Chronic hypertension differential diagnosis
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Assistant Editor-In-Chief: Yazan Daaboul, Serge Korjian, Taylor Palmieri
Overview
Before the diagnosis of primary (essential) hypertension is established with certainty, secondary causes of hypertension (secondary hypertension) should be considered as well as other conditions that may elevate the blood pressure which include white coat hypertension, masked hypertension, and pseudohypertension.
Secondary Hypertension
Although it is not practical to rule out secondary hypertension in every hypertensive patient, secondary hypertension should be considered if there is early onset of hypertension before the age of 30, if there is the abrupt onset of hypertension, if there rapid progression of hypertension, and if there is a hypertensive urgency or hypertensive emergency. The evaluation of secondary hypertension is discussed in detail here.
White Coat Hypertension
White coat hypertension, more commonly known as white coat syndrome, is a phenomenon in which patients exhibit elevated blood pressure in a clinical setting but not in other settings.[1] The prevalence of white coat hypertension is approximately 13%.[2] Risk factors for white coat hypertension in observational studies include age, female sex, and being a non-smoker. The higher the blood pressure in the clinical setting, the lower the probability of white coat hypertension.[1] Ambulatory blood pressure monitoring and patient self-measurement using a home blood pressure monitoring device are being increasingly used to differentiate patients with white coat hypertension from patients with true hypertension. Ambulatory monitoring has been found to be a more practical and reliable method in detecting patients with white coat hypertension and for the prediction of target organ damage. The 2013 ESC/ESH recommendations recommend that white coat hypertension be confirmed within 3-6 months of initial diagnosis and that close follow-up and periodic out-of-office BP measurements be obtained.[1] The treatment of white coat hypertension remains controversial.[3] Finally, the risk of target organ damage and prognosis among patients with white coat hypertension is still unknown. Although white coat hypertension was initially considered intermediate in risk between normal blood pressure and hypertension, larger subsequent meta-analyses have not demonstrated a significant difference in outcomes between patients with white coat hypertension and those with normal blood pressure levels.[2][4][5]
Masked Hypertension
The term "masked hypertension" can be used to describe a contrasting phenomenon from that of white coat hypertension, where blood pressure is elevated during daily living, but not in an office setting.[6] The prevalence of masked hypertension is approximately 13% and tends to be more likely when the office blood pressure values are high-normal.[7][8] Risk factors for masked hypertension include young age, male gender, smoking, alcohol, physical exercise, anxiety and stress, obesity, diabetes, chronic renal insufficiency, and family history of hypertension. In contrast to white coat hypertension, patients with masked hypertension are at a two-fold increased risk of cardiovascular events and target organ damage, especially when BP levels are elevated at night.[9][10]
Pseudohypertension
Pseudohypertension is defined as marked arterial stiffness associated with calcification of brachial arteries that requires much higher cuff-inflating pressures to occlude the artery leading to falsely elevated blood pressures.[1] Pseudohypertension is more common among elderly patients.[1]
Differetiating essential hypertension from other diseases
Disease | Prominent clinical features | Investigations |
---|---|---|
Hyperthyroidism | The main symptoms include:
|
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Essential hypertension | Most patients with hypertension are asymptomatic at the time of diagnosis. Common symptoms are listed below: | JNC 7 recommends the following routine laboratory tests before initiation of therapy for hypertension:
|
Generalized anxiety disorder | According to DSM V, the following criteria should be present to fit the diagnosis of generalized anxiety disorder:
|
- |
Menopause | The perimenopausal symptoms are caused by an overall drop, as well as dramatic but erratic fluctuations, in the levels of estrogens, progestin, and testosterone. Some of these symptoms such as formication etc may be associated with the hormone withdrawal process.
|
|
Opioid withdrawal disorder | According to DSM V, the following criteria should be present to fit the diagnosis of opioid withdrawal:
|
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Primary hyperaldosteronism | The hallmark symptoms of a primary hyperaldosteronism include:
|
Diagnostic lab findings associated with pheochromocytoma include:
|
Pheochromocytoma | The hallmark symptoms of a pheochromocytoma are those of sympathetic nervous system hyperactivity, symptoms usually subside in less than one hour and they may include:
Please note that not all patients with pheochromocytoma experience all classical symptoms. |
Diagnostic lab findings associated with pheochromocytoma include:
|
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Mancia G, Fagard R, Narkiewicz K, Redán J, Zanchetti A, Böhm M; et al. (2013). "2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension". J Hypertens. 31 (10): 1925–38. doi:10.1097/HJH.0b013e328364ca4c. PMID 24107724.
- ↑ 2.0 2.1 Fagard RH, Cornelissen VA (2007). "Incidence of cardiovascular events in white-coat, masked and sustained hypertension versus true normotension: a meta-analysis". J Hypertens. 25 (11): 2193–8. doi:10.1097/HJH.0b013e3282ef6185. PMID 17921809.
- ↑ Niiranen TJ, Kantola IM, Vesalainen R, Johansson J, Ruuska MJ (2006). "A comparison of home measurement and ambulatory monitoring of blood pressure in the adjustment of antihypertensive treatment". Am. J. Hypertens. 19 (5): 468–74. doi:10.1016/j.amjhyper.2005.10.017. PMID 16647616. Unknown parameter
|month=
ignored (help) - ↑ Pierdomenico SD, Cuccurullo F (2011). "Prognostic value of white-coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: an updated meta analysis". Am J Hypertens. 24 (1): 52–8. doi:10.1038/ajh.2010.203. PMID 20847724.
- ↑ Franklin SS, Thijs L, Hansen TW, Li Y, Boggia J, Kikuya M; et al. (2012). "Significance of white-coat hypertension in older persons with isolated systolic hypertension: a meta-analysis using the International Database on Ambulatory Blood Pressure Monitoring in Relation to Cardiovascular Outcomes population". Hypertension. 59 (3): 564–71. doi:10.1161/HYPERTENSIONAHA.111.180653. PMC 3607330. PMID 22252396.
- ↑ Pickering TG, Eguchi K, Kario K (2007). "Masked hypertension: a review" (– Scholar search). Hypertens. Res. 30 (6): 479–88. doi:10.1291/hypres.30.479. PMID 17664850. Unknown parameter
|month=
ignored (help)[dead link] - ↑ Parati G, Ulian L, Santucciu C, Omboni S, Mancia G (1998). "Difference between clinic and daytime blood pressure is not a measure of the white coat effect". Hypertension. 31 (5): 1185–9. PMID 9576133.
- ↑ Bobrie G, Clerson P, Ménard J, Postel-Vinay N, Chatellier G, Plouin PF (2008). "Masked hypertension: a systematic review". J Hypertens. 26 (9): 1715–25. doi:10.1097/HJH.0b013e3282fbcedf. PMID 18698202.
- ↑ Lurbe E, Redon J, Kesani A, Pascual JM, Tacons J, Alvarez V; et al. (2002). "Increase in nocturnal blood pressure and progression to microalbuminuria in type 1 diabetes". N Engl J Med. 347 (11): 797–805. doi:10.1056/NEJMoa013410. PMID 12226150.
- ↑ Wijkman M, Länne T, Engvall J, Lindström T, Ostgren CJ, Nystrom FH (2009). "Masked nocturnal hypertension--a novel marker of risk in type 2 diabetes". Diabetologia. 52 (7): 1258–64. doi:10.1007/s00125-009-1369-9. PMID 19396423.
- ↑ Cohen JB, Cohen DL, Herman DS, Leppert JT, Byrd JB, Bhalla V (2020). "Testing for Primary Aldosteronism and Mineralocorticoid Receptor Antagonist Use Among U.S. Veterans : A Retrospective Cohort Study". Ann Intern Med. doi:10.7326/M20-4873. PMID 33370170 Check
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value (help).
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