Secondary Hypertension: The Daily PANCE Blueprint

The answer is E. Primary adrenal insufficiency (Addison disease)

Hypertension is a common problem affecting about 30% of the U.S. population. Most of the time, hypertension is benign/idiopathic, but about 5-10% of patients have secondary hypertension, which is hypertension with an actual underlying and (possibly) reversible cause. In adults, the most common causes include primary aldosteronism, obstructive sleep apnea, chronic kidney disease (renal parenchymal disease), and renal artery stenosis. You should suspect secondary hypertension in people with severe hypertension, hypertension refractory to medications, an age of onset younger than 30, or an acute rise in blood pressure. Other causes of secondary hypertension include Cushing syndrome, thyroid disease, coarctation of the aorta, medication/drug-induced (NSAIDS, amphetamines), and pheochromocytoma. Primary adrenal insufficiency does the opposite: loss of aldosterone and cortisol causes hypotension (with hyponatremia and hyperkalemia), not hypertension. Work-up for secondary hypertension may include urinalysis, renal ultrasound, transthoracic echocardiogram, TSH, aldosterone-to-renin ratio (screen everyone with resistant hypertension for primary aldosteronism, even if potassium is normal), and sleep study.