Chronic hypertension differential diagnosis
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.
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. The prevalence of white coat hypertension is approximately 13%. 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. 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. The treatment of white coat hypertension remains controversial. 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.
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. The prevalence of masked hypertension is approximately 13% and tends to be more likely when the office blood pressure values are high-normal. 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.
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. Pseudohypertension is more common among elderly patients.
Differetiating essential hypertension from other diseases
|Disease||Prominent clinical features||Investigations|
|Hyperthyroidism||The main symptoms include:|
|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:
|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:|
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- 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.
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- 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.
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