Chronic hypertension differential diagnosis: Difference between revisions

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{{Template:Hypertension}}
[[Image:Home_logo1.png|right|250px|link=http://www.wikidoc.org/index.php/Chronic_hypertension]]


{{CMG}}; '''Assistant Editor-In-Chief:''' Taylor Palmieri
{{CMG}}; '''Assistant Editor-In-Chief:''' [[User:YazanDaaboul|Yazan Daaboul]], [[User:Sergekorjian|Serge Korjian]], Taylor Palmieri


==Overview==
==Overview==
Sustained hypertension should be distinguished from benign entities such as [[white coat hypertension]].
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 [[secondary hypertension|here]].


==White Coat Hypertension==
==White Coat Hypertension==
===Definition===
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.<ref name="pmid24107724">{{cite journal| author=Mancia G, Fagard R, Narkiewicz K, Redán J, Zanchetti A, Böhm M et al.| title=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. | journal=J Hypertens | year= 2013 | volume= 31 | issue= 10 | pages= 1925-38 | pmid=24107724 | doi=10.1097/HJH.0b013e328364ca4c | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24107724 }} </ref> The prevalence of white coat hypertension is approximately 13%.<ref name="pmid17921809">{{cite journal| author=Fagard RH, Cornelissen VA| title=Incidence of cardiovascular events in white-coat, masked and sustained hypertension versus true normotension: a meta-analysis. | journal=J Hypertens | year= 2007 | volume= 25 | issue= 11 | pages= 2193-8 | pmid=17921809 | doi=10.1097/HJH.0b013e3282ef6185 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17921809 }} </ref> 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.<ref name="pmid24107724">{{cite journal| author=Mancia G, Fagard R, Narkiewicz K, Redán J, Zanchetti A, Böhm M et al.| title=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. | journal=J Hypertens | year= 2013 | volume= 31 | issue= 10 | pages= 1925-38 | pmid=24107724 | doi=10.1097/HJH.0b013e328364ca4c | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24107724 }} </ref> 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.<ref name="pmid24107724">{{cite journal| author=Mancia G, Fagard R, Narkiewicz K, Redán J, Zanchetti A, Böhm M et al.| title=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. | journal=J Hypertens | year= 2013 | volume= 31 | issue= 10 | pages= 1925-38 | pmid=24107724 | doi=10.1097/HJH.0b013e328364ca4c | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24107724 }} </ref>  The treatment of white coat hypertension remains controversial.<ref name="pmid16647616">{{cite journal |author=Niiranen TJ, Kantola IM, Vesalainen R, Johansson J, Ruuska MJ |title=A comparison of home measurement and ambulatory monitoring of blood pressure in the adjustment of antihypertensive treatment |journal=Am. J. Hypertens. |volume=19|issue=5 |pages=468–74 |year=2006 |month=May |pmid=16647616 |doi=10.1016/j.amjhyper.2005.10.017}}</ref>  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.<ref name="pmid17921809">{{cite journal| author=Fagard RH, Cornelissen VA| title=Incidence of cardiovascular events in white-coat, masked and sustained hypertension versus true normotension: a meta-analysis. | journal=J Hypertens | year= 2007 | volume= 25 | issue= 11 | pages= 2193-8 | pmid=17921809 | doi=10.1097/HJH.0b013e3282ef6185 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17921809 }} </ref><ref name="pmid20847724">{{cite journal| author=Pierdomenico SD, Cuccurullo F| title=Prognostic value of white-coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: an updated meta analysis. | journal=Am J Hypertens | year= 2011 | volume= 24 | issue= 1 | pages= 52-8 | pmid=20847724 | doi=10.1038/ajh.2010.203 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20847724 }} </ref><ref name="pmid22252396">{{cite journal| author=Franklin SS, Thijs L, Hansen TW, Li Y, Boggia J, Kikuya M et al.| title=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. | journal=Hypertension | year= 2012 | volume= 59 | issue= 3 | pages= 564-71 | pmid=22252396 | doi=10.1161/HYPERTENSIONAHA.111.180653 | pmc=PMC3607330 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22252396 }} </ref>
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.<ref name="urlHypertension: Overview - eMedicine">{{cite web |url=http://emedicine.medscape.com/article/889877-overview |title=Hypertension: Overview - eMedicine }}</ref> It is believed that this is due to the [[anxiety]] some people experience during a clinic visit.<ref name="healthminutes01">{{cite video |people=Swan, Norman |date=20 June 2010 |title=Health Minutes - Hypertension |url=http://www.youtube.com/watch?v=YQC9PYgZ_Zw |accessdate=27 August 2010}}</ref>  In studies, white coat hypertension can be defined as the presence of a defined hypertensive average blood pressure in an office setting but not at home.<ref name="pmid18320786">{{cite journal |author=Ruxer J, Mozdzan M, Baranski M, Wozniak-Sosnowska U, Markuszewski L |title="White coat hypertension" in type 2 diabetic patients |journal=Pol. Arch. Med. Wewn. |volume=117 |issue=10 |pages=452–6 |year=2007 |month=October |pmid=18320786 |doi= |url=http://tip.org.pl/pamw/issue/search.html?lang=en&search=18320786}}</ref>


===Epidemiology and Demographics===
==Masked Hypertension==
In one Turkish study of 438 consecutive patients, 38% were normotensive, 43% had white coat hypertension, 2% had masked hypertension, and 15% had sustained hypertension. Even patients taking medication for sustained hypertension who are normotensive at home may exhibit white coat hypertension in the office setting.<ref name="pmid16778338">{{cite journal |author=Helvaci MR, Seyhanli M |title=What a high prevalence of white coat hypertension in society! |journal=Intern. Med. |volume=45 |issue=10 |pages=671–4 |year=2006 |pmid=16778338 |doi= 10.2169/internalmedicine.45.1650|url=http://joi.jlc.jst.go.jp/JST.JSTAGE/internalmedicine/45.1650?from=PubMed |format= &ndash; <sup>[http://scholar.google.co.uk/scholar?hl=en&lr=&q=intitle%3AWhat+a+high+prevalence+of+white+coat+hypertension+in+society%21&as_publication=Intern.+Med.&as_ylo=2006&as_yhi=2006&btnG=Search Scholar search]</sup>}} {{dead link|date=April 2009}}</ref>
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.<ref name="pmid17664850">{{cite journal |author=Pickering TG, Eguchi K, Kario K |title=Masked hypertension: a review |journal=Hypertens. Res. |volume=30 |issue=6 |pages=479–88 |year=2007 |month=June |pmid=17664850 |doi= 10.1291/hypres.30.479|url=http://joi.jlc.jst.go.jp/JST.JSTAGE/hypres/30.479?from=PubMed |format= &ndash; <sup>[http://scholar.google.co.uk/scholar?hl=en&lr=&q=intitle%3AMasked+hypertension%3A+a+review&as_publication=Hypertens.+Res.&as_ylo=2007&as_yhi=2007&btnG=Search Scholar search]</sup>}} {{dead link|date=April 2009}}</ref> The prevalence of masked hypertension is approximately 13% and tends to be more likely when the office blood pressure values are high-normal.<ref name="pmid9576133">{{cite journal| author=Parati G, Ulian L, Santucciu C, Omboni S, Mancia G| title=Difference between clinic and daytime blood pressure is not a measure of the white coat effect. | journal=Hypertension | year= 1998 | volume= 31 | issue= 5 | pages= 1185-9 | pmid=9576133 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9576133 }} </ref><ref name="pmid18698202">{{cite journal| author=Bobrie G, Clerson P, Ménard J, Postel-Vinay N, Chatellier G, Plouin PF| title=Masked hypertension: a systematic review. | journal=J Hypertens | year= 2008 | volume= 26 | issue= 9 | pages= 1715-25 | pmid=18698202 | doi=10.1097/HJH.0b013e3282fbcedf | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18698202 }} </ref> 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.<ref name="pmid12226150">{{cite journal| author=Lurbe E, Redon J, Kesani A, Pascual JM, Tacons J, Alvarez V et al.| title=Increase in nocturnal blood pressure and progression to microalbuminuria in type 1 diabetes. | journal=N Engl J Med | year= 2002 | volume= 347 | issue= 11 | pages= 797-805 | pmid=12226150 | doi=10.1056/NEJMoa013410 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12226150 }} </ref><ref name="pmid19396423">{{cite journal| author=Wijkman M, Länne T, Engvall J, Lindström T, Ostgren CJ, Nystrom FH| title=Masked nocturnal hypertension--a novel marker of risk in type 2 diabetes. | journal=Diabetologia | year= 2009 | volume= 52 | issue= 7 | pages= 1258-64 | pmid=19396423 | doi=10.1007/s00125-009-1369-9 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19396423 }} </ref>
 
===Risk Factors===
Patients with white coat hypertension do not exhibit the signs indicative of trepidation and their increased blood pressure is often not accompanied by [[tachycardia]].<ref name="Pickering1988">{{cite journal | author=Pickering T, James G, Boddie C, Harshfield G, Blank S, Laragh J | title=How common is white coat hypertension? | journal=JAMA | volume=259 | issue=2 | pages=225–8 | year=1988 | pmid=3336140 | doi=10.1001/jama.259.2.225}}</ref> This is supported by studies that repeatedly indicate that 15%&ndash;30% of those thought to have mild hypertension as a result of clinic or office recordings display normal blood pressure and no unusual response to pressure stimulus. These persons did not show any specific characteristics such as age that may be indicative of a higher susceptibility to white coat hypertension.<ref>{{cite journal | author=McGrath B | title=Is white-coat hypertension innocent? | journal=Lancet | volume=348 | issue=9028 | pages=630 | year=1996 | pmid=8782749 | doi=10.1016/S0140-6736(05)65069-6}} - commenatry on:<br>{{cite journal | author=Glen S, Elliott H, Curzio J, Lees K, Reid J | title=White-coat hypertension as a cause of cardiovascular dysfunction | journal=Lancet | volume=348 | issue=9028 | pages=654–7 | year=1996 | pmid=8782756 | doi=10.1016/S0140-6736(96)02303-3}}</ref>


===Natural History, Complications, Prognosis===
==Pseudohypertension==
In general, individuals with white coat hypertension have lower morbidity than patients with sustained hypertension, but higher morbidity than the clinically normotensive.<ref name="pmid17435652">{{cite journal |author=Khan TV, Khan SS, Akhondi A, Khan TW |title=White coat hypertension: relevance to clinical and emergency medical services personnel |journal=MedGenMed |volume=9 |issue=1 |pages=52 |year=2007 |pmid=17435652 |pmc=1924974 |doi= |url=http://www.medscape.com/viewarticle/552593}}</ref> Many cross sectional studies have shown that "[[target-organ damage]] (as exemplified by [[left ventricular hypertrophy]]) is less in white-coat hypertensive [patients] than in sustained hypertensive [patients] even after the allowance has been made for differences in clinic pressure".<ref name="Pickering1994"/>
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.<ref name="pmid24107724">{{cite journal| author=Mancia G, Fagard R, Narkiewicz K, Redán J, Zanchetti A, Böhm M et al.| title=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. | journal=J Hypertens | year= 2013 | volume= 31 | issue= 10 | pages= 1925-38 | pmid=24107724 |doi=10.1097/HJH.0b013e328364ca4c | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24107724 }} </ref> Pseudohypertension is more common among elderly patients.<ref name="pmid24107724">{{cite journal| author=Mancia G, Fagard R, Narkiewicz K, Redán J, Zanchetti A, Böhm M et al.| title=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. | journal=J Hypertens | year= 2013 | volume= 31 | issue= 10 | pages= 1925-38 | pmid=24107724 |doi=10.1097/HJH.0b013e328364ca4c | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24107724 }} </ref>


===Diagnosis===
==Differetiating essential hypertension from other diseases==
As the notion of "normal" is subjective and changes from individual to individual a reference measurement was necessary. As night-time and self measured values are often not subject to daily [[Stress (medicine)|stress]] and clinical values are subject to unusual [[anxiety]], daytime ambulatory blood pressure is used as a reference as it takes into account daily stress but not in excess.  Due to specificity involved in diagnosis of white coat hypertension, many problems have been incurred in its [[medical diagnosis|diagnosis]] and treatment.


The diagnosis is made difficult as a result of the unreliable measurements taken from the office setting itself. These methods often involve an interface with health care professionals and frequently results are tarnished by a list of factors including variability in the individual’s blood pressure, technical inaccuracies, anxiety of the patient,<ref>{{cite journal|url=http://www.bpmonitoring.com/pt/re/bpm/abstract.00126097-200512000-00006.htm;jsessionid=LpvGzJN7PDC1yqJtnQj3ZWfmzgdnhWycyzsKybSHsr2FLx3hR1vh!1805002056!181195629!8091!-1 |author=Jhalani, Juhee a; Goyal, Tanya a; Clemow, Lynn a; Schwartz, Joseph E. b; Pickering, Thomas G. a; Gerin, William a|title=Anxiety and outcome expectations predict the white-coat effect.  |volume=10 | issue = 6 |month= December | year=2005 |publisher= Lippincott Williams & Wilkins, Inc. |pages=pp317–319}}</ref> recent ingestion of [[pressor]] substances, and talking, amongst many other factors. The most common measure of blood pressure is taken from a noninvasive instrument called a [[sphygmomanometer]]. "A survey showed that 96% of primary care physicians habitually use a cuff size too small,"<ref name="Pickering1994">{{cite journal | author=Pickering T | title=Blood pressure measurement and detection of hypertension | journal=Lancet | volume=344 | issue=8914 | pages=31–5 | year=1994 | pmid=7912303 | doi=10.1016/S0140-6736(94)91053-7}}</ref> adding to the difficulty in making an informed diagnosis. For such reasons, white coat hypertension cannot be diagnosed with a standard clinical visit.  It can be reduced (but not eliminated) with automated blood pressure measurements over 15 to 20 minutes in a quiet part of the office or clinic.<ref name='Pickering2005p146'>{{cite journal|title=Recommendations for blood pressure measurement in humans and experimental animals: Part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research |journal=Hypertension |year=2005|first1=TG |last1=Pickering |first2=JE |last2=Hall |first3=LJ |last3=Appel |first4=BE |last4=Falkner |first5=J |last5=Graves |first6=MN |last6=Hill |first7=DW |last7=Jones |first8=T |last8=Kurtz |author9=Sheps, SG; Roccella, EJ |display-authors=3|volume=45|issue=5|pages=142–61|pmid=15611362 |doi=10.1161/01.HYP.0000150859.47929.8e |url=http://hyper.ahajournals.org/cgi/content/full/45/1/142|format=|accessdate=2009-10-01| ref=harv}} See p. 146, ''Masked Hypertension or Isolated Ambulatory Hypertension''.</ref>
{| class="wikitable"
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Disease}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Prominent clinical features}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Investigations}}
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Hyperthyroidism}}
|The main symptoms include:
* [[Palpitations]]
* [[Insomnia]]
* [[Anxiety]]
* [[Weight loss]]
* Heat intolerance
* [[Diarrhea]]
* Depending on the underlying diagnosis, the patient might have [[exophthalmus]] or [[goiter]]
|
* The patient usually has elevated [[T3]] and [[T4]]
* [[TSH]] might be increased or decreased depending on the underlying cause
* [[TSI|Thyroid stimulating antibodies (TSI)]] might be increased in cases of [[Graves’ disease]]
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Essential hypertension}}
|Most patients with hypertension are asymptomatic at the time of diagnosis. Common symptoms are listed below:
*[[Headache]]
*[[Blurry vision]]
*[[Dyspnea]]
*[[Epistaxis]]
*[[Tinnitus]]
*[[Fatigue]]
*[[Drowsiness]]
|JNC 7 recommends the following routine laboratory tests before initiation of therapy for hypertension''':'''
*[[ECG|12-Lead electrocardiogram (ECG)]]
*[[Urinalysis]], including urinary albumin excretion or albumin/creatinine ratio
*[[Blood glucose]]
*[[Hematocrit|Blood hematocrit]]
*[[Electrolyte|Serum electrolytes]], especially [[potassium]]
*[[Calcium|Serum calcium]]
*[[Lipid profile]]: [[Total cholesterol]], [[LDL]], [[HDL]], [[triglycerides]]
*[[Creatinine]] or estimated [[GFR]]
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Generalized anxiety disorder}}
|According to DSM V, the following criteria should be present to fit the diagnosis of [[generalized anxiety disorder]]:


[[Ambulatory blood pressure monitoring]] and patient self-measurement using a [[home blood pressure monitoring]] device is being increasingly used to differentiate those with white coat hypertension or experiencing the white coat effect from those with chronic hypertension. This does not mean that these methods are without fault. Daytime ambulatory values, despite taking into account stresses of everyday life when taken during the patient's daily routine, are still susceptible to the effects of daily variables such as physical activity, stress and duration of sleep. Ambulatory monitoring has been found to be the more practical and reliable method in detecting patients with white coat hypertension and for the prediction of target organ damage. Even as such, the diagnosis and treatment of white coat hypertension remains controversial.
#The presence of sense of apprehension or fear toward certain activities for most of the days for at least 6 months
#Difficulty to control the apprehension
#Associated restless, fatigue, irritability, difficult concentration, muscle tension or sleep disturbance (only one of these manifestations)
#The anxiety or the physical manifestations must affect the social and the daily life of the patient
#Exclusion of another medical condition or the effect of another administered substance
#Exclusion of another mental disorder causing the symptoms
|<nowiki>-</nowiki>
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|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.


Recent studies showed that [[home blood pressure monitoring]] is as accurate as a 24-hour ambulatory monitoring in determining blood pressure levels.<ref name="pmid16647616">{{cite journal |author=Niiranen TJ, Kantola IM, Vesalainen R, Johansson J, Ruuska MJ |title=A comparison of home measurement and ambulatory monitoring of blood pressure in the adjustment of antihypertensive treatment |journal=Am. J. Hypertens. |volume=19 |issue=5 |pages=468–74 |year=2006 |month=May |pmid=16647616 |doi=10.1016/j.amjhyper.2005.10.017}}</ref> Researchers at the [[University of Turku]], [[Finland]] studied 98 patients with untreated hypertension. They compared patients using a home blood pressure device and those wearing a 24-hour ambulatory monitor. Researcher Dr. Niiranen said that "home blood pressure measurement can be used effectively for guiding [[anti-hypertensive]] treatment". Dr. Stergiou added that home tracking of blood pressure "is more convenient and also less costly than ambulatory monitoring."
*Vasomotor instability in the form of [[hot flush]]es, including [[sleep hyperhidrosis|night sweats]] and [[Sleep disorder|sleep disturbances]]
 
*Urogenital atrophy causing [[Itch|itching]], dryness, [[bleeding]], watery discharge, [[Polyuria|urinary frequency]], [[urinary urgency]] and [[urinary incontinence]]
Use of breathing patterns has been proposed as a technique for identifying white coat hypertension.<ref name="pmid19009177">{{cite journal |author=Thalenberg JM, Póvoa RM, Bombig MT, de Sá GA, Atallah AN, Luna Filho B |title=Slow breathing test increases the suspicion of white-coat hypertension in the office |journal=Arq. Bras. Cardiol. |volume=91 |issue=4 |pages=243–9, 267–73 |year=2008 |month=October |pmid=19009177 |doi= |url=http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0066-782X2008001600010&lng=en&nrm=iso&tlng=en}}</ref>
*Skeletal symptoms in the form of [[osteoporosis]] (gradually developing over time), [[arthralgia|artharlgia]], [[myalgia|myalgia]] and [[back pain]]
 
*Psychological manifestations such as [[Mood disorder|mood disturbance]], [[irritability]], [[Fatigue (medical)|fatigue]], [[memory loss]] and [[Depression (mood)|depression]]
===Treatment===
*Sexual disorders: [[Libido|decreased libido]], [[Vaginal lubrication|vaginal dryness]], problems reaching orgasm and [[dyspareunia]]
It should be remembered that all the established published trials on the consequences of high blood pressure and the benefits of treating are based on one-time measurement in clinical settings rather than the generally slightly lower readings obtained from ambulatory recordings.  The debate and conflicting ideas revolve around whether or not it would be feasible to treat white coat hypertension, as there still is no conclusive evidence that a temporary rise in blood pressure during office visits has an adverse effect on health.  Many believe that patients with "white coat" hypertension do not require even very small doses of antihypertensive therapy as it may result in [[hypotension]].
|
 
* [[Human chorionic gonadotropin|B-HCG]] should always be done first to rule out [[pregnancy]] especially in women under the age of 45 years
==Masked Hypertension==
* [[FSH]] can be measured but it can be falsely normal or low
The term "masked hypertension" can be used to describe the contrasting phenomenon, where blood pressure is elevated during daily living, but not in an office setting.<ref name="pmid17664850">{{cite journal |author=Pickering TG, Eguchi K, Kario K |title=Masked hypertension: a review |journal=Hypertens. Res. |volume=30 |issue=6 |pages=479–88 |year=2007 |month=June |pmid=17664850 |doi= 10.1291/hypres.30.479|url=http://joi.jlc.jst.go.jp/JST.JSTAGE/hypres/30.479?from=PubMed |format= &ndash; <sup>[http://scholar.google.co.uk/scholar?hl=en&lr=&q=intitle%3AMasked+hypertension%3A+a+review&as_publication=Hypertens.+Res.&as_ylo=2007&as_yhi=2007&btnG=Search Scholar search]</sup>}} {{dead link|date=April 2009}}</ref>
* [[TSH]], [[T3]] and [[T4]] to rule out thyroid abnormalities
* [[Prolactin]] can be measured to rule out [[prolactinoma]] as a cause of [[menopause]]
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Opioid withdrawal disorder}}
|According to DSM V, the following criteria should be present to fit the diagnosis of opioid withdrawal:
# Cessation of (or reduction in) [[Opioid use disorders|opioid use]] that has been heavy and prolonged (i.e.,several weeks or longer) or administration of an [[opioid antagonist]] after a period of [[Opioid use disorders|opioid use]].
# Development of three or more of the following criteria minutes to days after cessation of drug use: [[Dysphoria|dysphoric mood]], [[nausea]] or [[vomiting]], [[muscle aches]], [[Lacrimation]] or [[rhinorrhea]], [[pupillary dilation]], [[piloerection]], or [[sweating]], [[diarrhea]], [[yawning]], [[fever]], and [[insomnia]].
# The signs or symptoms mentioned above must cause impairment of the daily functioning of the patient.
# The signs or symptoms mentioned above must not be attributed to other medical or mental disorders.
|
* Urine drug screen to rule out any other associated drug abuse
* Routine blood work such as electrolytes and hemoglobin to rule out any associated disease explaining the symptoms
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Primary hyperaldosteronism}}
|The hallmark symptoms of a [[primary hyperaldosteronism]] include:
*[[Hypokalemia]]
* Resistant hypertension
|Diagnostic lab findings associated with pheochromocytoma include:
*"concomitant measurement of blood aldosterone concentration and either plasma renin activity or plasma renin concentration"<ref name="pmid33370170">{{cite journal| author=Cohen JB, Cohen DL, Herman DS, Leppert JT, Byrd JB, Bhalla V| title=Testing for Primary Aldosteronism and Mineralocorticoid Receptor Antagonist Use Among U.S. Veterans : A Retrospective Cohort Study. | journal=Ann Intern Med | year= 2020 | volume= | issue= | pages= | pmid=33370170 | doi=10.7326/M20-4873 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370170  }} </ref>, preferably at 8:00 AM
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|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:
*[[Palpitations]] especially in epinephrine producing tumors.
*[[Anxiety]] often resembling that of a [[panic attack]]
*[[Sweating]]
*[[Headaches]] occur in 90 % of patients.
*Paroxysmal attacks of [[hypertension]] but some patients have normal blood pressure.
*It may be asymptomatic and discovered by incidence screening especially [[MEN, type 2|MEN]] patients.
''Please note that not all patients with pheochromocytoma experience all classical symptoms''.
|Diagnostic lab findings associated with pheochromocytoma include:
*Elevated plasma and urinary [[catecholamine]]s and [[metanephrine]]s
*Elevated urinary [[vanillyl mandelic acid]]
|}


==References==
==References==

Latest revision as of 02:59, 4 January 2021

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:
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:
  1. The presence of sense of apprehension or fear toward certain activities for most of the days for at least 6 months
  2. Difficulty to control the apprehension
  3. Associated restless, fatigue, irritability, difficult concentration, muscle tension or sleep disturbance (only one of these manifestations)
  4. The anxiety or the physical manifestations must affect the social and the daily life of the patient
  5. Exclusion of another medical condition or the effect of another administered substance
  6. Exclusion of another mental disorder causing the symptoms
-
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.
  • B-HCG should always be done first to rule out pregnancy especially in women under the age of 45 years
  • FSH can be measured but it can be falsely normal or low
  • TSH, T3 and T4 to rule out thyroid abnormalities
  • Prolactin can be measured to rule out prolactinoma as a cause of menopause
Opioid withdrawal disorder According to DSM V, the following criteria should be present to fit the diagnosis of opioid withdrawal:
  1. Cessation of (or reduction in) opioid use that has been heavy and prolonged (i.e.,several weeks or longer) or administration of an opioid antagonist after a period of opioid use.
  2. Development of three or more of the following criteria minutes to days after cessation of drug use: dysphoric mood, nausea or vomiting, muscle aches, Lacrimation or rhinorrhea, pupillary dilation, piloerection, or sweating, diarrhea, yawning, fever, and insomnia.
  3. The signs or symptoms mentioned above must cause impairment of the daily functioning of the patient.
  4. The signs or symptoms mentioned above must not be attributed to other medical or mental disorders.
  • Urine drug screen to rule out any other associated drug abuse
  • Routine blood work such as electrolytes and hemoglobin to rule out any associated disease explaining the symptoms
Primary hyperaldosteronism The hallmark symptoms of a primary hyperaldosteronism include: Diagnostic lab findings associated with pheochromocytoma include:
  • "concomitant measurement of blood aldosterone concentration and either plasma renin activity or plasma renin concentration"[11], preferably at 8:00 AM
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:
  • Palpitations especially in epinephrine producing tumors.
  • Anxiety often resembling that of a panic attack
  • Sweating
  • Headaches occur in 90 % of patients.
  • Paroxysmal attacks of hypertension but some patients have normal blood pressure.
  • It may be asymptomatic and discovered by incidence screening especially MEN patients.

Please note that not all patients with pheochromocytoma experience all classical symptoms.

Diagnostic lab findings associated with pheochromocytoma include:

References

  1. 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. 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.
  3. 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)
  4. 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.
  5. 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.
  6. 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]
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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 |pmid= value (help).

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