Hypertension

Population Covered By The Guidance

This pathway provides guidance on the investigation of adult patients with hypertension who need investigation for causes of secondary hypertension.

Lead Researcher: Sian Chin

Experts & Contributors: Aron Chakera, Ravinder Dhillon

Editorial Panel: Core membership
Link to Editorial Panel

Date reviewed: July 2018

Date Published: March 2019

Image 1a, 1b and 1c (Digital Subtraction Angiography): Pre- and post-stent images of bilateral renal artery stenosis

Bilateral Renal Artery Stenosis

Image 1a, 1b and 1c (Digital Subtraction Angiography): Pre- and post-stent images of bilateral renal artery stenosis

Bilateral Renal Artery Stenosis

Image 1a, 1b and 1c (Digital Subtraction Angiography): Pre- and post-stent images of bilateral renal artery stenosis

Bilateral Renal Artery Stenosis

Image 2a and 2b (Magnetic Resonance Imaging): There is a 13mm right sided pituitary adenoma (arrows) causing deviation of the stalk to the left. Slight suprasellar extension is noted without impingement of the chiasm or optic nerves.

Cushing's Disease

Image 2a and 2b (Magnetic Resonance Imaging): There is a 13mm right sided pituitary adenoma (arrows) causing deviation of the stalk to the left. Slight suprasellar extension is noted without impingement of the chiasm or optic nerves.

Cushing's Disease

Image 3 (Computed Tomography): Round low attenuation lesion at upper pole of left kidney consistent with phaeochromocytoma (arrow).

Phaeochromocytoma

Image 4a (I123-MIBG) and 4b (Computed Tomography): High grade focus of uptake identified at the left side of the upper abdomen posteriorly (arrow). CT demonstrates a cystic phaeochromocytoma (arrow).

Phaeochromocytoma

Image 4a (I123-MIBG) and 4b (Computed Tomography): High grade focus of uptake identified at the left side of the upper abdomen posteriorly (arrow). CT demonstrates a cystic phaeochromocytoma (arrow).

Phaeochromocytoma

Image 5a (I123-MIBG) and 5b (SPECT): Low grade focus of uptake identified at the left side of the upper abdomen posteriorly (arrow). SPECT imaging confirms the focus of uptake at the upper pole of the left kidney, in the region of the left adrenal gland (arrow).

Phaeochromocytoma

Image 5a (I123-MIBG) and 5b (SPECT): Low grade focus of uptake identified at the left side of the upper abdomen posteriorly (arrow). SPECT imaging confirms the focus of uptake at the upper pole of the left kidney, in the region of the left adrenal gland (arrow).

Phaeochromocytoma

Image 6 (H&E, x10): Histological section of a phaechromocytoma showing a nested architecture (zellballen pattern) separated by thin fibrous septae. The cells demonstrate finely granular amphophilic cytoplasm.

Phaeochromocytoma

  • Secondary hypertension is uncommon and blanket screening for secondary hypertension is not routinely recommended
  • If clinic blood pressure is ≥140/90mmHg, or hypertension is suspected, ambulatory and/or home monitoring should be offered to confirm the blood pressure level
  • In cases of apparent resistant hypertension, it is important to specifically ask about medication compliance
  • The initial assessment of patients with a new diagnosis of hypertension should include a thorough history and examination to elicit features that may suggest specific causes of secondary hypertension, as well as evidence of target organ damage. Basic screening tests include: urine dipstick, urinary albumin/creatinine ratio, fasting blood glucose, fasting lipid profile, serum urea, electrolytes, creatinine with eGFR, haemoglobin, fundoscopy and ECG (to assess for left ventricular hypertrophy)
  • There are many causes of secondary hypertension and investigations should be targeted depending on the differential diagnosis

Pathway User Guide

Yellow Boxes Denotes extra information. Some contain single or multiple white sub-boxes, click a white box to reveal detailed information in a pop-up.

White Boxes: Denotes standard pathway steps. (If inside a yellow box, they open a specific pop-up).

Zoom & Pan Controls: Use + / − or the slider to zoom. Reset returns to default. Tick Panning to drag the diagram when zoomed.

Blue “View Full Screen” Button: Opens the whole diagram in a large, full-screen pop-up window. Use Close to exit.

The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.

SYMBOL RRL EFFECTIVE DOSE RANGE
No radiation None 0
Minimal radiation Minimal < 1 millisieverts
Low radiation Low 1-5 mSv
Medium radiation Medium 5-10 mSv
High radiation High >10 mSv

Disclaimer

Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.

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Cardiovascular