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Child with hypertension
OBJECTIVES 
 
 Identify children and adolescents for whom 
hypertension screening is appropriate 
 Implement an initial workup for pediatric 
hypertension 
 Develop treatment plans for children with 
essential or secondary hypertension
BACKGROUND 
 
 Hypertensive children 
 Usually asymptomatic 
 HOWEVER already manifest evidence of target organ 
damage 
 Left ventricular hypertrophy ( up to 40%) 
 Increased carotid intima-media thickness 
 Children with BP > 90th percentile have a 2.4-fold greater 
risk having hypertension as adults
PREVALENCE OF HYPERTENSION 
IN CHILDREN 
 
 Systemic hypertension is uncommon (<1%) 
 If present  often indicative of an underlying disease 
process 
SEVERE and SYMPTOMATIC HYPERTENSION in 
children is usually due to SECONDARY 
HYPERTENSION 
 Prevalence of primary essential hypertension has 
increased, mostly in older school age and adolescents
DEFINITION 
 
 Hypertension is defined as average SBP and/or 
diastolic BP that is  95th percentile for gender , age 
and height on 3 or more occasions.
 
 Normal Blood Pressure : < 90th percentile for age, 
gender and height. 
 Pre-hypertension : SBP and/or DBP >90th percentile 
but less than 95th percentile for 
age, gender and height. 
 For age >12years, BP >120/80 regardless of 90th percentile 
considered pre-hypertension 
 Hypertension : SBP and/or DBP >95th percentile 
for age, gender and height 
 Stage 1: 95th – 99th percentile + 5 mmHg 
 Stage 2: > 99th percentile + 5 mmHg 
6 
CLASSIFICATION OF 
HYPERTENSION
 
 Hypertensive urgency: 
 Significant elevation in BP without accompanying end-organ 
damage; more common in children. 
 (180 or higher for your systolic pressure or 110 or higher for 
your diastolic pressure) 
 Symptoms include headache, blurred vision, and nausea 
 Hypertensive emergency: 
 Elevation of both systolic and diastolic BP 
 (exceeding 180 systolic or 120 diastolic) 
 with acute end-organ damage (e.g., cerebral infarction or 
hemorrhage, pulmonary edema, renal failure, hypertensive 
encephalopathy, or seizures) 
7 
HYPERTENSIVE CRISIS
BLOOD PRESSURE 
REGULATIONS 
 
 Short term mechanisms 
 Baroreceptors (low pressure & high pressure) 
 Hormonal 
 Noradrenaline-adrenaline system 
 Renin-angiotensin-aldosterone system 
 Vasopressin system 
 Long term mechanisms 
 Renal body fluid pressure control system
BARORECEPTOR 
REFLEX CONTROL 


Child with hypertension
How should blood pressure be 
measured in children? 

 
 The child should be calm and free of anxiety 
 The child should have been sitting quietly for 5 minutes. 
The child should be sitting with back supported, both feet 
on the floor and right cubital fossa supported at heart 
level. 
 Choose the appropriate cuff size: 
 The cuff width should cover ~70% of the distance 
between the acromion and the olecranon . 
 The cuff bladder length should be 80 to 100% of the arm 
circumference, and the cuff bladder width should be at 
least 40% of the arm circumference at the midpoint of the 
acromion-olecranon distance.
Choose the appropriate size cuff 

Recommended Dimensions 
for Blood Pressure Cuff Bladders 
 
Maximum Arm 
Age Range Width (cm) Length (cm) Circumference (cm)* 
Newborn 4 8 10 
Infant 6 12 15 
Child 9 18 22 
Small adult 10 24 26 
Adult 13 30 34 
Large adult 16 38 44 
Thigh 20 42 52 
*Calculated so that the largest arm would still allow the bladder to 
encircle the arm by at least 80 percent.
METHODS 
Palpatory Method BP recording is 10 mm Hg less 
than that obtained by auscultatory 
method . 
Auscultatory Method Preferred method. BP tables are 
based on it. 
Doppler Study Non invasive procedure 
Oscillometric Method Better to record mean BP. Useful in 
infants and young children. BP > 
90th percentile should be 
rechecked by auscultatory method. 
Flush Method Used in newborns. Only SBP can 
be recorded. 
Ambulatory Blood 
Pressure Monitoring 
White-coat hypertension 
Target-organ injury risk
POINTS TO BE 
REMEMBERED 
 
 BP should be recorded in all 4 limbs. 
 Cuff should not be applied too tight (low BP 
recording) or too loose (high BP recording). 
 BP monitoring subsequently should be taken in the 
same limb and position. 
 Normally the BP is 10-20mm Hg higher in lower 
limbs compared to the upper limbs.
ETIOLOGY 
COMMONEST CAUSES 
Newborn Umbilical artery catheterization and 
Renal artery thrombosis. 
Childhood Renal disease, COA, endocrine 
disorders or medications. 
Adolescents. Essential hypertension becomes 
increasingly common.
DEVELOPING A DIFFERENTIAL . . . 
“M.O.N.S.T.E.R.”: 
A simple pneumonic to start the thinking process 
 
19
CAUSES OF HYPERTENSION IN PEDIATRIC POPULATION 
Renal Causes Renal Parenchymal diseases (78%) 
Renal vascular diseases (12%) 
Cardiovascular CoA(2%) 
Condition with large stroke volume (PDA, AV fistula) 
Endocrine Hyperthyroidism 
Excessive Catecholamine levels (Pheochromocytoma) 
Adrenal dysfunction (CAH 11b, 17 a hydroxylase 
deficiency) 
Hyperaldosteronism (Conn's Syndrome, Renin 
Producing Tumors) 
Hyperparathyroidism 
Neurogenic Raised ICT, Poliomyelitis,GBS, encephalitis 
Drugs and Chemical Sympathomimetic drugs , Amphetamines, Steroids, 
OCP, Heavy matal poising (Hg, Lead), Cocaine, 
Cyclosporine 
Miscellaneous Hypercalcemia, After Coarctation repair, fractures 
of long bone,Pre eclampsia etc.
Obesity-- for each one unit increase in BMI 
z-score, children 8 to 17 years of age have been shown to 
have twice the risk of having a BP greater than the 95th 
percentile.1
CLINICAL 
MANIFESTATIONS 
 
 Usually asymptomatic 
 Mild to moderate obesity 
 Clinical manifestation of the underlying disease 
 Headache, dizziness, epistaxis, anorexia, visual 
changes, seizures 
 Hypertensive encephalopathy : vomiting, temperature 
elevation, ataxia, stupor, seizures

Acute Gromerulonephritis Oliguria, haematuria, mild proteinuria, oedema 
Pyelonephritis Urinary tract infection, fever 
Haemolytic Uraemic 
Syndrome 
AGE (bloody stool), weakness, irritability, 
oliguria, oedema 
Henoch-Schonlein purpura Palpable purpuric rash, abdominal pain, 
haematochezia, periarticular swelling, scalp & 
scrotal oedema, haematuria 
SLE Arthritis, arthralgia, weight loss, fever, malaise, 
malar rash, alopecia, oral ulcers, haematuria 
Renal vein thrombosis Abdominal pain, history of umbilical 
catheterization 
Familial nephritis Frequent haematuria 
Wilms tumour Abdominal mass, abd pain, fever, 
microscopic/gross haematuria 
Neuroblastoma Abdominal mass, fever, weight loss, limp, back 
pain 
Neufibromatosis Skin nodules, family history
Hyperthyroidism Tremor, anxiety, sweating, heat intolerance, 
inability to concentrate, weight loss, 
hyperactivity, neck mass 
Pheochromocytoma Anxiety, tremor, sweating, headache, flushing, 
nausea, vomiting, weight loss, 
constipation/diarrhoea, Raynaud’s, chest pain, 
polyuria/nocturia 
Cushing syndrome Obesity, failure of long. growth, hirsutism, 
weakness, acne, hyperpigmentation, history of 
taking steroid 
Congenital adrenal 
hyperplasia 
Ambiguous genitalia, virilization, precocious 
puberty
 
 Complete blood count : anaemia(chronic renal disease) 
 BUSE, Creatinine: Renal disease, hyperaldosteronism 
(hyperkalemia) 
 Urinalysis : proteinuria, haematuria 
 24 hr urinary protein or spot albumin to creatinine ratio 
 Urine culture& sensitivity: chronic pyelonephritis 
 Chest radiograph : CoA 
 Electrocardiogram : cardiac cause of HPT 
 Ultrasonography for kidneys , adrenals : hydroneprosis, 
PKD, Wilm’s tumour 
26 
SCREENING 
INVESTIGATION 
Aims; 
Assessment for target organ damage 
Assessment for aetiology 
Assessment for other cardiovascular risk factors
 
 Retinal fundus examination 
 Urine spot protein to creatinine ratio 
 Echocardiography : LVH, LV function 
27 
SCREENING FOR 
TARGET ORGAN 
DAMAGE
 
 Renin level : plasma renin (high-renovascular; low-hyperaldosteronism) 
 Toxicology screen 
 Thyroid and adrenal testing :T3 T4, plasma aldosterone, 
plasma catecholamines (pheochoromocytoma, neuroblastoma) 
 Urine catecholamines 
 Abdominal ultrasound : : Structure anomalies of kidney, renal 
vasculature and tumours; renal scarring, renal asymmetry(r. 
dysplasia, r. artery stenosis), extrarenal masses (neuroblastoma, 
Wilms tumour) 
 Renal Doppler ultrasound 
 Brain CT scan 
28 
CONSIDER
 
NON PHARMACOLOGICAL 
 Recommended in all children with prehypertension and 
hypertension 
 Weight management: reduction in obese children and 
maintenance in normal weight 
 Lifestyle modifications 
 Diet modification (reduce salt intake, low fat diet). 
 Note that those with severe HTN should avoid very 
strenuous exercises including weight lifting and high 
intensity sports, until evaluations clears an individual for 
participation 
 Some exercises can result in a brisk increase in BP that may 
result in significant adverse consequences 
29 
Management
GOALS OF 
ANTIHYPERTENSIVE 
 
THERAPY 
 Reduction of BP to < 95th percentile without any 
concurrent conditions . 
 Reduction of BP to <90th percentile with concurrent 
conditions (eg.Hyperlipidemia ,End organ damage, 
Obesity, CKD Complications etc)
 
Pharmacologic 
1. Hypertension but asymptomatic : 
 Bed rest. 
 Re-check BP ½ hour later. 
 Monitor BP hourly x 4 hours then 4 hourly until stable. 
 Oral nifedipine 0.25-0.5mg/kg if necessary 4 hourly basis. 
 Consider regular oral nifedipine (6-8 hourly) if BP 
persistently high. 
 Add frusemide 1mg/kg/dose if BP still not well controlled. 
 Other anti-hypertensive if BP still not well controlled : 
 Captopril 0.1-0.5 mg/kg 8 hourly. 
 Metoprolol 1-4 mg/kg 12 hourly

 
2.Long standing/poorly controlled hypertension: 
 Combination of antihypertensives. 
 Different sites or mechanism of action. 
 Compliance.
COMBINATION 
THERAPY 
 SYNERGISTIC 
COMBINATIONS. 
Drugs increasing renin 
activity+ Drugs decreasing 
renin activity 
ACE inhibitors , Diuretics 
+ 
b blockers 
Sympathic inhibitors and 
vasodilators cause fluid 
retention. Add diuretics 
b blockers + Thiazide, 
Lasix ( furosemide) 
ACE inhibitors + Diuretics Enalapril (Envas) + 
Thiazide, Lasix 
a Blocker + b blocker Prazosin + Propranolol
COMBINATIONS TO 
BE AVOIDED 
 
 a or b blocker + clonidine (antagonism) 
 b blocker + CCB (marked bradycardia/ AV block). 
 Any 2 drugs of same class.
Hypertensive crisis 
 
 Severe symptomatic hypertension with BP well above 
99th percentile . 
 Hypertensive emergencies(encepalopathy,chf) 
controlled reduction in BP 
25% in first 8hrs 
then gradually normalising BP 75% within 48 hours. .
EMERGENCIES 
 
 Nifedipine 
0.25-0.5 mg/kg/dose oral. 
May be repeated twice if no response. 
 Sodium nitroprusside 
Need to be given in ICU setting. 
0.5-1.0 mcg/kg/min IV infusion. 
May be increased to 8.0 mcg/kg/min maximum. 
Caution in renal and liver failure. 
 Labetolol 
0.2-1.0 mg/kg/dose repeated IV boluses 
0.25-2.0 mg/kg/hour IV infusion 
 Hydralazine 
0.2-0.4 mg/kg/dose IV bolus. 
May be repeated twice if no response.
SECONDARY 
HYPERTENSION 
 Treatment should be aimed at removing the cause of 
hypertension whenever possible. 
 Curable forms of Hypertension 
Renal Unilateral kidney disease (Nephritis, 
Pyelonephritis, hydronephrosis) 
Cardiovascular CoA, Renal artery stenosis, thrombosis. 
Adrenal Pheochromocytoma, Neuroblastoma, 
hyperaldosteronism 
Miscellaneous Drugs/ OCP etc.
 
Management Algorithm of Systemic Hypertension

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Child with hypertension

  • 2. OBJECTIVES   Identify children and adolescents for whom hypertension screening is appropriate  Implement an initial workup for pediatric hypertension  Develop treatment plans for children with essential or secondary hypertension
  • 3. BACKGROUND   Hypertensive children  Usually asymptomatic  HOWEVER already manifest evidence of target organ damage  Left ventricular hypertrophy ( up to 40%)  Increased carotid intima-media thickness  Children with BP > 90th percentile have a 2.4-fold greater risk having hypertension as adults
  • 4. PREVALENCE OF HYPERTENSION IN CHILDREN   Systemic hypertension is uncommon (<1%)  If present  often indicative of an underlying disease process SEVERE and SYMPTOMATIC HYPERTENSION in children is usually due to SECONDARY HYPERTENSION  Prevalence of primary essential hypertension has increased, mostly in older school age and adolescents
  • 5. DEFINITION   Hypertension is defined as average SBP and/or diastolic BP that is  95th percentile for gender , age and height on 3 or more occasions.
  • 6.   Normal Blood Pressure : < 90th percentile for age, gender and height.  Pre-hypertension : SBP and/or DBP >90th percentile but less than 95th percentile for age, gender and height.  For age >12years, BP >120/80 regardless of 90th percentile considered pre-hypertension  Hypertension : SBP and/or DBP >95th percentile for age, gender and height  Stage 1: 95th – 99th percentile + 5 mmHg  Stage 2: > 99th percentile + 5 mmHg 6 CLASSIFICATION OF HYPERTENSION
  • 7.   Hypertensive urgency:  Significant elevation in BP without accompanying end-organ damage; more common in children.  (180 or higher for your systolic pressure or 110 or higher for your diastolic pressure)  Symptoms include headache, blurred vision, and nausea  Hypertensive emergency:  Elevation of both systolic and diastolic BP  (exceeding 180 systolic or 120 diastolic)  with acute end-organ damage (e.g., cerebral infarction or hemorrhage, pulmonary edema, renal failure, hypertensive encephalopathy, or seizures) 7 HYPERTENSIVE CRISIS
  • 8. BLOOD PRESSURE REGULATIONS   Short term mechanisms  Baroreceptors (low pressure & high pressure)  Hormonal  Noradrenaline-adrenaline system  Renin-angiotensin-aldosterone system  Vasopressin system  Long term mechanisms  Renal body fluid pressure control system
  • 10.
  • 12. How should blood pressure be measured in children? 
  • 13.   The child should be calm and free of anxiety  The child should have been sitting quietly for 5 minutes. The child should be sitting with back supported, both feet on the floor and right cubital fossa supported at heart level.  Choose the appropriate cuff size:  The cuff width should cover ~70% of the distance between the acromion and the olecranon .  The cuff bladder length should be 80 to 100% of the arm circumference, and the cuff bladder width should be at least 40% of the arm circumference at the midpoint of the acromion-olecranon distance.
  • 14. Choose the appropriate size cuff 
  • 15. Recommended Dimensions for Blood Pressure Cuff Bladders  Maximum Arm Age Range Width (cm) Length (cm) Circumference (cm)* Newborn 4 8 10 Infant 6 12 15 Child 9 18 22 Small adult 10 24 26 Adult 13 30 34 Large adult 16 38 44 Thigh 20 42 52 *Calculated so that the largest arm would still allow the bladder to encircle the arm by at least 80 percent.
  • 16. METHODS Palpatory Method BP recording is 10 mm Hg less than that obtained by auscultatory method . Auscultatory Method Preferred method. BP tables are based on it. Doppler Study Non invasive procedure Oscillometric Method Better to record mean BP. Useful in infants and young children. BP > 90th percentile should be rechecked by auscultatory method. Flush Method Used in newborns. Only SBP can be recorded. Ambulatory Blood Pressure Monitoring White-coat hypertension Target-organ injury risk
  • 17. POINTS TO BE REMEMBERED   BP should be recorded in all 4 limbs.  Cuff should not be applied too tight (low BP recording) or too loose (high BP recording).  BP monitoring subsequently should be taken in the same limb and position.  Normally the BP is 10-20mm Hg higher in lower limbs compared to the upper limbs.
  • 18. ETIOLOGY COMMONEST CAUSES Newborn Umbilical artery catheterization and Renal artery thrombosis. Childhood Renal disease, COA, endocrine disorders or medications. Adolescents. Essential hypertension becomes increasingly common.
  • 19. DEVELOPING A DIFFERENTIAL . . . “M.O.N.S.T.E.R.”: A simple pneumonic to start the thinking process  19
  • 20. CAUSES OF HYPERTENSION IN PEDIATRIC POPULATION Renal Causes Renal Parenchymal diseases (78%) Renal vascular diseases (12%) Cardiovascular CoA(2%) Condition with large stroke volume (PDA, AV fistula) Endocrine Hyperthyroidism Excessive Catecholamine levels (Pheochromocytoma) Adrenal dysfunction (CAH 11b, 17 a hydroxylase deficiency) Hyperaldosteronism (Conn's Syndrome, Renin Producing Tumors) Hyperparathyroidism Neurogenic Raised ICT, Poliomyelitis,GBS, encephalitis Drugs and Chemical Sympathomimetic drugs , Amphetamines, Steroids, OCP, Heavy matal poising (Hg, Lead), Cocaine, Cyclosporine Miscellaneous Hypercalcemia, After Coarctation repair, fractures of long bone,Pre eclampsia etc.
  • 21. Obesity-- for each one unit increase in BMI z-score, children 8 to 17 years of age have been shown to have twice the risk of having a BP greater than the 95th percentile.1
  • 22. CLINICAL MANIFESTATIONS   Usually asymptomatic  Mild to moderate obesity  Clinical manifestation of the underlying disease  Headache, dizziness, epistaxis, anorexia, visual changes, seizures  Hypertensive encephalopathy : vomiting, temperature elevation, ataxia, stupor, seizures
  • 23.
  • 24. Acute Gromerulonephritis Oliguria, haematuria, mild proteinuria, oedema Pyelonephritis Urinary tract infection, fever Haemolytic Uraemic Syndrome AGE (bloody stool), weakness, irritability, oliguria, oedema Henoch-Schonlein purpura Palpable purpuric rash, abdominal pain, haematochezia, periarticular swelling, scalp & scrotal oedema, haematuria SLE Arthritis, arthralgia, weight loss, fever, malaise, malar rash, alopecia, oral ulcers, haematuria Renal vein thrombosis Abdominal pain, history of umbilical catheterization Familial nephritis Frequent haematuria Wilms tumour Abdominal mass, abd pain, fever, microscopic/gross haematuria Neuroblastoma Abdominal mass, fever, weight loss, limp, back pain Neufibromatosis Skin nodules, family history
  • 25. Hyperthyroidism Tremor, anxiety, sweating, heat intolerance, inability to concentrate, weight loss, hyperactivity, neck mass Pheochromocytoma Anxiety, tremor, sweating, headache, flushing, nausea, vomiting, weight loss, constipation/diarrhoea, Raynaud’s, chest pain, polyuria/nocturia Cushing syndrome Obesity, failure of long. growth, hirsutism, weakness, acne, hyperpigmentation, history of taking steroid Congenital adrenal hyperplasia Ambiguous genitalia, virilization, precocious puberty
  • 26.   Complete blood count : anaemia(chronic renal disease)  BUSE, Creatinine: Renal disease, hyperaldosteronism (hyperkalemia)  Urinalysis : proteinuria, haematuria  24 hr urinary protein or spot albumin to creatinine ratio  Urine culture& sensitivity: chronic pyelonephritis  Chest radiograph : CoA  Electrocardiogram : cardiac cause of HPT  Ultrasonography for kidneys , adrenals : hydroneprosis, PKD, Wilm’s tumour 26 SCREENING INVESTIGATION Aims; Assessment for target organ damage Assessment for aetiology Assessment for other cardiovascular risk factors
  • 27.   Retinal fundus examination  Urine spot protein to creatinine ratio  Echocardiography : LVH, LV function 27 SCREENING FOR TARGET ORGAN DAMAGE
  • 28.   Renin level : plasma renin (high-renovascular; low-hyperaldosteronism)  Toxicology screen  Thyroid and adrenal testing :T3 T4, plasma aldosterone, plasma catecholamines (pheochoromocytoma, neuroblastoma)  Urine catecholamines  Abdominal ultrasound : : Structure anomalies of kidney, renal vasculature and tumours; renal scarring, renal asymmetry(r. dysplasia, r. artery stenosis), extrarenal masses (neuroblastoma, Wilms tumour)  Renal Doppler ultrasound  Brain CT scan 28 CONSIDER
  • 29.  NON PHARMACOLOGICAL  Recommended in all children with prehypertension and hypertension  Weight management: reduction in obese children and maintenance in normal weight  Lifestyle modifications  Diet modification (reduce salt intake, low fat diet).  Note that those with severe HTN should avoid very strenuous exercises including weight lifting and high intensity sports, until evaluations clears an individual for participation  Some exercises can result in a brisk increase in BP that may result in significant adverse consequences 29 Management
  • 30. GOALS OF ANTIHYPERTENSIVE  THERAPY  Reduction of BP to < 95th percentile without any concurrent conditions .  Reduction of BP to <90th percentile with concurrent conditions (eg.Hyperlipidemia ,End organ damage, Obesity, CKD Complications etc)
  • 31.  Pharmacologic 1. Hypertension but asymptomatic :  Bed rest.  Re-check BP ½ hour later.  Monitor BP hourly x 4 hours then 4 hourly until stable.  Oral nifedipine 0.25-0.5mg/kg if necessary 4 hourly basis.  Consider regular oral nifedipine (6-8 hourly) if BP persistently high.  Add frusemide 1mg/kg/dose if BP still not well controlled.  Other anti-hypertensive if BP still not well controlled :  Captopril 0.1-0.5 mg/kg 8 hourly.  Metoprolol 1-4 mg/kg 12 hourly
  • 32.
  • 33.  2.Long standing/poorly controlled hypertension:  Combination of antihypertensives.  Different sites or mechanism of action.  Compliance.
  • 34. COMBINATION THERAPY  SYNERGISTIC COMBINATIONS. Drugs increasing renin activity+ Drugs decreasing renin activity ACE inhibitors , Diuretics + b blockers Sympathic inhibitors and vasodilators cause fluid retention. Add diuretics b blockers + Thiazide, Lasix ( furosemide) ACE inhibitors + Diuretics Enalapril (Envas) + Thiazide, Lasix a Blocker + b blocker Prazosin + Propranolol
  • 35. COMBINATIONS TO BE AVOIDED   a or b blocker + clonidine (antagonism)  b blocker + CCB (marked bradycardia/ AV block).  Any 2 drugs of same class.
  • 36. Hypertensive crisis   Severe symptomatic hypertension with BP well above 99th percentile .  Hypertensive emergencies(encepalopathy,chf) controlled reduction in BP 25% in first 8hrs then gradually normalising BP 75% within 48 hours. .
  • 37. EMERGENCIES   Nifedipine 0.25-0.5 mg/kg/dose oral. May be repeated twice if no response.  Sodium nitroprusside Need to be given in ICU setting. 0.5-1.0 mcg/kg/min IV infusion. May be increased to 8.0 mcg/kg/min maximum. Caution in renal and liver failure.  Labetolol 0.2-1.0 mg/kg/dose repeated IV boluses 0.25-2.0 mg/kg/hour IV infusion  Hydralazine 0.2-0.4 mg/kg/dose IV bolus. May be repeated twice if no response.
  • 38. SECONDARY HYPERTENSION  Treatment should be aimed at removing the cause of hypertension whenever possible.  Curable forms of Hypertension Renal Unilateral kidney disease (Nephritis, Pyelonephritis, hydronephrosis) Cardiovascular CoA, Renal artery stenosis, thrombosis. Adrenal Pheochromocytoma, Neuroblastoma, hyperaldosteronism Miscellaneous Drugs/ OCP etc.
  • 39.  Management Algorithm of Systemic Hypertension