Investigating hypertension in a young person
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1043 (Published 06 April 2009) Cite this as: BMJ 2009;338:b1043
All rapid responses
In response to the above, whilst not wishing to denigrate the
diagnostic importance of aldosterone and renin measurements in the
assessment of young hypertensive patients, I would like to stress the
helpfulness of measuring the blood pressure of both their parents - if
alive.
In young patients presenting with malignant hypertension, now less
commonly seen, I frequently found both their parents to be hypertensive,
though usually previously unknown to be so and asymptomatic.
This gives one the opportunity of prophylactive treatment - if
indicated - as well as making a secondary cause of hypertension in the
offspring much less likely.
Competing interests:
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Competing interests: No competing interests
An interesting article. What is the availability for renin and
aldosterone bloods around the UK. Are they very expensive to do?. These
tests are not routinely available in this area. (E Kent)
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Competing interests: No competing interests
I enjoyed reading this brief article on investigation of a young
patient but would like to make several points.
1)The suggestion is made that ABPM is warranted 'if white coat
hypertension is suspected'. This is all very well except we are given no
guidance as to how one might suspect this. It is a popular misconception
that such individuals can be identified by any clinical characteristic so
one either performs ABPM on every young individual with high BP (a
suggestion that has been shown to be cost effective) or check self
monitored BP first (a strategy promoted by the American Society of
Hypertension). UK guidelines do not help us but it is not sound to make
general statements as in this paper.
2)The patient was 27 but the text suggests investigation for a secondary
cause in individuals <_40yrs i="i" do="do" not="not" know="know" where="where" this="this" has="has" come="come" from.="from." bhs="bhs" guidelines="guidelines" say="say" _30="_30" but="but" any="any" figure="figure" will="will" be="be" a="a" little="little" arbitrary.="arbitrary." to="to" suggest="suggest" that="that" full="full" screen="screen" for="for" secondary="secondary" cause="cause" should="should" carried="carried" out="out" in="in" anyone="anyone" under="under" _40="_40" being="being" the="the" only="only" criterion="criterion" would="would" expensive="expensive" and="and" without="without" an="an" evidence="evidence" base="base" p="p"/>3)The text suggests that primary hyperaldosteronism accounts for 5 - 10%
of all hypertensive patients. This is misleading. The authors define
this condition as starting with a screening test that has 'a high plasma
aldosterone concentration and suppressed PRA'(a definition that has my
support at least). If they stick to this then the prevalence is much
lower than 10 or even 5%. It is when the definition shifts (as it does in
the box entitled 'learning points') to simply describe the ratio of
aldosterone to renin (ARR) that the prevalence appears to increase. There
has been much debate elsewhere on this issue and I will not elaborate
further.
4)I do not agree that the ratio, ARR, is relatively unaffected by drug
therapy. As the ratio is largely driven by PRA the concommitant use of B
blockers should not be allowed.
There, I did enjoy it!
Competing interests:
None declared
Competing interests: No competing interests
Hammer and Stewart did not perform adrenal venous sampling to
ascertain a lateralized aldosterone hypersecretion in their patient. This
is discrepant with the recommendation of the recent guideline on the
detection, diagnosis, and treatment of patients with primary aldosteronism
[1].
Given the high prevalence of adrenal incidentalomas, their fortuitous
association with bilateral or contralateral aldosterone hypersecretion
must be expected in some patients with primary aldosteronism. The
proportion of patients with a unilateral adrenal nodule > 1 cm on CT-
scan but a bilateral or contralateral secretion documented by adrenal
venous sampling was 38% in one study [2] and 40% in another [3].
However, adrenal incidentalomas are mostly seen in older patients.
Therefore, some experts consider the presence of an isolated
characteristic adrenal adenoma in patients aged less than 40 as an
acceptable surrogate for unilateral aldosterone hypersecretion [4]. The
choice not to perform AVS in this young patient was reasonable but it must
be stressed that AVS should otherwise always be performed to locate the
culprit adrenal before removing it.
References
[1] Funder JW, Carey RM, Fardella C, Gomez-Sanchez CE, Mantero F,
Stowasser M, et al. Case detection, diagnosis, and treatment of patients
with primary aldosteronism: an endocrine society clinical practice
guideline. J Clin Endocrinol Metab 2008;93:3266-81.
[2] Young WF, Stanson AW, Thompson GB, Grant CS, Farley DR, van
Heerden JA. Role for adrenal venous sampling in primary aldosteronism.
Surgery 2004;136:1227-35.
[3] Nwariaku FE, Miller BS, Auchus R, Holt S, Watumull L, Dolmatch B,
et al. Primary hyperaldosteronism: effect of adrenal vein sampling on
surgical outcome. Arch Surg 2006;141:497-502.
[4] Young WF. Primary aldosteronism: renaissance of a syndrome. Clin
Endocrinol (Oxf). 2007;66:607-18.
Competing interests:
None declared
Competing interests: No competing interests
Echocardiography in the young person with hypertension
I enjoyed this article on investigation of hypertension in a young
person and would like to suggest an addition. Coarctation of the aorta is
often diagnosed only after years of difficult to treat hypertension. In
the given case the family history is also relevant as the recurrence risk
is around ten fold higher than in the general population. Although
cardiovascular examination should reveal an ejection systolic murmur and
weak or delayed femoral pulses, and a chest radiograph rib notching, these
are not universally detected. The diagnosis can easily be made by
transthoracic echocardiography, also more useful than ECG for the
assessment of left ventricular hypertrophy.
Coarctation is an important diagnosis to make, both because
successful surgical or percutaneous treatment generally improves the
hypertension to such an extent that significantly reduced (or no) drug
treatment is required, and because lifelong specialist follow up is
necessary. I would therefore suggest that all young people with proven
hypertension have an echocardiogram including the suprasternal view.
Competing interests:
None declared
Competing interests: No competing interests