Diagnostic Imaging Pathways - Hypertension
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Population Covered By The Guidance
This pathway provides guidance on the investigation of adult patients with hypertension who need investigation for causes of secondary hypertension.
Date reviewed: July 2018
Date of next review: July 2021
Published: March 2019
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
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| 1a |  |
Bilateral Renal Artery Stenosis Image 1a, 1b and 1c (Digital Subtraction Angiography): Pre- and post-stent images of bilateral renal artery stenosis. |
| 1b |  |
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| 1c |  |
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| 2a |  |
Cushing's Disease Image 2a and 2b (Magnetic Resonance Imaging): There is a 13mm right sided pituitary adenoma (arrows) causing deviation of the stalk to the left. Slight suprasellar extension is noted without impingement of the chiasm or optic nerves. |
| 2b |  |
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| 3 |  |
Phaeochromocytoma Image 3 (Computed Tomography): Round low attenuation lesion at upper pole of left kidney consistent with phaeochromocytoma (arrow). |
| 4a |  |
Phaeochromocytoma Image 4a (I123-MIBG) and 4b (Computed Tomography): High grade focus of uptake identified at the left side of the upper abdomen posteriorly (arrow). CT demonstrates a cystic phaeochromocytoma (arrow). |
| 4b |  |
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| 5a |  |
Phaeochromocytoma Image 5a (I123-MIBG) and 5b (SPECT): Low grade focus of uptake identified at the left side of the upper abdomen posteriorly (arrow). SPECT imaging confirms the focus of uptake at the upper pole of the left kidney, in the region of the left adrenal gland (arrow). |
| 5b |  |
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| 6 |  |
Phaeochromocytoma Image 6 (H&E, x10): Histological section of a phaechromocytoma showing a nested architecture (zellballen pattern) separated by thin fibrous septae. The cells demonstrate finely granular amphophilic cytoplasm. |
Teaching Points
Teaching Points
- Secondary hypertension is uncommon and blanket screening for secondary hypertension is not routinely recommended
- If clinic blood pressure is ≥140/90mmHg, or hypertension is suspected, ambulatory and/or home monitoring should be offered to confirm the blood pressure level
- In cases of apparent resistant hypertension, it is important to specifically ask about medication compliance
- The initial assessment of patients with a new diagnosis of hypertension should include a thorough history and examination to elicit features that may suggest specific causes of secondary hypertension, as well as evidence of target organ damage. Basic screening tests include: urine dipstick, urinary albumin/creatinine ratio, fasting blood glucose, fasting lipid profile, serum urea, electrolytes, creatinine with eGFR, haemoglobin, fundoscopy and ECG (to assess for left ventricular hypertrophy)
- There are many causes of secondary hypertension and investigations should be targeted depending on the differential diagnosis
screening
Screening for Secondary Hypertension
- Only 5-10% of patients with hypertension have secondary hypertension 1
- Blanket screening for secondary hypertension is not routinely recommended 2
- If clinic blood pressure is ≥140/90mmHg, or hypertension is suspected, ambulatory and/or home monitoring should be offered to confirm the blood pressure level 3
- The initial assessment of patients with a new diagnosis of hypertension should include a thorough history and examination to elicit features that may suggest specific causes of secondary hypertension, as well as evidence of target organ damage. Basic screening tests include: urine dipstick, urinary albumin/creatinine ratio, fasting blood glucose, fasting lipid profile, serum urea, electrolytes, creatinine with eGFR, haemoglobin, fundoscopy and ECG (to assess for left ventricular hypertrophy) 3
- In cases of apparent resistant hypertension, it is important to specifically ask about medication compliance
- Screening for specific form(s) of secondary hypertension is recommended in certain circumstances:
- There are many causes of secondary hypertension and investigations should be targeted depending on the differential diagnosis
- Causes of secondary hypertension include: 4
- Renal parenchymal disease
- Renovascular disease, including renal artery stenosis due to fibromuscular dysplasia
- Primary hyperaldosteronism
- Obstructive sleep apnoea (although there is mixed evidence on the benefit of treatment)
- Drug or alcohol induced
- Rarer causes: 4
- Phaeochromocytoma
- Cushing’s syndrome
- Hypo/hyperthyroidism
- Aortic coarctation
- Primary hyperparathyroidism
- Congenital adrenal hyperplasia
- Other mineralocorticoid excess syndromes
- Acromegaly
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Characteristics Suggestive of Secondary Hypertension |
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Early onset <30 years 1,4,5 |
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Resistant hypertension 1,4,6 – (>140/90mmHg despite three antihypertensive agents including a diuretic) |
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Severe hypertension >180/110mmHg or hypertensive emergencies 1,4,5 |
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Exacerbation of previously controlled hypertension 1,4-6 |
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Clinical features specific to certain secondary causes 1,5,6 – including biochemical abnormalities (such as excessive hyperkalaemia 4), or renal dysfunction |
References
References
- Rimoldi SF, Scherrer U, Messerli FH. Secondary arterial hypertension: when, who, and how to screen? Eur Heart J. 2014;35(19):1245-54. (Review article).View the reference
- Ng FL, Lobo MD. Investigation and management of adult hypertension. Heart. 2018. (Review article).View the reference
- National Heart Foundation of Australia. Guideline for the diagnosis and management of hypertension in adults - 2016. Melbourne: National Heart Foundation of Australia; 2016. (Guideline). View the reference
- Whelton PK, Carey RM, Aronow WS, Casey DE, Jr., Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Hypertension. 2018;71(6):1269-324. (Guideline). View the reference
- Leung AA, Daskalopoulou SS, Dasgupta K, McBrien K, Butalia S, Zarnke KB, et al. Hypertension Canada's 2017 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults. Can J Cardiol. 2017;33(5):557-76. (Guideline). View the reference
- Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Bohm M, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2013;31(7):1281-357. (Guideline). View the reference
Information for Consumers
Information for Consumers
Information from this website |
Information from the Royal Australian and New Zealand College of Radiologists’ website |
|
Consent to Procedure or Treatment Radiation Risks of X-rays and Scans |
Radiation Risk of Medical Imaging During Pregnancy Radiation Risk of Medical Imaging for Adults and Children |
copyright
Copyright
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