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S H
ECONDARY YPERTENSION
C H
LINICAL YPERTENSION
V D
AND ASCULAR ISEASES
WILLIAM B. WHITE, MD
SERIES EDITOR
Secondary Hypertension:Clinical Presentation, Diagnosis,
and Treatment, edited by George A. Mansoor, MD, 2004
Pediatric Hypertension, edited by Ronald J. Portman, MD,
Jonathan M. Sorof, MD, and Julie R. Ingelfinger, MD, 2004
S
ECONDARY
H
YPERTENSION
Clinical Presentation, Diagnosis,
and Treatment
Edited by
G A. M , ,
EORGE ANSOOR MD FRCP (EDIN)
Section of Hypertension and Clinical Pharmacology,
University of Connecticut School of Medicine,
Farmington, CT
© 2004 Humana Press Inc.
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necessarily reflect the views of the publisher.
Due diligence has been taken by the publishers, editors, and authors of this book to assure the accuracy of the
information published and to describe generally accepted practices. The contributors herein have carefully
checked to ensure that the drug selections and dosages set forth in this text are accurate and in accord with the
standards accepted at the time of publication. Notwithstanding, as new research, changes in government regu-
lations, and knowledge from clinical experience relating to drug therapy and drug reactions constantly occurs,
the reader is advised to check the product information provided by the manufacturer of each drug for any change
in dosages or for additional warnings and contraindications. This is of utmost importance when the recom-
mended drug herein is a new or infrequently used drug. It is the responsibility of the treating physician to
determine dosages and treatment strategies for individual patients. Further it is the responsibility of the health
care provider to ascertain the Food and Drug Administration status of each drug or device used in their clinical
practice. The publisher, editors, and authors are not responsible for errors or omissions or for any consequences
from the application of the information presented in this book and make no warranty, express or implied, with
respect to the contents in this publication.
Production Editor: Robin B. Weisberg.
Cover Illustration: (Foreground) From Chapter 13, “Biochemical Diagnosis and Localization of Pheochro-
mocytoma,” by Emmanuel L. Bravo. (Background) From Chapter 4, “Diagnostic Evaluation for Patients With
Renovascular Hypertension,” by Sumeska Thavarajah and William B. White.
Cover design by Patricia F. Cleary.
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Printed in the United States of America. 10 9 8 7 6 5 4 3 2 1
1-59259-757-2 (e-ISBN)
Library of Congress Cataloging-in-Publication Data
Secondary hypertension : clinical presentation, diagnosis, and treatment / edited by George A. Mansoor.
p. ; cm. -- (Clinical hypertension and vascular diseases)
Includes bibliographical references and index.
ISBN 1-58829-141-3 (alk. paper)
1. Hypertension.
[DNLM: 1. Hypertension--etiology. 2. Hypertension--diagnosis. 3. Hypertension--therapy.
WG 340 S445 2004] I. Mansoor, George A. II. Series.
RC685.H8S43 2004
616.1'32--dc22 2003022071
S E ’ I
ERIES DITOR S NTRODUCTION
Secondary forms of hypertension are not uncommon in clinical prac-
tice, but they are often overlooked or forgotten by clinicians in many
fields of medicine. Dr. George Mansoor’s volume on Secondary Hyper-
tensionis an important contribution to the field of clinical hypertension
and vascular diseases, since it brings up to date the numerous diagnostic
and therapeutic advances in the evaluation for secondary types of hyper-
tension. In the past, textbooks usually stated that an etiology could be
determined in less than 5% of patients presenting with newly diagnosed
hypertension. We now know this is far too low a proportion (e.g., pri-
mary hyperaldosteronism alone may account for hypertension in 5% of
patients presenting with chronic elevations in blood pressure).
Secondary Hypertensionhas been thoughtfully organized into chap-
ters evaluating screening and diagnosis, as well as medical and/or sur-
gical intervention of the well-known etiologies of secondary
hypertension in adults and children. Additional coverage is given to such
exogenous or lesser appreciated causes of secondary hypertension as
obstructive sleep apnea and drugs. These sections make this book novel
because in the past little attention has been paid to the effects of noncar-
diac drugs that interfere with antihypertensive therapy or to exogenous
substances that might induce refractory hypertension.
As series editor of Clinical Hypertension and Vascular Diseases, I
was delighted to learn of the superb authors recruited by Dr. Mansoor
during the development of this volume. Each chapter has been written by
an authority in his or her field. Secondary Hypertensionwill be of great
value to all students and physicians interested in hypertension research,
education, and practice for the years to come.
William B. White, MD
Professor of Medicine
University of Connecticut School of Medicine,
Farmington, CT
v
P
REFACE
Secondary Hypertension: Clinical Presentation, Diagnosis, and
Treatmentreviews the essential clinical, diagnostic, and treatment aspects
of secondary hypertension. The need for such a book is great as knowl-
edge in this field has progressed rapidly and new and unique forms of
secondary hypertension are being described on a regular basis. How-
ever, such traditional disorders as renal artery stenosis, aldosteronism,
and pheochromocytoma have remained major considerations when sec-
ondary hypertension is suspected and still occupy a significant part of
our time as specialists in hypertension. The discovery of secondary hy-
pertension is important; it provides a potential cure for the patient, but
at other times provides physiological information on which the clinician
can base drug therapy. This book, therefore, covers in detail the forms
of secondary hypertension likely to be considered in persons with sug-
gestive clinical features or resistant hypertension.
Our knowledge regarding most forms of secondary hypertension has
grown significantly and our conventional impressions of some of these
have certainly changed. The availability of magnetic resonance imaging
has helped us in the evaluation of coarctation of the aorta and renal artery
stenosis. Reliable biochemical tests allow us to screen relatively easily
for a variety of endocrine causes of hypertension. In terms of treatment,
we have a vast array of drugs available to treat hypertension, but also
interventional therapy directed at the form of secondary hypertension,
e.g., surgery or anti-aldosterone drugs. Finally, it is becoming clear that
some disorders contribute more often to hypertension than previously
believed; this is the case with obstructive sleep apnea and possibly pri-
mary aldosteronism. There is a need for a book collating and updating
knowledge in this area; the causes and management of secondary hyper-
tension span several traditional disciplines, including internal medicine,
nephrology, cardiovascular medicine, endocrinology, and pulmonology.
Each chapter gives a concise approach to its topic and therefore can be
read on its own.
Chapter 1 discusses the most common reason that an evaluation for
secondary hypertension is performed: refractory hypertension. With
today’s lower goals for blood pressure, we may need to re-examine how
we define refractory hypertension. In Chapter 2, Dr. Ehud Grossman and
Dr. Franz Messerli consider the exogenous causes of hypertension. They
vii
viii Preface
review old and new culprit substances that raise blood pressure and
discuss possible mechanisms for their undesirable actions.
Part II reviews renal disease and secondary hypertension. In Chapter
3, Dr. Robert Toto tackles the area of renal disease and hypertension.
Hypertension is almost universally found in the presence of renal disease
and may have a role in the progression of intrinsic renal disorders. Dr.
Toto reviews current approaches to evaluating and managing hyperten-
sion in this setting. Dr. Sumeska Thavarajah and Dr. William White
(Chapter 4) provide a comprehensive account of diagnostic strategies
for renovascular hypertension and renal artery stenosis. Chapter 5 is
devoted to the role of interventional therapies such as balloon angioplasty
and stenting in the management of renovascular hypertension. In Chap-
ter 6, Dr. Vincent Canzanello reviews important information regarding
the medical treatment of renovascular hypertension and emphasizes that
the majority of patients can be controlled medically. A debate continues
in the literature about the relative merits of medical vs interventional
treatments for renovascular hypertension. Finally, secondary hyperten-
sion caused by excessive renin production, as in renin-producing tu-
mors, is reviewed by Dr. Timothy Reudelhuber in Chapter 7.
Part III covers adrenal medullary and cortical causes of secondary
hypertension. Dr. William Young (Chapter 8) reviews expertly the diag-
nostic strategy for primary aldosteronism, and Dr. Emmanuel Bravo
(Chapter 9) reviews the treatment aspects of primary aldosteronism.
They emphasize the advantages of ambulatory screening of hyperten-
sive patients without hypokalemia as well as the fact that most patients
with bilateral adrenal hyperplasia can enjoy excellent blood pressure
control with medical treatment. The laparoscopic surgical removal of
aldosteronomas is detailed by Dr. Mihir Desai and Dr. Inderbir Gill
(Chapter 10) so as to make it understandable to both physicians and
surgeons. In Chapter 11, Dr. William Kendrick, Dr. Jean-Michel Achard,
and Dr. David Warnock then review the other forms of low-renin hyper-
tension, including monogenic forms. They emphasize the fact that all
these disorders cause hypertension through sodium retention. The last
chapter in this section, by Dr. Judith Whitworth, Dr. George Mangos,
and Dr. John Kelly (Chapter 12), reviews the mechanisms, clinical evalu-
ation, and treatment of hypertension from Cushing’s syndrome, result-
ing from a variety of pathological entities.
Part IV on adrenal medulla and hypertension is given detailed consid-
eration because pheochromocytoma can be a malignant condition. This
section not only considers pheochromocytoma, but other disorders mim-
icking it. In Chapter 13, Dr. Emmanuel Bravo leads the reader through
Preface ix
a superlative account of when to suspect and how to screen for pheochro-
mocytoma. Dr. Carl Malchoff, Dr. Dougald MacGillivray, and Dr.
Steven Shichman (Chapter 14) review the current management of
pheochromocytoma, including preoperative management and care
ofadvanced cases. In Chapter 15, Dr. Otto Kuchel reviews a number of
conditions that may mimic pheochromocytoma, so-called pseudo-pheo-
chromocytoma, and also reviews the differentiating features of these
disorders.
In their chapter, Dr. Empar Lurbe and Dr. Joseph Redon (Chapter 16)
provide an excellent review of secondary hypertension in children and
adolescents. Obviously, the younger a child with hypertension is, the
more likely that a secondary form of hypertension will be discovered.
Finally, Chapter 17 by Dr. Thomas Pickering and Dr. Mona Yacoub
reviews the normal hemodynamic and other changes during sleep, con-
siders the relationship of sleep apnea to hypertension and its complica-
tions, and brings us up to date on its clinical features, diagnosis, and
treatment.
We have invited contributors who are easily recognizable as leaders
in the field of hypertension. They have worked hard to expertly and
concisely review traditional and established causes of secondary hyper-
tension as well as new and less well known ones. Each chapter merits
multiple reads and can act as a starting point for anyone seeking an up-
to-date, scientifically accurate review of a particular area in secondary
hypertension. Of course, we are grateful to the authors who have worked
hard on this book and provided us with excellent work. Special thanks
to Diane Webster from the editorial office of Blood Pressure Monitoring
at the University of Connecticut Health Center for helping with chapter
preparation.
We also thank Paul Dolgert at Humana Press for recognizing the
importance of this book and the need for it. We hope you find Secondary
Hypertension: Clinical Presentation, Diagnosis, and Treatmentenjoy-
able and scientifically current.
George A. Mansoor, MD,FRCP (EDIN)
