Hypertension (Resistant)

#Concern for secondary hypertension
This patient has indication for a secondary hypertension work-up (age < 30 in a non-obese, non-black patient with no family Hx; resistant hypertension defined as persistent HTN on >= 3 hypertensives at adequate doses or 4 at 50% doses, at least one of which is a diuretic; malignant hypertension w/ end-organ damage; or proven age of onset before puberty). Most common etiologies are OSA (60-70%), hyperaldo (7-20%), RAS (2-24%), meds/illicits (2-24%), CKD (1-2%), endocrine (1%).
- TSH, UTox, Scr for CKD
- medication review for OCPs, NSAIDs, SNRIs, stimulants, VEGFi/TKIs
- 24 hr ambulatory BP monitor for baseline
- sleep study (if obese, snoring, daytime somnolence, headaches, fatigue)
- renin/aldosterone (consider oral sodium suppression test if negative)
- 24 hr urine free cortisol (only if facies, obesity, bruising, muscle weakness, or adrenal incidentaloma)
- renal artery dopplers (only if patient might be a surgical candidate: flash pulmonary edema, refractory heart failure with unexplained impaired kidney function, short duration of BP elevation, intolerance to optimal medical therapy) and something to suggest RAS (> 50% Cr bump after RAAS inhibition, unexplained kidney asymmetry, abdominal bruit)
- consider 24 hr urine catecholeamines and metanephrins (prefer over plasma fractionated metanephrines given high false positive rate if not measured supine via indwelling cannula after 30 minutes of supine rest)
- consider referral to cardiology/renal