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Marwah Abdalla, MD, MPH: Hello. I am Dr Marwah Abdalla. Welcome to the Medscape InDiscussion podcast series on secondary hypertension, an important and often underrecognized contributor to high blood pressure.
Recognizing when hypertension has an underlying cause can change how patients are evaluated and managed, and ultimately their overall risk. In this episode, we'll discuss when clinicians should suspect a secondary cause and how to approach evaluation in everyday practice.
First, let me introduce my guest, Dr Sandra Taler. Dr Taler is a professor of medicine at the Mayo Clinic, where she's a staff consultant in the Division of Nephrology and Hypertension and in the William von Liebig Center for Transplantation and Clinical Regeneration.
Welcome to the Medscape InDiscussion: Secondary Hypertension podcast.
Sandra J. Taler, MD: Thank you. Thanks for having me.
Abdalla: So, to start us off — in everyday practice, secondary hypertension is often something clinicians think about later, usually once blood pressure becomes difficult to control. In your opinion, at what point should clinicians pause and suspect that there may be a secondary cause of hypertension?
Taler: I think about secondary hypertension from the first time I meet the patient, probably because I am in a subspecialty area. But I think there are things that the clinician can do right away that will help open this possibility. During the history, the physical exam, and looking at the labs that I have available and what I might want to order, I'm thinking about whether there could be a secondary cause. But in particular, I'd say a young person, somebody who's under 30. We do see primary hypertension a lot, and it probably will be that, but it's worth thinking about another cause. Certainly in somebody with an onset in their teens who comes to you at 20 and says, "Well, I've had high blood pressure for a number of years," think about a secondary cause.
Then I think about people who have been controlled, but they're not controlled currently, and why? Could they have developed a secondary cause in addition to their primary hypertension that leads to this more severe high blood pressure?
Abdalla: Once clinicians start to suspect a secondary cause, as you mentioned, the history often provides some of the most important clues. What symptoms or clinical features should prompt clinicians to think more seriously about secondary hypertension?
Taler: I'll ask about snoring. Does a patient snore? If there's somebody with them and they sleep in the same room, are they aware of snoring and apnea? Does the patient stop breathing in their sleep? Sometimes they've already moved to a different room because of the snoring and the apnea. That's pretty telling. I'll ask about any history of hypokalemia, whether they've had low potassium measurements. It's interesting that primary aldosteronism is supposed to be sort of asymptomatic, but often these individuals feel fatigued. They may have muscle aching or cramping. They're often thirsty, and so they're just not well. Sometimes you'll pick that up.
Urinary frequency can be a symptom of chronic kidney disease, or poor ability to concentrate the urine — polyuria, so to speak. Or it could be somebody with prostatism and outlet obstruction that then has kind of overflow, urinary frequency. Hyperthyroidism, I think most people might pick up — weight loss, palpitations — but it's certainly worth thinking about. And then, of course, in the patient with headaches, palpitations, sweats, very labile blood pressure, you would think about pheochromocytoma, but that is so often screened for and so rare. I think it's worth doing a screening once, but not to keep going back to that.
Abdalla: As a follow-up, when you're questioning patients, we often forget about over-the-counter medications or herbal supplements that may contribute to high blood pressure. What's your approach? Do you rely mostly on patient history as you're coming through these symptoms, or do you ask them to bring in their meds? Or are you reviewing pharmacy fill histories to catch hidden exposures?
Taler: I don't usually use pharmacy fill. A lot of these are over-the-counter, so that wouldn't help you. But I ask about nonsteroidals directly. I always go through the meds, so the first thing I do with each patient is specifically go through their meds. I have to know what they're taking from the standpoint of blood pressure control. I also want to know about drugs that might be contributing to their blood pressure. Then I ask specifically about nonsteroidal anti-inflammatory agents by name. You don't just say ibuprofen; you've got to mention the brand names: Advil, Aleve. Remember meloxicam and other nonsteroidals that are prescribed directly. I would ask about those.
The other area would be patients who have drugs for ADHD (attention-deficit/hyperactivity disorder), amphetamine-type drugs. They might not bring those up first, or they might use them intermittently. And so that's another area.
The big thing now is chemotherapy. So, VEGF (vascular endothelial growth factor) inhibitors, the BTK (Bruton tyrosine kinase) inhibitors, are a number of chemotherapy agents that are expected to raise blood pressure, and so you want to make sure you know what the patient's going through and that you're not missing something that they might get by infusion.
There have even been cases of VEGF inhibitor injections into the eye, causing hypertension or worsening hypertension. So that's something you would also want to think about. There are supplements — yohimbine, ephedra — so you do want to ask about all of the things they're taking. Licorice root, black licorice, is one that patients don't think about — confectionery licorice. So it would be important to ask about those, too.
Abdalla: And beyond the history, obviously moving to the physical exam, it can offer important clues. What physical exam findings do you think should prompt clinicians to think about specific secondary causes of hypertension using the framework you outlined?
Taler: I always try to look in the patient's mouth, at their throat; if you can't see the uvula, you can't see the back of their throat. There's a Mallampati score that's used in anesthesia, but basically, the more crowded it is back there, the more likely that the patient has obstructive sleep apnea. And so I look in their throat, I think about oximetry and screening, and I ask if they have been told they had sleep apnea, because that's a big one.
Certainly, cushingoid facies — you know: a very full face, cervical fat pad, pigmented striae. A lot of people are obese but they don't have that cushingoid look. On the other hand, it can be more subtle, and it may not be very obvious, even in somebody with Cushing's disease. In a young person under 30, I check their thigh blood pressure. If the thigh blood pressure is [lower] than the brachial blood pressure, then that can suggest coarctation. It's a little awkward to do. You have to put your stethoscope at the popliteal fossa and use a bigger cuff on the thigh, but in a young person, they really should be screened for coarctation. Somebody with neurofibromas, or café au lait spots, may have an MEN (multiple endocrine neoplasia) syndrome. So if you see these spots, think about a pheochromocytoma, just screening for that. Feel the thyroid. Look for an enlarged thyroid, a goiter. Rarely will you feel the kidneys in somebody with polycystic kidney disease; their abdomen is just kind of firm all over. But I would say that's not so easy to do.
Abdalla: Obviously, with the growth of telehealth, clinicians are often limited in how much of the physical exam they can perform. In that setting, what physical findings, when present or reported, should still raise a concern for a secondary cause and prompt further evaluation?
Taler: Honestly, I find telehealth very frustrating for the very reason that you really can't do a thorough exam. What I didn't mention in the physical exam in your last question is an abdominal bruit. I listen over the carotid arteries, the femoral arteries, and the abdomen for bruit, and often that's the clue.
And if you don't have that clue, you're less likely to say, "I’ve got to look for renovascular disease." Although I would say you probably do need to at some point. I think that's a big deal. On a video, I think the best you're going to do is cushingoid facies. It's very hard to do any other physical exam there; the history you could ask, but yeah — I really think you're stuck. So I would strongly encourage at least that initial assessment to be in person.
Abdalla: I'd offer another perspective for telehealth. I agree with you that it's hard to do these physical exam findings, but maybe this is the area where you can figure out, in the home environment, their over-the-counter medications or herbal supplements. I find that in my practice, if I'm talking to someone, just looking at them and asking, "What are you drinking in the cup?" [can be helpful], potentially asking them to show on the video what [supplements] they are using; that might be another way to augment. I agree with you: The physical exam might be very tough in telehealth, but it may also provide another opportunity to take some time to figure this out.
Taler: It's difficult, though, and they might not have their supplements with them, so you might get more information if they show you the bottle or read it to you. I just think that telehealth is not a great option in this setting, the initial assessment of somebody for secondary causes.
Abdalla: I agree with you. In-person is great. So, once clinicians start to suspect a secondary cause, the next challenge is deciding how to evaluate patients efficiently without overtesting or delaying care. What does a practical, real-world diagnostic strategy look like for a busy clinician who may have only 15-20 minutes?
Taler: That 15-20 minutes is very much a challenge. All of these patients, being evaluated for hypertension, even primary hypertension, deserve certain tests to be done at the start, and probably annually. That would be a complete blood count, electrolytes (including BUN and creatinine), and estimated GFR (eGFR).
Urinalysis, thyroid function, and sensitive TSH should certainly be checked. And then, I would suggest thinking about doing a plasma aldosterone and renin at that initial assessment, especially if they're not controlled, because we are underdetecting primary aldosteronism. And if that screen is abnormal, then that could really redirect where you go. I usually will do a chest x-ray and an ECG to look at cardiac size, left ventricular hypertrophy, or evidence for heart disease. Those are my initial screenings. Also, with the urine, I would check a spot urine for microalbumin or an albumin-to-creatinine ratio. That's a very strong predictor of cardiovascular risk as well as kidney disease, early kidney disease, and it would guide therapy. Those are the basics, I would say.
Abdalla: Naturally, this leads to the question of management. Most clinicians appropriately refer patients when secondary hypertension is suspected, based on their thinking. But in many settings, particularly in rural areas or where specialist wait times are long, that care may not be immediately available. How should clinicians think about managing suspected secondary hypertension? As you know, it's a shared care problem when specialist input is delayed.
Taler: One thing would be that they could go a little bit further on the evaluation, possibly. So think about a renal ultrasound, but with Doppler. Frequently, patients are sent for a renal ultrasound with no look at the renal arteries, and that could really help guide you if you can send them to a center that does renal ultrasound well. It's really risk-free and can be very helpful to the referred provider — the person they're going to see for a more detailed evaluation. I think thyroid disease could be diagnosed and treated if they're hypothyroid. If they're hyperthyroid and overtreatment is not the cause (ie, iatrogenic), then that will require thyroid expertise.
You could start a mineralocorticoid receptor antagonist, like spironolactone, as a trial if things are looking like primary aldosteronism, but realizing that it would need to be stopped for 4-6 weeks before definitive testing. It's a little more difficult to do that if you're trying to get the patient in to see a specialist.
I think the best they could do is add additional drugs, try to control the electrolytes and the blood pressure, and then get that person to a specialist.
Abdalla: I want to think about this also with your expertise in mind. You know, chronic kidney disease is so prevalent. Thinking specifically about patients with chronic kidney disease, what management decisions do you find most important or potentially harmful when clinicians are waiting for nephrology input in the outpatient setting?
Taler: Well, the first issue to raise is that, to me, chronic kidney disease is a secondary form of hypertension. It's the most common; a lot of people don't think of it as a secondary cause because it's not curable, but it's still a contributing cause.
As kidney function declines, these patients tend to have trouble handling salt and getting rid of salt and water. One of the things that happens is that a patient has started on an ACE (angiotensin-converting enzyme) inhibitor or an angiotensin receptor blocker, their creatinine goes up — and I think most clinicians know that it may go up as much as 30% — and the best thing to do is to kind of hold the line, check it again, and see if it equilibrates or goes back down a little bit before you take away the drug. But the other big thing is adding a diuretic, which will also raise creatinine. And many times the clinician will stop the diuretic or stop the ACE inhibitor because they don't like the creatinine to be higher, and then the patient is uncontrolled.
I think that does more harm to the patient than maybe lowering the dose or holding and restarting, or trying to work with the drug so that you can control the blood pressure, even using drugs that the patient really does need. Is that kind of what you were thinking with that?
Abdalla: I'd love to get your perspective as this comes up all the time about the creatinine issue and bumping, but really preparing patients for that, too. So when you are seeing this in a patient, what advice would you give clinicians? A lot of the time, the withdrawal of the medication is because the patient is seeing their labs, they're seeing their creatinine bumping, and they're having this uncomfortable feeling like they're moving fast toward dialysis when in reality they're not. Do you have any tips for better preparing our patients for this?
Taler: Well, with every SGLT2 inhibitor that's added for chronic kidney disease, we know that the creatinine's going to first go up and then level off. And so I actually pull up one of the studies, show them the picture, and say, "You're going to see this; your kidney function is going to look worse before it settles out. And in the long run, it's going to be better for you," so that they're prepared right off the bat. I've talked to other nephrologists, and they do that too. And the same goes for creatinine: It's important to warn them that their creatinine may go up.
We're going to watch it, check it, and adjust things. But it's important to get the blood pressure down or their creatinine will go up later and not be fixable. So having that conversation is really important, because patients focus a lot on their eGFR and they do get worried about it for sure.
Abdalla: Pushing a little bit more on this, because it's such an important topic: When people are referring patients to you, what are the pre-referral steps that would make the biggest difference in how quickly you are able, as a nephrologist, to move the patient's care forward?
Taler: One would be to not have them on a mineralocorticoid receptor antagonist. Even after I mentioned starting them, I worry a little bit because then I'll need to stop it to really do a good evaluation. I'd look at the over-the-counter issue; if they can take away some of the over-the-counter medications or supplements, that would be good.
I spend a lot of time on lifestyle and diet, so I think some of that education could be done before they get to me. Home blood pressure measurements are really helpful, so you need to think about white coat hypertension and masked hypertension. It's very helpful if the patient has a machine, if they check their blood pressure. Bring those in to show me what the blood pressure has been doing at home, not just in the office. And blood pressure technique is really important.
Abdalla: Great. So switching to the inpatient setting and what I think of as opportunistic screening, or diagnosis: In many patients with hypertension or who are hospitalized for reasons unrelated to high blood pressure, do you think there are opportunities during those inpatient settings and hospitalizations — you know, labs, imaging, medication review — to recognize clues to secondary hypertension that may not have been apparent in the outpatient setting?
Taler: I disagree a little bit. I don't think the hospital setting is ideal for the evaluation. I think there are things like nocturnal hypertension — you know, blood pressure spikes. Sleep apnea could easily be detected; they're even having their oxygen monitored, and they desaturate at night. That might be something that you wouldn't otherwise know. There's a lot of imaging that goes on. So I think there may be some incidental imaging of the kidneys, the renal arteries, and adrenal masses that come up. But ultimately, the definitive workup would be as an outpatient for most of those people.
I think you can miss things. One of the classics is severe blood pressure lability and spikes in blood pressure with the induction of anesthesia as a sign of pheochromocytoma. And so then they stop the surgery, they don't do it, and that should immediately trigger, Could this person have a pheochromocytoma? It's not a common problem, but a common presentation of an uncommon problem would be severe blood pressure with anesthesia induction. Flash pulmonary edema is another one: somebody who goes into pulmonary edema suddenly and comes out of it suddenly, and their hearts are otherwise doing okay. It could be bilateral renal artery disease. So that's something that, if you're thinking about it in the hospital, you may pick it up.
Abdalla: Those are all fantastic tips. I could bring my perspective as a cardiologist. We do a lot of ECGs, and obviously now there's a lot of AI ECG-based frameworks. I often see if someone's coming in through the ED, coming in for something unrelated, and the ECG gets checked or they get hospitalized, and an echo (echocardiogram) gets done, and we miss the fact that they have LVH (left ventricular hypertrophy) already. So, there are signs of target organ damage in the absence of really putting the whole picture together. I feel like there might be subtle clues that come out, and I totally agree with you that the definitive diagnosis really should be done in the outpatient setting.
But, we should be thinking through some of these things early on, or at least putting it in the discharge summary for the patient's provider at the other end to say, "Hmm, maybe I should be thinking about this" as the patient recovers and transitions to the outpatient world.
Taler: Hopefully they read that and get that information. It would probably be good to tell the patient, too, that there are some things that need more evaluation. And it's interesting because you're looking at it from the cardiology standpoint with echo, which is something we don't always get. I think that LVH will be picked up more on the echo. Obviously, when it's on an ECG, it's quite advanced. And so the echo findings may be telling.
Abdalla: Fantastic. Dr Taler, it's been a privilege and a pleasure. Thank you so much for joining us. Before we close, are there any additional points regarding secondary hypertension you'd want to emphasize for clinicians?
Taler: It's important to think about it. That sounds simple, but it's a detective game kind of thing. You know — look for clues in the history, the exam, the labs, and the behavior of the blood pressure with medications. I would say if there are things that aren't right or the blood pressure's not coming under control, it's good to refer.
Abdalla: Great. I'm going to summarize and reemphasize the exact points you made that really stood out to me from our discussion. Secondary hypertension is very easy to overlook, particularly early in its course. I absolutely agree to pause and think of secondary causes of hypertension when blood pressure becomes difficult to control or starts at a young age.
I think it's really important what you said about age, particularly less than 30, or when the degree of target organ damage doesn't quite fit the overall clinical picture. Asking the right questions about medications, substances, and sleep can point us in the right direction.
And importantly, while waiting for specialty input, I think the point is that the blood pressure still needs to be managed. And we should think about this as a collaborative approach to care. Making thoughtful medication choices and doing a bit of the pre-referral groundwork can make a big difference once patients reach specialty care.
Thank you again, Dr Taler. It's been a pleasure. And thank you for tuning in. Please take a moment to download the Medscape app to listen to and subscribe to this podcast series on secondary hypertension. This is Dr Marwah Abdalla for the Medscape InDiscussion podcast.
Resources
Approach to the Diagnosis of Secondary Hypertension in Adults
Herbal Products That May Contribute to Hypertension
The Effects of Nonsteroidal Anti-Inflammatory Drugs on Blood Pressure in Hypertensive Patients
Attention Deficit Hyperactivity Disorder (ADHD)
Attention-Deficit/Hyperactivity Disorder Medications and Long-Term Risk of Cardiovascular Diseases
Multiple Endocrine Neoplasia Type 2 (MEN2)
Evaluation and Management of Secondary Hypertension
Guidelines for the Management of Hypertension in CKD Patients: Where Do We Stand in 2024?
Flash Pulmonary Edema: Pickering Syndrome Due to Bilateral Renal Artery Stenosis
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Cite this: The Missed Diagnosis: Rethinking Secondary Hypertension in 2026 - Medscape - Jan 29, 2026.
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