Chronic hypertension causes

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

Overview

The most common cause of hypertension in 90% of cases is essential hypertension where no clear identifying underlying cause can be identified, and the pathophysiology of which is incompletely understood. There are many secondary causes of hypertension.

The Most Common Cause

The most common cause of hypertension is essential hypertension which accounts for about 90% of cases of elevated blood pressure.

Common Causes of Secondary Hypertension

In only a small minority of patients with elevated arterial pressure can a specific cause be identified. An underlying endocrine or renal defect is most often identified, that if corrected, may restore the blood pressure back to normal.

When to Suspect Secondary Hypertension

A secondary cause of hypertension should be suspected if the patient has resistant hypertension. The AHA Scientific Statement 2008 defines resistant hypertension as a blood pressure which remains above the goal of 140/90 mm Hg despite concurrent use of 3 antihypertensive medications of different classes at optimal doses, including a diuretic..

Other features that suggest secondary hypertension include:

• Recent onset of hypertension
• Unprovoked hypokalemia or an inappropriately low potassium (e.g. a "normal K" on an ACE inhibitor plus a K sparing diuretic)
• Presence of peripheral arterial disease
• Increase in creatine with ACE inhibition
• Loss of control of previously controlled hypertension

Before evaluating the patient for secondary hypertension, non-compliance with antihypertensives should be ruled out. Given its prevalence in the Unites States population, sleep apnea should also be ruled out early in the evaluation.

Common Causes of Secondary Hypertension

Common causes of secondary hypertension include:

• Anxiety: Hypertension is often confused with mental tension, stress and anxiety. While chronic anxiety is associated with poor outcomes in people with hypertension, it alone probably does not cause it.
• Arteriosclerosis
• Chronic kidney disease. This includes diseases such as polycystic kidney disease or chronic glomerulonephritis.
• Congenital adrenal hyperplasia
• Cushing's syndrome due to an excessive secretion of glucocorticoids which in turn causes the hypertension
• Drugs:

• Nasal decongestants with adrenergic effects
• NSAIDs
• Oral contraceptives
• Steroids

• Fever
• Hyperaldosteronism (Conn's syndrome): 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. Suspect hyperaldosteronism if the patient has an unusual sensitivity to a diuretic in causing hypokalemia, if there is frequent hypokalemia, and if there is a normal potassium in the setting of ACE inhibition with a potassium spairing diuretic. The plasma renin activity is suppressed and there is elevated aldosterone on adrenal vein sampling.

• Idiopathic hyperaldosteronism
• Liddle's syndrome (also called pseudoaldosteronism)
• Glucocorticoid remediable aldosteronism

• Hyperthyroidism
• Hypothyroidism
• Increased salt intake
• Metabolic syndrome
• Non-compliance with antihypertensives
• Obesity
• Obstructive sleep apnea can cause a rise in catecholamines
• Perioperative hypertension: this is the development of hypertension just before, during or after surgery. It may occur before surgery during the induction of anesthesia; intraoperatively e.g. by pain-induced sympathetic nervous system stimulation; in the early postanesthesia period, e.g. by pain-induced sympathetic stimulation, hypothermia, hypoxia, or hypervolemia from excessive intraoperative fluid therapy; and in the 24 to 48 hours after the postoperative period as fluid is mobilized from the extravascular space. In addition, hypertension may develop perioperatively because of discontinuation of long-term antihypertensive medication.
• Pheochromocytoma: Caused by an excessive secretion of norepinephrine and epinephrine which promotes vasoconstriction. Consider this diagnosis in the patient who has headaches, diaphoresis, palpitations, orthostatic hypotension, hypertension with anesthesia induction and those patients with a dilated cardiomyopathy (which a pheochromocytoma can cause) who still have an elevated blood pressure despite a loss in cardiac output. This diagnosis is confirmed by demonstrating increased urinary excretion of epinephrine and norepinephrine and/or their metabolites (vanillylmandelic acid).
• Pregnancy causing gestational hypertension
• Renovascular hypertension: Due to fibromuscular dysplasia and renal artery stenosis. In both conditions, increased blood pressure occurs due to narrowing of arteries supplying to the kidney. Decreased perfusion of renal tissue due to stenosis of a main or branch renal artery activates the renin-angiotensin system.

Tests to Assess for Renovascular Hypertension

• Renal Ultrasound: Look for a difference in the size of kidneys
• CT: Although there is a dye load, there is no Gadollinium which can be toxic with an MRI, the images are better than MRI
• Indications for Arteriographic Imaging to Rule Out Renovascular Hypertension

Class I

• Hypertension in a patient < 30 yrs old
• Severe increase in blood pressure in a patient > 55 yrs old
• Accelerated increase in BP
• Resistant increase in BP
• Complicated malignant increase in BP
• Reduction in GFR or rise in Cr with RAS blockade
• > 1.5 cm difference in renal size on ultrasound
• Flash pulmonary edema

Class IIa

• Unexplained renal failure

Class IIb

• Multivessel CAD or PAD
• Unexplained CHF or refractory angina

• Scleroderma
• Stress
• White coat hypertension

Common causes of Resistant hypertension

• Improper blood pressure measurement

• Volume overload
  • Excess sodium intake
  • Volume retention from kidney disease
  • Inadequate diuretic therapy

• Drug-induced or other causes
  • Non-adherence
  • Inadequate doses
  • Inappropriate combinations
  • NSAIDs, COX inhibitors
  • Cocaine, amphetamines, other illicit drugs
  • Sympathomimetics (decongestants, anorectics)
  • Oral contraceptive therapy
  • Adrenal steroid hormones
  • Cyclosporine, tacrolimus
  • Erythropoietin
  • Licorice (including some chewing tobacco)
  • Selected over the counter dietary supplements (like ephedra, ma huang, bitter orange)

Less Common Cuases

• Acromegaly
• Coarctation of the aorta
• Hyperparathyroidism
• Liquorice (black, not red). Drives up cortisol causing a Cushing-like syndrome.
• Neurofibromatosis

Complete List of Causes 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 , Lobelia poisoning
Dermatologic	No underlying causes
Drug Side Effect	Almotriptan, Dihydroergotamine, Ergotamine, Frovatriptan, Isometheptene, Rizatriptan, Sumatriptan, Zolmitriptan, Amitriptyline, Cyclosporine, Desipramine, Dexamethasone sensitive hypertension, Doxepin, Ephedrine, Glucocorticoid resistance , Imipramine, Nasal decongestants, Nortriptyline, Combined oral contraceptive pill, Phencyclidine, Phenylpropanolamine, Protriptyline, Sedative dependence, Serotonin toxicity, Steroid abuse, Pseudoephedrine
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, 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	Congenital adrenal hyperplasia due to 11-Beta-hydroxylase deficiency, Congenital adrenal hyperplasia due to 17-alpha-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 , Vitamin D -- adverse effects
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, Almotriptan, Dihydroergotamine, Ergotamine, Frovatriptan, Isometheptene, Rizatriptan, Sumatriptan, Zolmitriptan, Amitriptyline, Cyclosporine, Desipramine, Dexamethasone sensitive hypertension, Doxepin, Ephedrine, Glucocorticoid resistance , Imipramine, Nasal decongestants, Nortriptyline, Combined oral contraceptive pill, Phencyclidine, Phenylpropanolamine, Protriptyline, Serotonin toxicity, Steroid abuse, Pseudoephedrine
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 sclerosis , 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, Wagener syndrome , Pain, Post-exercise, Transfusion of large blood volumes, White coat hypertension

Causes in Alphabetical Order

Abdominal obesity metabolic syndrome Absence of pulmonary artery Acetaldehyde Acid-Base Imbalance Acquired total Lipodystrophy Acrodynia Acromegaly Acute intermittent porphyria Acute renal failure Acute severe vascular damage Adams Nance syndrome Adrenal Cancer Adrenal incidentaloma After Kidney transplantation Age Albuminuria Alcohol withdrawal Alcohol-induced pseudo-Cushing syndrome Allain Babin Demarquez syndrome Almotriptan Amitriptyline Amphetamine abuse Amyloidosis Analgesic nephropathy syndrome Aneurysm Anxiety Aortic coarctation Aortic regurgitation Aortic stenosis Apparent mineralocorticoid excess Aristolochic Acid poisoning Arizona Bark Scorpion poisoning Arterial occlusive disease, progressive - -- heart defects -- bone fragility -- brachysyndactyly Arteriosclerosis Asphyxia Atheroma Atypical Hemolytic uremic syndrome Autoimmune Vasculitis Autonomic dysreflexia syndrome Autosomal dominant Polycystic kidney disease Autosomal Recessive Polycystic Kidney Disease Avasthey syndrome Bartter's Syndrome Bilateral Renal artery stenosis Binswanger's Disease Black widow spider envenomation Bone cement implantation syndrome Brachydactyly with hypertension Brain stem Encephalitis Bright's Disease Bronchopulmonary dysplasia Cadmium poisoning Carcinoid Syndrome Carnevale-Canun-Mendoza syndrome Carotid paraganglioma Catastrophic Antiphospholipid Syndrome Central sleep apnea Choroideremia -- hypopituitarism Chronic kidney disease Chronic pyelonephritis Cocaine poisoning Cockayne syndrome Codeine withdrawal Collagen disease Congenital adrenal hyperplasia due to 11-Beta-hydroxylase deficiency Congenital adrenal hyperplasia due to 17-alpha-hydroxylase deficiency Congenital hepatic porphyria Congenital Membranous glomerulonephritis Congenital Mitral stenosis Congenital stenosis of renal artery Congenital Hydronephrosis Conn's syndrome COPD Cushing's disease Cushing's syndrome Cyclosporine Desipramine Dexamethasone sensitive hypertension Diabetes Diffuse Systemic sclerosis Diffuse Mesangial sclerosis Dihydroergotamine Disequilibrium syndrome Aortic dissection Dissection of the renal arteries Down Syndrome Doxepin Dysautonomia Eclampsia Ecstasy abuse

Eisenmenger's Syndrome Electrical burns Endothelin producing tumor Ephedrine poisoning Ergotamine Essential hypertension Essential mixed Cryoglobulinemia Fabry's Disease Familial Renal cell carcinoma Familial Adrenal adenoma Familial Cushing syndrome Faye-Petersen-Ward-Carey syndrome Fibromuscular dysplasia of arteries Fitzsimmons-Walson-Mellor syndrome Fowler-Christmas-Chapple syndrome Frovatriptan Gaucher disease type 3 Gestational hypertension Ginseng Gitelman's Syndrome Glomerulonephritis Glucocorticoid resistance Glycine encephalopathy - classical neonatal form Glycine synthase deficiency Goodpasture syndrome Gouty nephropathy Gram's syndrome Grange syndrome Graves Disease Guillain-Barre Syndrome Head injury Heavy metal poisoning HELLP syndrome Familial Hemangiomatosis - pulmonary capillary Familial Osteodysplasia - Anderson type Hemolytic uremic syndrome Hepatorenal tyrosinemia Hereditary nephritis (X-linked) Hereditary sensory and autonomic neuropathy 3 Hyperadrenalism Hypereosinophilic syndrome Hyperparathyroidism Hyperpituitarism Hypertensive heart disease Hyperthyroidism Hyperventilation Hypoglycemia Hypoplastic kidney Hypothermia Hypothyroidism IgA nephropathy Imipramine Increased intracranial pressure Increased salt intake Indian Tobacco Poisoning Irradiation Isolated secretion of 18-hydroxy-deoxycorticosterone Isolated secretion of corticosterone Isolated secretion of deoxycorticosterone Isolated Ectopia lentis Isometheptene Jimsonweed poisoning Kashani-Strom-Utley syndrome Kidney arteriovenous fistula Renal Cancer Kimmelstiel-Wilson disease Lead poisoning Liddle's syndrome Lobelia poisoning Lockwood-Feingold syndrome Lupus nephritis Lymphomatoid granulomatosis Meningitis Metabolic syndrome Mineralocorticoid excess MSBD syndrome Mucopolysaccharidosis type I Hurler syndrome Multicentric Reticulohistiocytosis Multiple endocrine neoplasia type 1 Mustard tree poisoning Myxoedema Nasal decongestants Nephrocalcinosis Nephrosclerosis Nephrosis -- deafness -- urinary tract -- digital malformation Nephrotic syndrome Neuroblastoma Neurofibromatosis syndrome Type II Neurogenic hypertension Neuroleptic malignant Syndrome Nicotine addiction Nipah virus encephalitis Nortriptyline Obesity

Obstructive sleep apnea Oculo skeletal renal syndrome Oral contraceptive pill Ovarian dysgenesis Paget's disease of bone Pain Pancreatitis Patent ductus arteriosus PCOS Pheochromocytoma Phencyclidine Phenylpropanolamine Physical inactivity Pierre Robin's sequence Pierson syndrome Pituitary Cancer Poliomyelitis Polyarteritis nodosa Polycystic kidneys, severe infantile, with tuberous sclerosis Polycythemia Polyradiculitis Post streptococcal glomerulonephritis Post-exercise Pregnancy toxemia /hypertension Primary aldosteronism Primary cortisol resistance Protriptyline Pseudoephedrine Pseudohyperaldosteronism Pseudohypoaldosteronism Pulmonary artery agenesis Pulmonary cystic lymphangiectasis Pulmonary embolism Pulmonary fibrosis /granuloma Pulmonary veno-occlusive disease Pulmonary Lymphangiomatosis Quadriplegia Renal artery thrombosis Renal emboli Renal segmental hypoplasia-induced Hypertension Renal tuberculosis Renin-secreting tumors Respiratory acidosis Respiratory failure Retroperitoneal fibrosis Rhabdoid tumor Rizatriptan Salcedo syndrome Schroeder syndrome 1 Scleroderma Sedative dependence Selye syndrome Senior-Loken Syndrome Serotonin Syndrome Serotonin toxicity Shaken Baby Syndrome Silicosis Simple kidney cysts Skull fracture Sneddon Syndrome Steroid abuse Stress-induced hypertension Sumatriptan Systemic lupus erythematosus Takayasu arteritis Thieffry and Sorrell Dejerine syndrome Third degree AV block Thromboembolism Thrombotic thrombocytopenic purpura Toxic mushrooms -- Psychedelic Transfusion of large blood volumes Turner Syndrome Twin-Twin Transfusion Syndrome Type A personality Tyrosinemia Unilateral pulmonary agenesis Upper spinal cord lesions Urinary tract infections Urinary tract obstruction Vasculitis Vater-like syndrome, with pulmonary hypertension, abnormal ears and growth deficiency Vesicoureteral reflux Vitamin D -- adverse effects Von Gierke disease IB Von Hippel-Lindau Disease Wagener syndrome Wegener's granulomatosis Werner syndrome White coat hypertension Williams Syndrome Wilms' tumor Wolfram's disease Zolmitriptan