Resistant hypertension workup and secondary hypertension

To diagnose hypertension, you need to qualify and quantify it (use 24h-RR), screen for endorgan failure (eyes, brain, heart, kidneys, peripheral vessels) with TTE, fundoscopy and basic labs (urine proteine).

Whenever you introduce the third antihypertensive agent in your stroke patient, you deal with resistant hypertension and thus should think of the AHA guidelines on this topic. In particular you ought to think of the ABCDE mnemonic for secondary hypertension causes (to be found here and slightly enhanced below):

  • A: Adherence [history], aldosterone [elytes, do a morning aldosterone/renin plasma test], apnea (obstructive) [history/physical]
  • B: Bruits (renal artery stenosis) [auscultation, ultrasound/MRA/CTA]), bad kidneys [urine proteine, creatinine, urea]
  • C: Cushing [physical, basic labs, cortisole profile], Catecholamines [history, 24h-urine for the homovanillin… thingy, metanephrines and normetanephrines], aortic Coarctation [RR left/right, legs]
  • D: Drugs (NSAIDS, estrogens, cortisone, bromocriptine, cyclosporine, tacrolimus, ephedrine/catecholamines, …), Diet (obesity!, sodium)
  • E: ndocrine [TSH, hyperparathyroidism], EPO