Chronic hypertension causes

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Hypertension Main page

Overview

Causes

Classification

Primary Hypertension
Secondary Hypertension
Hypertensive Emergency
Hypertensive Urgency

Screening

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Assistant Editor-In-Chief: Taylor Palmieri

Hypothesized Underlying Causes of Primary Hypertension

Salt sensitivity

Sodium is the environmental factor that has received the greatest attention. Approximately 60% of the essential hypertension population is responsive to sodium intake. This is due to the fact that increasing amounts of salt in a person's bloodstream causes the body to draw in more water, increasing the pressure on the blood vessel walls. In addition to sodium, choride plays an important role as it causes volume expansion increasing blood pressure as sodium with combined with other anions does not increase blood pressure.[1] Also salt sensitivity is known to be increased with increasing age, obesity, in African americans and in the metabolic syndrome.[2]

Mechanisms

The proposed mechanism for salt-sensitvity is incraesed salt intake over a long period of time leads to impaired excretion of salt which causes hypertension. There may be several other pathways involved in the pathophysiology of salt-sensitivity leading to hypertension. Salt-sensitive patients are known to have a dysregulated renin-angiotensin pathway and patients show an abnormal vascular response to angiotensin II[3]. Increased sodium re absorption, though not well understood, is mostly related abnormalities across Na-H proximal tubule channels, Na-K-Cl co-transporter across the thick ascending limb, Na-Cl distal tubule co-transporter and epithelial Na channels. Dietary deficiency in potassium is also known to trigger increased sodium sensitivity in patients in particular African-Americans, but the mechanism is still not clearly determined.

Role of renin

Renin is a hormone secreted by the juxtaglomerular cells of the kidney and linked with aldosterone in a negative feedback loop. The range of renin activity observed in hypertensive subjects tends to be broader than in normotensive individuals. In consequence, some hypertensive patients have been defined as having low-renin and others as having essential hypertension. Low-renin hypertension is more common in African Americans than Caucasians and may explain why they tend to respond better to diuretic therapy than drugs that interfere with the renin-angiotensin system.

High Renin levels predispose to Hypertension: Increased Renin --> Increased Angiotensin II --> Increased Vasoconstriction, Thirst/ADH and Aldosterone --> Increased Sodium Reabsorption in the Kidneys (DCT and CD) --> Increased Blood Pressure.

Insulin resistance

Insulin is a polypeptide hormone secreted by the pancreas. Its main purpose is to regulate the levels of glucose in the body antagonistically with glucagon through negative feedback loops. Insulin also exhibits vasodilatory properties. In normotensive individuals, insulin may stimulate sympathetic activity without elevating mean arterial pressure. However, in more extreme conditions such as that of the metabolic syndrome, the increased sympathetic neural activity may over-ride the vasodilatory effects of insulin. Insulin resistance and/or hyperinsulinemia have been suggested as being responsible for the increased arterial pressure in some patients with hypertension. This feature is now widely recognized as part of syndrome X, or the metabolic syndrome.

Sleep apnea

Sleep apnea is a common, under-recognized cause of hypertension.[4] It is best treated with UPPP, tonsilectomy, adenoidectomy, sinus surgery, or weight loss, nocturnal nasal positive airway pressure, or the Mandibular advancement splint (MAS).

Genetics

Hypertension is one of the most common complex disorders, with genetic heritability averaging 30%. Data supporting this view emerge from animal studies as well as in population studies in humans. Most of these studies support the concept that the inheritance is probably multifactorial or that a number of different genetic defects each have an elevated blood pressure as one of their phenotypic expressions.

More than 50 genes have been examined in association studies with hypertension, and the number is constantly growing.

Causes of Secondary Hypertension

Only in a small minority of patients with elevated arterial pressure, can a specific cause be identified. These individuals will probably have an endocrine or renal defect that, if corrected, could bring blood pressure back to normal values. Common causes include:

Renal hypertension
Hypertension produced by diseases of the kidney. This includes diseases such as polycystic kidney disease or chronic glomerulonephritis. Hypertension can also be produced by diseases of the renal arteries supplying the kidney. This is known as renovascular hypertension; it is thought that decreased perfusion of renal tissue due to stenosis of a main or branch renal artery activates the renin-angiotensin system.
Adrenal hypertension
Hypertension is a feature of a variety of adrenal cortical abnormalities. In primary aldosteronism there is a clear relationship between the aldosterone-induced sodium retention and the hypertension.
In patients with pheochromocytoma increased secretion of catecholamines such as epinephrine and norepinephrine by a tumor (most often located in the adrenal medulla) causes excessive stimulation of [adrenergic receptors], which results in peripheral vasoconstriction and cardiac stimulation. This diagnosis is confirmed by demonstrating increased urinary excretion of epinephrine and norepinephrine and/or their metabolites (vanillylmandelic acid).
Diet
The North American diet that is high in fat and salt has been proven to exacerbate hypertension. A study in the U.S. found that patients placed on a strict vegetarian diet showed a significant benefit to their condition over the one year. Certain medications, especially NSAIDS (Motrin/ibuprofen) and steroids can cause hypertension. Imported licorice (Glycyrrhiza glabra) inhibits the 11-hydroxysteroid hydrogenase enzyme (catalyzes the reaction of cortisol to cortison) which allows cortisol to stimulate the Mineralocorticoid Receptor (MR) which will lead to effects similar to hyperaldosteronism, which itself is a cause of hypertension.
Age
Over time, the number of collagen fibers in artery and arteriole walls increases, making blood vessels stiffer. With the reduced elasticity comes a smaller cross-sectional area in systole, and so a raised mean arterial blood pressure.

Complete List of Secondary Causes of Hypertension [5][6]

By organ system

Cardiovascular Aortic regurgitation, Aortic dissection, Acute severe vascular damage, Adams Nance syndrome , Aneurysm, Aortic coarctation , Aortic stenosis, Arterial occlusive disease, progressive - -- heart defects -- bone fragility -- brachysyndactyly , Arteriosclerosis, Atheroma, Avasthey syndrome , Carotid paraganglioma ,Congenital Mitral stenosis , Eisenmenger's Syndrome , Fibromuscular dysplasia of arteries , Grange syndrome , Hemangiomatosis - familial pulmonary capillary, Hypertensive heart disease , Pulmonary artery agenesis , Vasculitis , Patent ductus arteriosus, Third degree AV block
Chemical / poisoning Acetaldehyde , Aristolochic acid poisoning , Arizona Bark Scorpion poisoning , Black widow spider envenomation , Cadmium poisoning, Cocaine poisoning , Ecstasy abuse , Ginseng , Heavy metal poisoning, Indian Tobacco poisoning, Jimsonweed poisoning , Lead poisoning , Lockwood-Feingold syndrome , Mustard tree poisoning , Nicotine addiction , Pseudoephedrine poisoning , Silicosis , Toxic mushrooms -- Psychedelic
Dermatologic No underlying causes
Drug Side Effect Almotriptan, Dihydroergotamine, Ergotamine, Frovatriptan, Isometheptene, Rizatriptan, Sumatriptan, Zolmitriptan, Amitriptyline, Cyclosporine, Desipramine, Dexamethasone sensitive hypertension, Doxepin, Ephedrine poisoning, Glucocorticoid resistance , Imipramine, Nasal decongestants, Nortriptyline, Combined oral contraceptive pill, Phencyclidine, Phenylpropanolamine, Protriptyline, Sedative dependence, Serotonin toxicity, Steroid abuse
Ear Nose Throat Nephrosis -- deafness -- urinary tract -- digital malformation , Fitzsimmons-Walson-Mellor syndrome
Endocrine Carcinoid Syndrome, Acromegaly , Adrenal incidentaloma , Alcohol-induced pseudo-Cushing syndrome , Apparent mineralocorticoid excess , Congenital adrenal hyperplasia - 11-Beta-hydroxylase deficiency, Congenital adrenal hyperplasia - 17-alpha-hydroxylase deficiency, Conn's syndrome, Cushing's disease, Cushing's syndrome , Diabetes, Familial Cushing syndrome , Graves Disease , Hyperadrenalism , Hyperparathyroidism , Hyperpituitarism , Hyperthyroidism, Hypothyroidism,Isolated secretion of corticosterone, Isolated secretion of deoxycorticosterone, Lobelia poisoning , Mineralocorticoid excess, Multiple endocrine neoplasia type 1, Myxoedema, Pheochromocytoma, Primary aldosteronism, Primary cortisol resistance, Pseudohyperaldosteronism , Pseudohypoaldosteronism , Schroeder syndrome 1 , Hyperthyroidism, Hypoglycemia, Isolated secretion of 18-hydroxy-deoxycorticosterone, Renin-secreting tumors
Environmental No underlying causes
Gastroenterologic Hepatorenal tyrosinemia , Pancreatitis, Retroperitoneal Fibrosis
Genetic 11-Hydroxylase deficiency, 17-Hydroxylase deficiency, Cockayne syndrome , Down Syndrome , Fabry's Disease , Isolated secretion of 18-hydroxy-deoxycorticosterone, Pierre Robin's sequence , Senior-Loken Syndrome, Turner Syndrome , Vater-like syndrome with pulmonary hypertension, abnormal ears and growth deficiency , Von Hippel-Lindau Disease , Werner syndrome , Williams Syndrome , Gaucher disease type 3 , Mucopolysaccharidosis type I Hurler syndrome
Hematologic Atypical Hemolytic uremic syndrome, Catastrophic Antiphospholipid Syndrome , Essential mixed Cryoglobulinemia , Faye-Petersen-Ward-Carey syndrome , Hemolytic uremic syndrome , Hypereosinophilic syndrome , Liddle's syndrome, Multicentric Reticulohistiocytosis , Polycythemia , Thromboembolism , Thrombotic thrombocytopenic purpura
Iatrogenic No underlying causes
Infectious Disease Poliomyelitis, Meningitis, Post streptococcal glomerulonephritis , Renal tuberculosis, Nipah virus encephalitis
Musculoskeletal / Ortho Acrodynia , Allain Babin Demarquez syndrome , Familial Osteodysplasia - Anderson type, Paget's disease of bone , Grange syndrome , Faye-Petersen-Ward-Carey syndrome , Oculo skeletal renal syndrome , Thieffry and Sorrell Dejerine syndrome
Neurologic Guillain-Barre Syndrome, Autonomic dysreflexia syndrome , Binswanger's Disease , Brain stem encephalitis, Central sleep apnea , Choroideremia -- hypopituitarism , Disequilibrium syndrome , Dysautonomia , Hereditary sensory and autonomic neuropathy 3 , Increased intracranial pressure, Neurofibromatosis syndrome Type II , Neurogenic hypertension , Nipah virus encephalitis , Obstructive sleep apnea , Sneddon Syndrome , Upper spinal cord lesions, Wolfram's disease, Meningitis, Polyradiculitis, Quadriplegia, Adams Nance syndrome , Glycine encephalopathy - classical neonatal form, Pituitary Cancer , Fitzsimmons-Walson-Mellor syndrome
Nutritional / Metabolic Abdominal obesity metabolic syndrome , Acute intermittent porphyria , Congenital hepatic porphyria , Gaucher disease type 3, Glycine encephalopathy - classical neonatal form, Glycine synthase deficiency , Gouty nephropathy, Metabolic syndrome, Tyrosinemia , Von Gierke disease IB, Increased salt intake, Mucopolysaccharidosis type I Hurler syndrome, Fabry's Disease
Obstetric/Gynecologic Eclampsia , Fowler-Christmas-Chapple syndrome , Gestational hypertension, HELLP syndrome , Ovarian dysgenesis, PCOS, Pregnancy toxemia /hypertension , Twin-Twin Transfusion Syndrome
Oncologic Endothelin producing tumor, Adrenal Cancer , Familial Adrenal adenoma , Renal Cancer , Neuroblastoma

Pituitary Cancer , Renin-secreting tumors, Rhabdoid tumor , Wilms' tumor , Adrenal incidentaloma , Familial renal cell carcinoma

Opthalmologic Isolated Ectopia lentis, Oculo skeletal renal syndrome
Overdose / Toxicity Amphetamine abuse
Psychiatric Anxiety
Pulmonary Asphyxia , Bronchopulmonary dysplasia, COPD , Goodpasture syndrome , Pulmonary cystic lymphangiectasis , Pulmonary embolism , Pulmonary fibrosis /granuloma , Pulmonary veno-occlusive disease , Pulmonary Lymphangiomatosis, Respiratory acidosis , Respiratory failure , Unilateral pulmonary agenesis , Hyperventilation, Obstructive sleep apnea , Wegener's granulomatosis
Renal / Electrolyte Bartter's Syndrome, Dissection of the renal arteries, Acid-Base Imbalance , Acute Renal Failure , Albuminuria , Analgesic nephropathy syndrome , Autosomal dominant Polycystic kidney disease , Autosomal Recessive Polycystic Kidney Disease , Bilateral Renal artery stenosis , Bright's Disease , Chronic kidney disease , Chronic pyelonephritis, Congenital Membranous Glomerulonephritis, Congenital stenosis of renal artery, Congenital Hydronephrosis , Diffuse Mesangial sclerosis, Familial Renal cell carcinoma , Fitzsimmons-Walson-Mellor syndrome , Glomerulonephritis , Hereditary nephritis (X-linked), Hypoplastic kidney, IgA nephropathy , Kidney arteriovenous fistula , Kimmelstiel-Wilson disease, Lupus nephritis , Nephrocalcinosis , Nephrosclerosis , Nephrosis -- deafness -- urinary tract -- digital malformation , Nephrotic syndrome , Oculo skeletal renal syndrome , Pierson syndrome , Severe infantile Polycystic kidneys with Tuberous sclerosis , Post streptococcal glomerulonephritis , Renal artery thrombosis, Renal emboli, Renal segmental hypoplasia-induced Hypertension , Renal tuberculosis, Salcedo syndrome , Simple kidney cysts , Thieffry and Sorrell Dejerine syndrome , Urinary tract infections , Urinary tract obstruction, Vesicoureteral reflux , Wegener's granulomatosis , Gitelman's Syndrome, Hepatorenal tyrosinemia , Atypical Hemolytic uremic syndrome, Gouty nephropathy, Goodpasture syndrome
Rheum / Immune / Allergy Autoimmune Vasculitis , Systemic lupus erythematosus, Diffuse systemic sclerosi , Polyarteritis nodosa , , Takayasu arteritis
Sexual No underlying causes
Trauma Electrical burns , Head injury, Skull fracture
Urologic No underlying causes
Dental No underlying causes
Miscellaneous Acquired total Lipodystrophy , After Kidney transplantation, Age, Alcohol withdrawal, Amyloidosis , Bone cement implantation syndrome , Brachydactyly with hypertension, Carnevale-Canun-Mendoza syndrome , Codeine withdrawal , Collagen disease, Essential hypertension, Gram's syndrome , Hypothermia, Irradiation, Kashani-Strom-Utley syndrome , Lymphomatoid Granulomatosis , MSBD syndrome , Neuroleptic Malignant Syndrome , Obesity, Physical inactivity , Selye syndrome , Serotonin Syndrome , Shaken Baby Syndrome , Stress-Induced Hypertension , Type A personality, Vitamin D -- adverse effects, Wagener syndrome , Pain, Post-exercise, Transfusion of large blood volumes, White coat hypertension

By alphabetical order


References

  1. Kurtz TW, Al-Bander HA, Morris RC (1987). ""Salt-sensitive" essential hypertension in men. Is the sodium ion alone important?". N. Engl. J. Med. 317 (17): 1043–8. PMID 3309653. Unknown parameter |month= ignored (help)
  2. Obarzanek E, Proschan MA, Vollmer WM; et al. (2003). "Individual blood pressure responses to changes in salt intake: results from the DASH-Sodium trial". Hypertension. 42 (4): 459–67. doi:10.1161/01.HYP.0000091267.39066.72. PMID 12953018. Unknown parameter |month= ignored (help)
  3. Chamarthi B, Williams JS, Williams GH (2010). "A mechanism for salt-sensitive hypertension: abnormal dietary sodium-mediated vascular response to angiotensin-II". J. Hypertens. 28 (5): 1020–6. doi:10.1097/HJH.0b013e3283375974. PMID 20216091. Unknown parameter |month= ignored (help)
  4. Silverberg DS, Iaina A and Oksenberg A (2002). "Treating Obstructive Sleep Apnea Improves Essential Hypertension and Quality of Life". American Family Physicians. 65 (2): 229–36. PMID 11820487. Unknown parameter |month= ignored (help)
  5. isbn=140510368X Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:85
  6. isbn=1591032016 Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:194-195

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