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. 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.

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. 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

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: 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 Thyroid stimulating antibodies (TSI) might be increased in cases of Graves’ disease
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: 12-Lead electrocardiogram (ECG) Urinalysis, including urinary albumin excretion or albumin/creatinine ratio Blood glucose Blood hematocrit Serum electrolytes, especially potassium Serum calcium Lipid profile: Total cholesterol, LDL, HDL, triglycerides Creatinine or estimated GFR
Generalized anxiety disorder	According to DSM V, the following criteria should be present to fit the diagnosis of generalized anxiety disorder: 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	-
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. Vasomotor instability in the form of hot flushes, including night sweats and sleep disturbances Urogenital atrophy causing itching, dryness, bleeding, watery discharge, urinary frequency, urinary urgency and urinary incontinence Skeletal symptoms in the form of osteoporosis (gradually developing over time), artharlgia, myalgia and back pain Psychological manifestations such as mood disturbance, irritability, fatigue, memory loss and depression Sexual disorders: decreased libido, vaginal dryness, problems reaching orgasm and dyspareunia	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: 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. 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. 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
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", 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: Elevated plasma and urinary catecholamines and metanephrines Elevated urinary vanillyl mandelic acid