBC
• Blood Chemistry (Na, K, Cre, fasting glucose)
• Fasting lipid profile (LDL, HDL, triglycerides,
  total cholesterol)
• 12-lead ECG

51
Flow Chart