The document discusses the differential diagnosis and treatment of elevated systemic arterial blood pressure, which accounts for 10-20% of hypertensive patients. It covers various etiologies, including renal, endocrine, cardiovascular, neurologic, and drug-induced causes, as well as clinical manifestations, complications, and diagnostic measures. Treatment strategies are outlined based on patient age and may involve a combination of medications, including ACE inhibitors, calcium channel blockers, and diuretics.

1. Differential diagnosis and treatment
Ilkin Bakirli

2. Definition
• Elevated systemic arterial blood pressure due to a known and potentially treatable
cause
• Accounting for 10-20% of hypertensive patients

3. Differential diagnosis / etiologies
Cause
Renal Chronic glomerulonephritis, chronic tubulointerstitial nephritis, PKD, obstructive
uropathy, diabetic nephropathy, renovascular stenosis, tumour
Endocrine Primary hyperaldosteronism, Cushing syndrome, pheochromocytoma,
hyperthyroidism, hyperparathyroidism, congenital adrenal hyperplasia
Cardiovascular Coarctation of the aorta, vasculitis
Neurologic Raised ICP, brainstem lesions
Drug-induced NSAIDs, sympathomimetics, oral contraceptives, alcohol, glucocorticoids, vasopressin
Pregnancy Pre-eclampsia
Miscellaneous Sleep apnea

4. Pathophysiology
• Increased peripheral vascular resistance (increased afterload)
•  LVH
•  Decreased LV function
•  Chamber dilation
•  Heart failure

6. Clinical manifestations
Symptoms
• Asymptomatic for years
• Dizziness and headaches
• Impaired vision
• Dyspnoea (during physical activity)
Signs
• Elevated blood pressure, LVH, loud 2nd heart sound, sinus tachycardia in HF

7. End organ damage / complications
Organ/ organ system Complications
Vascular Atherosclerosis, aneurysms, aortic dissection
Cardiac Heart failure, myocardial infarction, pulmonary edema, ascites
CNS Stroke,TIA haemorrhage, seizure, vascular dementia
Kidneys Chronic renal failure
Eyes Papilledema, haemorrhages, hypertensive retinopathy
Malignant hypertension Very high blood pressure of >200/120mmHg

8. Diagnosis
• Blood pressure: >140/90mmHg in 3 consecutive measurements
• Suspicion: Resistant hypertension, very high pressure >180/120mmHg,
sudden/early onset, no family history of hypertension
• History (medication history), physical examination
• ECG: LVH (deep QRS complexes),
• Echo: determine LV muscle mass, CXR: LVH
• Kidney function: urine stick test (protein and blood), renal USG, renal
arteriography, 24h urinary metanephrines
• Serum urea, creatinine, electrolytes, aldosterone, cortisol, renin,TSH, glucose,
LDL, HDL, cholesterol,

9. Treatment
• Treat the cause

10. Treatment
Scheme:
• Step 1: patient age <55:ACEI or ARBs
patient age >55: CCBs or diuretics
• Step 2: ACEI + CCB or ACEI + diuretics
• Step 3: ACEI + CCB + diuretics
• Step 4: further add beta or alpha blockers