A 45 y/o female patient presents for her annual check-up and refills on her oral contraceptives (OCPs). Her labs (drawn pre-appt) are WNL. Her physical exam and vitals are fine except for a BP of 145/94. Her weight is a little high based on her height. She does not smoke. She is a social drinker, consuming 1-2 drinks at a happy hour after work on Friday. She has no other health problems and no other significant past medical history.

What is causing her hypertension? How would you treat it?

SELECT  here for discussion

Since we cannot generally diagnose hypertension on a single blood pressure (BP) measurement, probably the first step would be to do a 3 or 5 days BP measurement. This should rule out "white coat" hypertension.

Assuming the 3 or 5-day BP check reveals hypertension, we need to look for a cause. Approximately, 90+% of all cases of hypertension are primary or essential hypertension (i.e. a definitive cause cannot be identified). One should look for secondary causes of hypertension such as pheochromocytoma, Cushing's syndrome (hyperadrenalism), hyperthyroidism, hypothyroidism, hyperparathyroidism, primary hyperaldosteronism, coarctation of the aorta, and drugs/toxins. In this case, assuming all other causes are excluded, drugs would be high on the differential list. In our patient, the most likely cause based on the information provided would be her OCPs.

The other most common drug causes include:

    -    Estrogens - esp with higher doses - hormone replacement therapies, high dose OCPs, and high-dose estrogens used to treat certain kinds of cancer

    -    Erythropoietin - from increased HCT and RBC mass (sludging of the blood)

    -    Licorice (or licorice-containing chewing tobacco) - this is the old-fashioned licorice made from natural ingredients containing
glycrrhiza (with aldosterone-like activity) NOT the synthetic candy stuff

    -    Cyclosporine - Probable mechanisms for cyclosporine-induced hypertension involve increased prostaglandin synthesis, decreased free water excretion, and decreased sodium and potassium excretion

    -    Drug of abuse - specifically, cocaine, amphetamines - increased heart rate, increased peripheral resistance

    -    OTC oral decongestants - sympathomimetics such as phenylephrine, phenylpropanolamine, pseudoephedrine - same mechanisms as above

    -    Corticosteroids - probably from salt and water retention

    -    Ethanol - reported with acute and chronic ingestion - probably from a pressor effect but ethanol can also cause minor increases in heart rate and cardiac output

    -    Non-steroidal anti-inflammatory drugs (NSAIDs) - including COX2 inhibitors - impairs renal handling of water and sodium

    -    Monoamine oxidase inhibitors (MAOIs) - esp with aged (tyramine containing) foods

    -    Caffeine - large doses

    -    b blockers - 'rebound' hypertension esp with abrupt withdrawal

    -    Centrally acting a agonists - 'rebound' hypertension esp with abrupt withdrawal

There are other agents that have been reported anecdotally to cause hypertension but the ones listed above are probably the most common.

So how to treat this patient? Consider switching to a lower dose estrogen OCP, consider a different mechanism of contraception (condoms, diaphragm, etc), treat with an anti-hypertensive agent, probably low dose diuretic (chlorthalidone or thiazide). Advise on life style/non-medication options such as weight loss, exercise, lowered salt intake, lowered caffeine intake (if present), stop smoking (if present).