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Secondaryhypertension
FromWikipedia,thefreeencyclopedia

Secondaryhypertension(or,lesscommonly,inessentialhypertension)isatypeofhypertensionwhichby
definitioniscausedbyanidentifiableunderlyingsecondarycause.Itismuchlesscommonthantheothertype,
calledessentialhypertension,affectingonly5%ofhypertensivepatients.Ithasmanydifferentcausesincluding
endocrinediseases,kidneydiseases,andtumors.Italsocanbeasideeffectofmanymedications.

Contents
1 Types
1.1 Renal/Kidney
1.1.1 Renovascularhypertension(I15.0)
1.1.2 Kidney
1.1.3 Hypertensionsecondarytootherrenaldisorders(I15.1)
1.2 Hypertensionsecondarytoendocrinedisorders(I15.2)
1.2.1 Adrenal
1.3 Othersecondaryhypertension(I15.8)
1.4 Medicationsideeffects
1.5 Pregnancy
1.6 Sleepdisturbances
1.7 Arsenicexposure
1.8 Potassiumdeficiency
2 Diagnosis
3 References
4 Externallinks

Secondaryhypertension
Classificationandexternalresources
Specialty cardiology
ICD10

I15(http://apps.who.int/classifications/ic
d10/browse/2016/en#/I15)

ICD9
CM

405(http://www.icd9data.com/getICD9C
ode.ashx?icd9=405)

Types
Renal/Kidney
Renovascularhypertension(I15.0)

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Ithastwomaincauses:fibromusculardysplasiaandatheromatousstenosis.Alsodiabetes
SeemainarticleatRenovascularhypertension.
Kidney
Otherwellknowncausesincludediseasesofthekidney.Thisincludesdiseasessuchaspolycystickidneydiseasewhichisacysticgeneticdisorderofthekidneys,
PKDischaracterizedbythepresenceofmultiplecysts(hence,"polycystic")inbothkidneys,canalsodamagetheliver,pancreas,andrarely,theheartand
brain.[1][2][3][4]Itcanbeautosomaldominantorautosomalrecessive,withtheautosomaldominantformbeingmorecommonandcharacterizedbyprogressivecyst
developmentandbilaterallyenlargedkidneyswithmultiplecysts,withconcurrentdevelopmentofhypertension,renalinsufficiencyandrenalpain.[5]Orchronic
glomerulonephritiswhichisadiseasecharacterizedbyinflammationoftheglomeruli,orsmallbloodvesselsinthekidneys.[6][7][8]
Hypertensioncanalsobeproducedbydiseasesoftherenalarteriessupplyingthekidney.Thisisknownasrenovascularhypertensionitisthoughtthatdecreased
perfusionofrenaltissueduetostenosisofamainorbranchrenalarteryactivatesthereninangiotensinsystem.[9][10][11]
Also,somerenaltumorscancausehypertension.ThedifferentialdiagnosisofarenaltumorinayoungpatientwithhypertensionincludesJuxtaglomerularcell
tumor,Wilms'tumor,andrenalcellcarcinoma,allofwhichmayproducerenin.[12]
Hypertensionsecondarytootherrenaldisorders(I15.1)
Chronicrenalfailure
Kidneydisease/renalarterystenosisthenormalphysiologicalresponsetolowbloodpressureintherenalarteriesistoincreasecardiacoutput(CO)to
maintainthepressureneededforglomerularfiltration.Here,however,increasedCOcannotsolvethestructuralproblemscausingrenalarteryhypotension,
withtheresultthatCOremainschronicallyelevated.
Renalsegmentalhypoplasia(AskUpmarkkidney)

Hypertensionsecondarytoendocrinedisorders(I15.2)
Neurogenichypertensionexcessivesecretionofnorepinephrineandepinephrinewhichpromotesvasoconstrictionresultingfromchronichighactivityof
thesympathoadrenalsystem,thesympatheticnervoussystemandtheadrenalgland.Thespecificmechanisminvolvedisincreasedreleaseofthe"stress
hormones",epinephrine(adrenaline)andnorepinephrinewhichincreasebloodoutputfromtheheartandconstrictarteries.Peoplewithneurogenic
hypertensionrespondpoorlytotreatmentwithdiureticsastheunderlyingcauseoftheirhypertensionisnotaddressed.[13]
Pheochromocytomaatumorwhichresultsinanexcessivesecretionofnorepinephrineandepinephrinewhichpromotesvasoconstriction
Hyperaldosteronism(Conn'ssyndrome)idiopathichyperaldosteronism,liddle'ssyndrome(alsocalledpseudoaldosteronism),glucocorticoidremediable
aldosteronism
Cushing'ssyndromeanexcessivesecretionofglucocorticoidscausesthehypertension
Hyperparathyroidism
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Acromegaly
Hyperthyroidism
Hypothyroidism
Adrenal
Avarietyofadrenalcorticalabnormalitiescancausehypertension,Inprimaryaldosteronismthereisaclearrelationshipbetweenthealdosteroneinducedsodium
retentionandthehypertension.[14]
Congenitaladrenalhyperplasia,agroupofautosomalrecessivedisordersoftheenzymesresponsibleforsteroidhormoneproduction,canleadtosecondary
hypertensionbycreatingatypicallyhighlevelsofmineralocorticoidsteroidhormones.Thesemineralocorticoidscrossreactwiththealdosteronereceptor,
activatingitandraisingbloodpressure.
17alphahydroxylasedeficiencycausesaninabilitytoproducecortisol.Instead,extremelyhighlevelsoftheprecursorhormonecorticosteroneare
produced,someofwhichisconvertedto11Deoxycorticosterone(DOC),apotentmineralocorticoidnotnormallyclinicallyimportantinhumans.DOChas
bloodpressureraisingeffectssimilartoaldosterone,andabnormallyhighlevelsresultinhypokalemichypertension.[15]
11hydroxylasedeficiency,akaapparentmineralocorticoidexcesssyndrome,involvesadefectinthegenefor11hydroxysteroiddehydrogenase,an
enzymethatnormallyinactivatescirculatingcortisoltothelessactivemetabolitecortisone.[16]Athighconcentrationscortisolcancrossreactandactivate
themineralocorticoidreceptor,leadingtoaldosteronelikeeffectsinthekidney,causinghypertension.[17]Thiseffectcanalsobeproducedbyprolonged
ingestionofliquorice(whichcanbeofpotentstrengthinliquoricecandy),bycausinginhibitionofthe11hydroxysteroiddehydrogenaseenzymeand
likewiseleadingtosecondaryapparentmineralocorticoidexcesssyndrome.[18][19][20]Frequently,ifliquoriceisthecauseofthehighbloodpressure,alow
bloodlevelofpotassiumwillalsobepresent.[19]CortisolinducedhypertensioncannotbecompletelyexplainedbytheactivityofCortisolonAldosterone
receptors.ExperimentsshowthattreatmentwithSpironolactone(aninhibitorofthealdosteronereceptor),doesnotpreventhypertensionwithexcess
cortisol.Itseemsthatinhibitionofnitricoxidesynthesismayalsoplayaroleincortisolinducedhypertension.[21]
Yetanotherrelateddisordercausinghypertensionisglucocorticoidremediablealdosteronism,whichisanautosomaldominantdisorderinwhichtheincreasein
aldosteronesecretionproducedbyACTHisnolongertransient,causingofprimaryhyperaldosteronism,theGenemutatedwillresultinanaldosteronesynthase
thatisACTHsensitive,whichisnormallynot.[22][23][24][25][26]GRAappearstobethemostcommonmonogenicformofhumanhypertension.[27]
ComparetheseeffectstothoseseeninConn'sdisease,anadrenocorticaltumorwhichcausesexcessreleaseofaldosterone,[28]thatleadstohypertension.[29][30][31]
AnotheradrenalrelatedcauseisCushing'ssyndromewhichisadisordercausedbyhighlevelsofcortisol.Cortisolisahormonesecretedbythecortexofthe
adrenalglands.Cushing'ssyndromecanbecausedbytakingglucocorticoiddrugs,orbytumorsthatproducecortisoloradrenocorticotropichormone(ACTH).[32]
Morethan80%ofpatientswithCushing'ssyndromedevelophypertension.,[33]whichisaccompaniedbydistinctsymptomsofthesyndrome,suchascentral
obesity,lipodystrophy,moonface,sweating,hirsutismandanxiety.[34]

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Neuroendocrinetumorsarealsoawellknowncauseofsecondaryhypertension.Pheochromocytoma[35](mostoftenlocatedintheadrenalmedulla)increases
secretionofcatecholaminessuchasepinephrineandnorepinephrine,causingexcessivestimulationofadrenergicreceptors,whichresultsinperipheral
vasoconstrictionandcardiacstimulation.Thisdiagnosisisconfirmedbydemonstratingincreasedurinaryexcretionofepinephrineandnorepinephrineand/ortheir
metabolites(vanillylmandelicacid).

Othersecondaryhypertension(I15.8)
Hormonalcontraceptives
Neurologicdisorders
Obstructivesleepapnea
Liquorice(whenconsumedinexcessiveamounts)
Scleroderma
Neurofibromatosis
Pregnancy:unclearetiology.
Cancers:tumoursinthekidneycanoperateinthesamewayaskidneydisease.Morecommonly,however,tumorscauseinessentialhypertensionbyectopic
secretionofhormonesinvolvedinnormalphysiologicalcontrolofbloodpressure.
Drugs:Inparticular,alcohol,nasaldecongestantswithadrenergiceffects,NSAIDs,MAOIs,adrenoceptorstimulants,andcombinedmethodsofhormonal
contraception(thosecontainingethinylestradiol)cancausehypertensionwhileinuse.
Heavyalcoholuse
Steroiduse
Nicotineuse.[36]
Malformedaorta,slowpulse,ischemia:thesecausereducedbloodflowtotherenalarteries,withphysiologicalresponsesasalreadyoutlined.
Aorticvalvedisease:unclearetiology.
Coarctationoftheaorta
Atherosclerosis
Anemia:unclearetiology.
Fever:unclearetiology.
Whitecoathypertension,thatis,elevatedbloodpressureinaclinicalsettingbutnotinothersettings,probablyduetotheanxietysomepeopleexperience
duringaclinicvisit.
Perioperativehypertensionisdevelopmentofhypertensionjustbefore,duringoraftersurgery.Itmayoccurbeforesurgeryduringtheinductionof
anesthesiaintraoperativelye.g.bypaininducedsympatheticnervoussystemstimulationintheearlypostanesthesiaperiod,e.g.bypaininduced
sympatheticstimulation,hypothermia,hypoxia,orhypervolemiafromexcessiveintraoperativefluidtherapyandinthe24to48hoursafterthepostoperativ
periodasfluidismobilizedfromtheextravascularspace.Inaddition,hypertensionmaydevelopperioperativelybecauseofdiscontinuationoflongterm
antihypertensivemedication.[37]

Medicationsideeffects

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Certainmedications,includingNSAIDs(Motrin/Ibuprofen)andsteroidscancausehypertension.[38][39][40][41][42]Othermedicationsincludeextrogens(suchas
thosefoundinoralcontraceptiveswithhighestrogenicactivity),certainantidepressants(suchasvenlafaxine),buspirone,carbamazepine,bromocriptine,
clozapine,andcyclosporine.[36]Highbloodpressurethatisassociatedwiththesuddenwithdrawalofvariousantihypertensivemedicationsiscalledrebound
hypertension.[43][44][45][46][47][48][49]Theincreasesinbloodpressuremayresultinbloodpressuresgreaterthanwhenthemedicationwasinitiated.Dependingon
theseverityoftheincreaseinbloodpressure,reboundhypertensionmayresultinahypertensiveemergency.Reboundhypertensionisavoidedbygradually
reducingthedose(alsoknownas"dosetapering"),therebygivingthebodyenoughtimetoadjusttoreductionindose.Medicationscommonlyassociatedwith
reboundhypertensionincludecentrallyactingantihypertensiveagents,suchasclonidine[50]andmethyldopa.[49]
Otherherbalor"naturalproducts"whichhavebeenassociatedwithhypertensionincludemahuang,StJohn'swort,andlicorice.[36]

Pregnancy
Fewwomenofchildbearingagehavehighbloodpressure,upto11%develophypertensionofpregnancy.[51]Whilegenerallybenign,itmayheraldthree
complicationsofpregnancy:preeclampsia,HELLPsyndromeandeclampsia.Followupandcontrolwithmedicationisthereforeoftennecessary.[52][53]

Sleepdisturbances
Anothercommonandunderrecognizedsignofhypertensionissleepapnea,[54][55]whichisoftenbesttreatedwithnocturnalnasalcontinuouspositiveairway
pressure(CPAP),butotherapproachesincludetheMandibularadvancementsplint(MAS),UPPP,tonsillectomy,adenoidectomy,septoplasty,orweightloss.
AnothercauseisanexceptionallyrareneurologicaldiseasecalledBinswanger'sdisease,causingdementiaitisarareformofmultiinfarctdementia,andisoneof
theneurologicalsyndromesassociatedwithhypertension.[56]

Arsenicexposure
Becauseoftheubiquityofarsenicingroundwatersuppliesanditseffectoncardiovascularhealth,lowdosearsenicpoisoningshouldbeinferredasapartofthe
pathogenesisofidiopathichypertension.Idiopathicandessentialarebothsomewhatsynonymouswithprimaryhypertension.Arsenicexposurehasalsomanyof
thesamesignsofprimaryhypertensionsuchasheadache,somnolence,[57]confusion,proteinuria[58]visualdisturbances,andnauseaandvomiting[59]

Potassiumdeficiency
Duetotheroleofintracellularpotassiuminregulationofcellularpressuresrelatedtosodium,establishingpotassiumbalancehasbeenshowntoreverse
hypertension.[60]

Diagnosis
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TheABCDEmnemoniccanbeusedtohelpdetermineasecondarycauseofhypertension
A:Accuracy,Apnea,Aldosteronism
B:Bruits,BadKidney
C:Catecholamines,CoarctationoftheAorta,Cushing'sSyndrome
D:Drugs,Diet
E:Erythropoietin,EndocrineDisorders[61]

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