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Practice Rational Testing

Investigating hypertension in younger patients

BMJ 2022; 376 doi: https://doi.org/10.1136/bmj-2021-067924 (Published 24 March 2022) Cite this as: BMJ 2022;376:e067924
  1. Stuart CG Rison, , general practitioner and, clinical research fellow1 2,
  2. Chris Carvalho, general practitioner and clinical research fellow1 3,
  3. Gurvinder Rull, consultant in clinical pharmacology and therapeutics4 5,
  4. John Robson, reader1 6
  1. 1Centre for Primary Care, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
  2. 2Bromley by Bow Health Centre, London, UK
  3. 3De Beauvoir Surgery, London, UK
  4. 4Barts BP Centre of Excellence, William Harvey Research Institute, London, UK
  5. 5NIHR Barts Cardiovascular Biomedical Research Centre, London, UK
  6. 6UCL Partners, London, UK
  1. Correspondence to S C G Rison s.rison{at}qmul.ac.uk

What you need to know

  • Secondary hypertension may account for up to 30% of diagnoses of young onset hypertension

  • Thyroid dysfunction, renal parenchymal disease, and renal artery stenosis secondary to fibromuscular dysplasia are the most common causes of secondary hypertension in younger patients

  • Testing for 24 hour urinary metanephrines should be carried out only if the patient has phaeochromocytoma symptoms, clinical signs, or relevant family history

  • Random (spot) serum cortisol tests are usually uninformative. Consider late evening salivary cortisol if available

  • If treating patients with young onset hypertension empirically, revisit a diagnosis of secondary hypertension following post-treatment blood tests, or if blood pressure control is not achieved or deteriorates

A 38 year old patient attends her GP reporting several high blood pressure readings at home. The GP records a clinic blood pressure of 159/101 mmHg.

Hypertension is often thought of as a disease of older age, but it occurs across all adult ages, including in younger patients. In the US, 22.4% of people aged 18-39 are estimated to have a blood pressure of above 130/80 mmHg.1 The 2018 Health Survey for Health for England found that 2.6% of people aged 16-24 and 12.2% of those aged 35-44 had hypertension (on antihypertensive medication and/or blood pressure over 140/90 mmHg).2 Various guidelines define young onset differently. This article uses the definition in guidelines from the UK’s National Institute for Health and Care Excellence (NICE), which is hypertension in patients under the age of 40.3

Essential hypertension remains the most common cause of hypertension, even in young onset hypertension, but secondary hypertension—which has an underlying pathological cause—accounts for 5% to 30% of cases of young onset hypertension.456 Secondary hypertension is not a diagnosis in itself, but rather a collective term for hypertension caused by a defect in one or more of the …

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