The Demystification of Secondary Hypertension: Diagnostic Strategies and Treatment Algorithms


Purpose of review

Hypertension is one of the most common conditions encountered in the primary care setting, affecting 32–46% of people. While essential or primary hypertension is the most common form of the disease, secondary hypertension is quite prevalent, occurring in 10–20% of patients with hypertension. Accurately diagnosing secondary hypertension is a challenging and often time-consuming process that requires considerable expertise and effort. However, once the secondary etiology is identified, the patient benefits profoundly from a potentially curative treatment that may lead to significant improvements in quality of life, morbidity, and mortality.

Recent findings

Common causes of secondary hypertension include medication-induced hypertension, renal parenchymal disease, renovascular hypertension, obstructive sleep apnea, and primary aldosteronism. Other rarer forms include mineralocorticoid-driven hypertension or its mimics, as well as hypercortisolism and pheochromocytoma. Although complex, standard protocols have emerged for investigation, diagnosis, and treatment of these conditions.


The current review aims to elucidate the many causes of secondary hypertension and describe their respective prevalence, clinical presentation, screening, diagnosis, treatment, and follow-up. By demystifying secondary hypertension, it is hoped that this disease will be more easily identified and treated so that the associated cardiovascular morbidity and end-organ damage may be mitigated.

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Fig. 1
Fig. 2


ACEi :

Angiotensin-converting enzyme inhibitor


Adrenocorticotropic hormone


Apparent mineralocorticoid excess


Angiotensin receptor blocker


Aldosterone-to-renin ratio


Adrenal vein sampling


Congenital adrenal hyperplasia


Calcium channel blocker


Chronic kidney disease


Continuous positive airway pressure


Overnight dexamethasone suppression testing

ENaC :

Epithelial sodium channels

FH :

Familial hyperaldosteronism


Fibromuscular dysplasia


Glucocorticoid-remediable hypertension


Monoamine oxidase


Mineralocorticoid receptor antagonist


Nonsteroidal anti-inflammatory drugs


Obstructive sleep apnea

PA :

Primary aldosteronism


Plasma aldosterone concentration


Plasma renin activity


Renin-angiotensin-aldosterone system


Peak systolic velocities


Renal-to-aortic ratio


Renal artery stenosis


Vascular endothelial growth factor

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Correspondence to Jamie S. Hirsch MD, MA, MSB.

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Hirsch, J.S., Hong, S. The Demystification of Secondary Hypertension: Diagnostic Strategies and Treatment Algorithms. Curr Treat Options Cardio Med 21, 90 (2019).

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  • Secondary hypertension
  • Endocrine hypertension
  • Drug-induced hypertension
  • Renovascular hypertension
  • Renal artery stenosis
  • Obstructive sleep apnea
  • Primary aldosteronism
  • Mineralocorticoid
  • Cushing’s syndrome
  • Pheochromocytoma