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Endgames Case Review

A young man with severe hypertension

BMJ 2018; 362 doi: (Published 03 August 2018) Cite this as: BMJ 2018;362:k2935
  1. Jin Ern Tan, principal house officer1,
  2. Danielle Wu, nephrology consultant,, adjunct senior lecturer2,
  3. Michael Stowasser, professor and director of hypertension unit3
  1. 1Mackay Base Hospital, Mackay, Queensland, Australia
  2. 2College of Medicine and Dentistry, James Cook University, Mackay Base Hospital, Mackay, Queensland, Australia
  3. 3Hypertension Unit, Department of Medicine, University of Queensland, Princess Alexandra and Greenslopes Hospitals, Brisbane, Queensland, Australia
  1. Correspondence to JE Tan tanjinern{at}

A 31 year old man with a background of sleep apnoea was referred to the endocrine clinic for his newly diagnosed hypertension. He had a documented blood pressure of 170/128 mm Hg. On repeat measurements, he was found to have persistent hypertension (164/110 mm Hg and 173/110 mm Hg on separate measurements). He complained of lethargy for the past six months and reported intermittent headaches. He was an ex-smoker with a 20 pack-year history and had had follow-up appointments with his general practitioner for his sleep apnoea. He was started on prazosin 4 mg twice daily by his GP for the hypertension.

On examination, his heart rate was 106 beats per minute. There was no evidence of cushingoid features, hyperpigmentation, renal bruits, carotid bruits, or fine tremors. Apart from his elevated blood pressure and his raised body mass index of 34, he had an unremarkable physical examination.

His full blood count, urea, and electrolyte levels were normal. In view of his young age, history of sleep apnoea, and severe hypertension, further investigations were carried out (table 1)

View this table:
Table 1

Investigations and results

Renal artery Doppler showed no evidence of renal artery stenosis.


  • 1. What is the most likely diagnosis?

  • 2. What initial investigation is performed in primary care?

  • 3. What further investigation is required once the diagnosis has been made?


1. What is the most likely diagnosis?

The most likely diagnosis is primary aldosteronism. Suspect this diagnosis in patients with:

  • blood pressure above 150/100 mm Hg on three days, requiring four or more antihypertensive medications to obtain blood pressure control;

  • hypertension with

    • spontaneous or diuretic induced hypokalaemia

    • adrenal incidentaloma

    • sleep apnoea

    • family history of early onset hypertension or

    • first degree relatives with primary aldosteronism

    • cerebrovascular accident at <40 years.123


Primary …

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