Essential hypertension
Differentials
Drug-induced hypertension
SIGNS / SYMPTOMS
There may be signs of acute intoxication, withdrawal, or cravings with cocaine/sympathomimetics use.
History of treatment with or ingestion of non-steroidal anti-inflammatory drugs, oral contraceptive pills, sympathomimetics, herbal medications (e.g., black cohosh, capsicum, ma huang), liquorice, immunosuppressants (ciclosporin, tacrolimus), erythropoietin, higher-dose corticosteroids, chemotherapeutic anti-endothelial growth factor agents (bevacizumab), tyrosine kinase inhibitors (e.g., sunitinib, sorafenib), mirabegron, or paracetamol.[78][79]
INVESTIGATIONS
Drug toxicology screen may detect an illicit substance.
Hypokalaemia if excessive liquorice.
Chronic kidney disease
SIGNS / SYMPTOMS
There may be pruritus, oedema, or change in urine output.
INVESTIGATIONS
High serum creatinine and/or albuminuria.
Chronic anaemia may be seen.
Renal ultrasound may identify sclerotic or polycystic kidneys.
Renal artery stenosis
SIGNS / SYMPTOMS
Typically younger patients with difficult-to-control hypertension or older patients at risk of atherosclerotic disease.
Renal artery bruits may be present.
INVESTIGATIONS
Renal duplex ultrasound, magnetic resonance angiogram, or CT angiogram of renal arteries confirms diagnosis.
Aortic coarctation
SIGNS / SYMPTOMS
Differential blood pressure in upper and lower extremities. Absent femoral pulses.
INVESTIGATIONS
CT, angiogram, or MRI confirms diagnosis.
Obstructive sleep apnoea
SIGNS / SYMPTOMS
Typically obese patients with daytime somnolence, snoring, or choking during sleep.
INVESTIGATIONS
Polysomnography shows nocturnal oxygen desaturation.
Hyperaldosteronism
SIGNS / SYMPTOMS
Few signs and symptoms other than mild metabolic alkalosis, relative hypernatraemia, potassium depletion, and elevated fasting glucose.
INVESTIGATIONS
Unprovoked hypokalaemia.
Plasma aldosterone high.
Plasma renin low.
Failure to suppress aldosterone with salt loading.
Hypothyroidism
SIGNS / SYMPTOMS
Dry skin, cold intolerance, weight gain, sluggishness, and goitre.
INVESTIGATIONS
Thyroid-stimulating hormone elevated in primary hypothyroidism.
Hyperthyroidism
SIGNS / SYMPTOMS
Heat intolerance, weight loss, hyperphagia, palpitations.
INVESTIGATIONS
Thyroid-stimulating hormone suppressed and levels of free thyroid hormones elevated.
Hyperparathyroidism
SIGNS / SYMPTOMS
There are often no differentiating symptoms; however, renal colic, abdominal pain, or bone fracture may occur.
INVESTIGATIONS
Hypercalcaemia, with elevated or inappropriately normal serum PTH.
Cushing syndrome
SIGNS / SYMPTOMS
Classic symptoms and signs include weight gain, moon face, dorsocervical fat pad, abdominal striae, and easy bruisability.
INVESTIGATIONS
Abnormal dexamethasone suppression, 24-hour urine free cortisol, and/or late-night salivary cortisol.
Phaeochromocytoma
SIGNS / SYMPTOMS
Paroxysms of hypertension, flushing, and headache.
INVESTIGATIONS
24-hour urine screen shows elevated vanillylmandelic acid, metanephrines, and/or catecholamines.
Acromegaly
SIGNS / SYMPTOMS
Acral (hand/foot/jaw) enlargement.
INVESTIGATIONS
Elevated insulin-like growth factor-1. Elevated serum growth hormone level, not suppressed by glucose load.
Collagen vascular disease
SIGNS / SYMPTOMS
Signs/symptoms of systemic lupus erythematosus, rheumatoid arthritis, sclerodactyly, or history of vasculitis.
INVESTIGATIONS
Elevated erythrocyte sedimentation rate, abnormal complement levels, positive anti-DNA, anti-ribonucleoprotein, anti-Smith antibodies, positive rheumatoid factor.
Gestational hypertension
SIGNS / SYMPTOMS
Detected after 20 weeks' gestation in a previously normotensive patient.
INVESTIGATIONS
Urinary albumin excretion of 300 mg/L/24 hours if pre-eclampsia occurs.
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