History

Fact Explanation
History of sudden, new onset severe high blood pressure History of sudden onset, severe hypertension in a patient previously known to have had normal blood pressure point towards the possibility of a secondary hypertension.[1,2,3,4]
Age of the patient at the onset Detection of hypertension at a younger age (< 25 years) or older (> 55 years) age suggests secondary hypertension due to an underlying cause, as essential hypertension is now more commonly diagnosed in the third decade. .[1,2,3,4]
Palpitations Palpitations can occur due to catecholamine excess.[1,2]
Sweating Excessive sweating may be found in patients with thyrotoxicosis and some patients may complain spontaneous sweating due to catecholamine excess.[1,2]
Headache Patients may present with a severe headache like in migraine in paroxysms as a result of excessive catecholamine levels or severe hypertension itself can cause headache with dizziness.[1,3]
Muscle weakness When there is excessive aldosterone levels it will in turn cause reduction in potassium concentration causing muscle weakness.[1,4]
Polyuria Decreased potassium levels in blood as a result of increased aldosterone levels will give rise to polyuria.[1,2,3]
Thinning of skin Excess cortisol levels in blood like in Cushing's syndrome which is a well known cause of secondary hypertension, will cause thinning of the skin.[1]
Snoring and daytime somnolence Sleep apnea is another cause of secondary hypertension and patients can present with snoring and daytime somnolence.[1,2,3]
Heat intolerance Patients with hyperthyroidism may complain of heat intolerance.[1]
Weight loss or weight gain Patients with hyperthyroidism and Cushing's syndrome may develop weight loss and weight gain respectively.[1,2,3]
History of contributing factors Patient may have a history of contributing factors for the development of high blood pressure, such as excessive salt intake, physical inactivity and psychosocial stress.[1]
Drug history Use of some medications can cause elevation of blood pressure. These causative drugs include non-aspirin nonsteroidal anti-inflammatory drugs, oral contraceptives, corticosteroids, licorice.[1]
Personal or family history of renal disease Favours secondary hypertension due to renal disease,[1,2,3]
Chest pain Due to ventricular hypertrophy or possible coronary artery disease as a result of hypertension causing ischemia of the myocardium.[1]
Neurologic symptoms such as body weakness, paralysis, numbness and transient visual loss These are symptoms suggestive of stroke or transient ischemic attack, due to severe hypertension.[1]
Dyspnea and easy fatigue Can occur in patients who has developed heart failure as a complication of hypertension.[1]
References
  1. KATAKAM R., BRUKAMP K., TOWNSEND R. R.. What is the proper workup of a patient with hypertension?. Cleveland Clinic Journal of Medicine [online] 2008 September, 75(9):663-672 [viewed 06 July 2014] Available from: doi:10.3949/ccjm.75.9.663
  2. VIERA AJ, NEUTZE DM. Diagnosis of secondary hypertension: an age-based approach. Am Fam Physician [online] 2010 Dec 15, 82(12):1471-8 [viewed 06 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21166367
  3. ONUSKO E. Diagnosing secondary hypertension. Am Fam Physician [online] 2003 Jan 1, 67(1):67-74 [viewed 06 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12537168
  4. CHOBANIAN A. V., BAKRIS G. L., BLACK H. R., CUSHMAN W. C., GREEN L. A., IZZO J. L., JONES D. W., MATERSON B. J., OPARIL S., WRIGHT J. T., ROCCELLA E. J.. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension [online] December, 42(6):1206-1252 [viewed 06 July 2014] Available from: doi:10.1161/​01.HYP.0000107251.49515.c2

Examination

Fact Explanation
Hypertension Blood pressure should be measured using proper technique ( correct cuff size, support the arm at the heart level, patient should be quiet for 5 minutes before taking the measurement). Multiple readings, at least 3 should be taken at different occasions, in both arms and legs and with the patient supine, sitting and standing.[1,2,3,4]
Measurement of height, weight, waist circumference Increased body mass index with central obesity favors towards Cushing's syndrome.[1,2,4]
General appearance, skin lesions (striae), distribution of body fat In thyrotoxicosis, patient may look thin build with a staring eyes. In Cushing's syndrome, patient will look obese with a moon face, central abdominal obesity, may have a buffalo hump and striae.[1,2,4]
Fundoscopic examination Retinal changes shows the vascular impact, severity of hypertension. These changes include, arteriolar narrowing (grade 1), arteriovenous compression (grade 2), hemorrhages or exudates (grade 3), and papilledema.[1,2,3,4]
Enlarged thyroid gland Diffuse goiter suggests Graves disease causing thyrotoxicosis.[1,3]
Precordial examination - cardiomegaly, murmurs, additional heart sounds Displaced cardiac apex and sustained apical impulse indicate left ventricular enlargement and hypertrophy respectively. Fourth heart sound (S4) is one of the earliest findings of hypertension, indicating that the left atrium is working hard to overcome the stiffness of the left ventricle. S3 indicates an impairment in left ventricular function. In coarctation of aorta, interscapular murmur can be heard.[1,3,4]
Pulse examination Absent, weak or delayed femoral pulses are a sign of aortic coarctation.[1,2]
Bruits Bruits in the neck may indicate carotid artery stenosis, bruits in the abdomen(epigastric region) may indicate renal artery stenosis and femoral bruits are a sign of general atherosclerosis.[1]
Abdominal examination - enlarged kidneys Palpable enlarged kidneys can be found in polycystic kidney disease.[1,2,3]
Neurologic examination including level of consciousness Decreased level of consciousness may be found in hypertensive encephalopathy. Signs such as reduced grip, hyperreflexia, spasticity, positive Babinski sign, muscle atrophy, gait disturbances act as evidence of previous stroke due to severe hypertension.[1,2,4]
References
  1. KATAKAM R., BRUKAMP K., TOWNSEND R. R.. What is the proper workup of a patient with hypertension?. Cleveland Clinic Journal of Medicine [online] 2008 September, 75(9):663-672 [viewed 06 July 2014] Available from: doi:10.3949/ccjm.75.9.663
  2. VIERA AJ, NEUTZE DM. Diagnosis of secondary hypertension: an age-based approach. Am Fam Physician [online] 2010 Dec 15, 82(12):1471-8 [viewed 06 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21166367
  3. ONUSKO E. Diagnosing secondary hypertension. Am Fam Physician [online] 2003 Jan 1, 67(1):67-74 [viewed 06 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12537168
  4. CHOBANIAN A. V., BAKRIS G. L., BLACK H. R., CUSHMAN W. C., GREEN L. A., IZZO J. L., JONES D. W., MATERSON B. J., OPARIL S., WRIGHT J. T., ROCCELLA E. J.. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension [online] December, 42(6):1206-1252 [viewed 06 July 2014] Available from: doi:10.1161/​01.HYP.0000107251.49515.c2

Differential Diagnoses

Fact Explanation
Hypertension due to renal paranchymal disease Consider in patients with a history of unitary tract infection/obstruction, hematuria, excessive use of analgesics, family history of polycystic kidney disease.[1,4]
Hypertension due to renal vascular disease - renal artery stenosis Suspect in young women (renal artery stenosis due to fibromuscular dysplasia) and in elderly (atherosclerotic stenosis) with an abdominal bruit on examination.[1,2,3]
Coartation of aorta Patient will have low blood pressure reading in legs compared to arms. Femoral pulse may be absent, weak or delayed.[1,3,4]
Aldosteronism Consider in patients with muscle weakness. Hypokalemia also signals aldosterone excess.[1,4]
Pheochromocytoma Patients will present with paroxysmal hypertension, headache, sweating and palpitations.[1,2,3]
Thyroid dysfunction - hyperthyroidism, hypothyroidism Symptoms such as weight changes, constipation/diarrhea, heat/cold intolerance and finding of a thyroid lump on examination point towards thyroid disorder.[1,2,3,4]
Cushing syndrome Polyuria, polydipsia, skin changes and rapid weight gain with central obesity suggests Cushing syndrome.[2,4]
Obstructive sleep apnea Suspect in patients with a history of snoring and daytime somnolence.[1,2,3]
Essential hypertension Since essential hypertension is the commonest cause of hypertension, it is important to keep this in mind as a differential diagnosis.[1,2,4]
White coat hypertension Blood pressure can be influenced by an environment such as an office or hospital clinic and as a result of that, blood pressure may be elevated persistently only in the presence of a physician. When measured elsewhere, including at work, the blood pressure is not elevated in those with the white-coat effect. Need ambulatory blood pressure monitoring to exclude this phenomena.[1,3,4]
Pseudohypertension There are some patients with blood vessels that are stiff and difficult to compress. If the pressure required to compress the brachial artery and stop audible blood flow with a standard blood pressure cuff is greater than the actual blood pressure within the artery as measured invasively, the condition is called pseudohypertension. The stiffness is thought to be due to calcification of the arterial wall. A procedure known as Osler’s maneuver can be used to check this condition. Detection of this condition is important because the patients in whom it occurs (elderly or the chronically ill with diabetes or chronic kidney disease), are prone to orthostatic or postural hypotension, which may be aggravated by increasing their antihypertensive treatment on the basis of a cuff pressure that is actually much higher than the real blood pressure.[1,4]
References
  1. KATAKAM R., BRUKAMP K., TOWNSEND R. R.. What is the proper workup of a patient with hypertension?. Cleveland Clinic Journal of Medicine [online] 2008 September, 75(9):663-672 [viewed 06 July 2014] Available from: doi:10.3949/ccjm.75.9.663
  2. VIERA AJ, NEUTZE DM. Diagnosis of secondary hypertension: an age-based approach. Am Fam Physician [online] 2010 Dec 15, 82(12):1471-8 [viewed 06 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21166367
  3. ONUSKO E. Diagnosing secondary hypertension. Am Fam Physician [online] 2003 Jan 1, 67(1):67-74 [viewed 06 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12537168
  4. MANCIA GIUSEPPE, FAGARD ROBERT, NARKIEWICZ KRZYSZTOF, REDóN JOSEP, ZANCHETTI ALBERTO, BöHM MICHAEL, CHRISTIAENS THIERRY, CIFKOVA RENATA, DE BACKER GUY, DOMINICZAK ANNA, GALDERISI MAURIZIO, GROBBEE DIEDERICK E., JAARSMA TINY, KIRCHHOF PAULUS, KJELDSEN SVERRE E., LAURENT STéPHANE, MANOLIS ATHANASIOS J., NILSSON PETER M., RUILOPE LUIS MIGUEL, SCHMIEDER ROLAND E., SIRNES PER ANTON, SLEIGHT PETER, VIIGIMAA MARGUS, WAEBER BERNARD, ZANNAD FAIEZ. 2013 ESH/ESC Guidelines for the management of arterial hypertension. Journal of Hypertension [online] 2013 July, 31(7):1281-1357 [viewed 06 July 2014] Available from: doi:10.1097/01.hjh.0000431740.32696.cc

Investigations - for Diagnosis

Fact Explanation
Serum potassium, Serum calcium and phosphorus levels Hypokalemia may indicate aldosterone excess. In hyperparathyroidism calcium and phosphorus levels are increased and decreased, respectively.[1,2]
Urinalysis, Urinary albumin excretion, 24-hour urine protein To detect excess protein, glucose, cells in urine, if there is suspicious of underlying renal parenchymal disease as cause of hypertension.[1,2]
Serum creatinine, Glomerular filtration rate Increased serum creatinine and decreased glomerular filtration rate point towards impaired renal function.[1,2]
Serum parathyroid hormone level Increased serum parathyroid hormone level can be found in patients with hyperparathyroidism.[1,2]
Thyroid function tests - Thyroid stimulating hormone (TSH), T4, T3 Should be carried out if the history and the examination suggests thyroid dysfunction. TSH level is increased and T4, T3 levels are suppressed in hyperthyroidism.[1,2]
Serum calcitonin level Consider in patients suspicious of multiple endocrine neoplasia.[1,2]
Dexamethasone suppression test, 24-hour urinary free cortisol These are diagnostic tests of Cushing syndrome. Failure to suppress cortisol in Dexamethasone suppression test and increased 24-hour urinary free cortisol level aid the diagnosis.[1,2]
Plasma renin levels, serum aldosterone concentrations, Plasma aldosterone/renin ratio, Aldosterone excretion rate during salt loading In a patient suspecting aldosteronism, these tests should be done. The aldosterone/renin ratio is the initial investigation of choice and it will be elevated in the presence of excess of aldosterone. Plasma renin levels and serum aldosterone concentrations are useful as a screening test to identify aldosterone excess. Aldosterone excretion rate during salt loading also increased.[1,2]
Plasma catecholamines or metanephrines, Urine catecholamines or metanephrines, Clonidine suppression test Should be done to diagnose pheochromocytoma, if the history and clinical examination highly suggestive. Both plasma and urine catecholamines/metanephrines are increased. Failure to suppress plasma norepinephrine after clonidine administration (Clonidine suppression test) also aid in diagnosing pheochromocytoma.[1,2]
Chest X-ray, Two-dimensional echocardiography, Aortography Should be carried out to diagnose coarctation of the aorta. Chest X-ray will show notching of the ribs (reverse "3" sign due to tortuous intercostal arteries. Two-dimensional echocardiography and aortography will show coarctation of aorta directly.[1,2]
Computed tomography (CT), Magnetic resonance imaging (MRI) If the patient's presentation and other basic investigations suggest primary aldosteronism adrenal CT should be done to detect adenoma with low Hounsfield units. T2-weighted MRI has characteristic appearance when there is an adrenal tumor.[1,2]
Captopril renography, Renal duplex sonography, Magnetic resonance angiography, CT angiography, Angiography These investigations are needed to diagnose renal vascular disease (renal artery stenosis). Renal duplex sonography, requires good operators, higher velocity in the renal artery than in the aorta velocities suggests stenosis. Magnetic resonance angiography, CT angiography and angiography may also demonstrate renal vessel narrowing.[1,2]
Renal ultrasonography To assess the kidney size and architecture. In patients having renal parenchymal disease may show kidneys, small in size with unusual architecture.[1,2]
Renal biopsy Should be done in patients with renal paranchymal disease as the cause of hypertension to determine the type of underlying glomerular disease.[1,2]
Sleep study with O2 saturation Should be done if suspecting obstructive sleep apnea as the cause of hypertension.[1,2]
Ambulatory blood pressure monitoring To exclude white-coat hypertension ambulatory blood pressure monitoring can be carried out.[1,2]
References
  1. KATAKAM R., BRUKAMP K., TOWNSEND R. R.. What is the proper workup of a patient with hypertension?. Cleveland Clinic Journal of Medicine [online] 2008 September, 75(9):663-672 [viewed 06 July 2014] Available from: doi:10.3949/ccjm.75.9.663
  2. CHOBANIAN A. V., BAKRIS G. L., BLACK H. R., CUSHMAN W. C., GREEN L. A., IZZO J. L., JONES D. W., MATERSON B. J., OPARIL S., WRIGHT J. T., ROCCELLA E. J.. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension [online] December, 42(6):1206-1252 [viewed 06 July 2014] Available from: doi:10.1161/​01.HYP.0000107251.49515.c2

Investigations - Fitness for Management

Fact Explanation
Hemoglobin To detect anemia.[1]
Casual Venous Plasma Glucose level To identify diabetes.[1]
Lipid profile High triglycerides or cholesterol, low high-density lipoprotein cholesterol suggest associated dyslipidemia which should be treated.[1]
Serum uric acid Only in patients with a history of gout, since some antihypertensive drugs (eg, diuretics) may increase serum uric acid and predispose to further episodes of gout.[1]
References
  1. KATAKAM R., BRUKAMP K., TOWNSEND R. R.. What is the proper workup of a patient with hypertension?. Cleveland Clinic Journal of Medicine [online] 2008 September, 75(9):663-672 [viewed 06 July 2014] Available from: doi:10.3949/ccjm.75.9.663

Investigations - Followup

Fact Explanation
Plasma renin level and serum aldosterone concentrations Useful follow-up tests in patients with either hypokalemia or failure to achieve blood pressure control on a three-drug regimen in which at least one drug is a diuretic.[1,2]
Serum potassium Should be monitored at least 1 to 2 times/year to detect any abnormality.[1,2]
Serum creatinine Should be measured at least 1 to 2 times/year to assess the renal function[1,2].
Echocardiogram Should be done to assess the target organ damage.[1,2]
Fasting blood sugar Should be done in diabetic patients to have a proper glyceamic control.[1,2]
References
  1. KATAKAM R., BRUKAMP K., TOWNSEND R. R.. What is the proper workup of a patient with hypertension?. Cleveland Clinic Journal of Medicine [online] 2008 September, 75(9):663-672 [viewed 06 July 2014] Available from: doi:10.3949/ccjm.75.9.663
  2. CHOBANIAN A. V., BAKRIS G. L., BLACK H. R., CUSHMAN W. C., GREEN L. A., IZZO J. L., JONES D. W., MATERSON B. J., OPARIL S., WRIGHT J. T., ROCCELLA E. J.. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension [online] December, 42(6):1206-1252 [viewed 06 July 2014] Available from: doi:10.1161/​01.HYP.0000107251.49515.c2

Management - General Measures

Fact Explanation
Patient and family education It is important to educate patient and the family members regarding the disease condition, possible complications, medical and surgical management plan, lifestyle changes etc, to improve patient compliance and get the maximum support from the family to achieve good control of blood pressure and also to minimize complications.[1]
Life style modifications Lifestyle modifications are cornerstone of the management of hypertension. These modifications include dietary changes such as salt restriction, intake of more vegetables and fresh fruits, avoidance of habits such as cessation of smoking, consumption of moderate amount of alcohol. Also if the patient is obese or overweight should educate regarding weight reduction. Regular physical exercise also should be encouraged. [1]
References
  1. MANCIA GIUSEPPE, FAGARD ROBERT, NARKIEWICZ KRZYSZTOF, REDóN JOSEP, ZANCHETTI ALBERTO, BöHM MICHAEL, CHRISTIAENS THIERRY, CIFKOVA RENATA, DE BACKER GUY, DOMINICZAK ANNA, GALDERISI MAURIZIO, GROBBEE DIEDERICK E., JAARSMA TINY, KIRCHHOF PAULUS, KJELDSEN SVERRE E., LAURENT STéPHANE, MANOLIS ATHANASIOS J., NILSSON PETER M., RUILOPE LUIS MIGUEL, SCHMIEDER ROLAND E., SIRNES PER ANTON, SLEIGHT PETER, VIIGIMAA MARGUS, WAEBER BERNARD, ZANNAD FAIEZ. 2013 ESH/ESC Guidelines for the management of arterial hypertension. Journal of Hypertension [online] 2013 July, 31(7):1281-1357 [viewed 06 July 2014] Available from: doi:10.1097/01.hjh.0000431740.32696.cc

Management - Specific Treatments

Fact Explanation
Management of hypertensive emergency Requires immediate blood-pressure reduction to prevent/limit target organ damage. ICU admission for close supervision will be needed. Blood pressure should be reduced in a controlled, predictable, and safe way. Parenteral drug therapy is usually preferred and available drugs include sodium nitroprusside, glyceryl trinitrate (GTN), hydralazine, fenoldopam, phentolamine, labetalol, enalaprilat and nicardipine. If there is acute heart failure intravenous(IV) GTN or sodium nitroprusside are preferred, as these will reduce cardiac afterload. If an acute coronary syndrome is present, IV GTN will improve coronary perfusion, while IV labetalol proves beneficial by reducing heart rate. Diuretics are generally avoided (except in heart failure), as many patients are hypovolemic due to pressure-induced natriuresis.[1,3]
Pharmacological mangement Antihypertensive drug treatment should be given to reduce the risk of major clinical cardiovascular outcomes such as fatal and non-fatal stroke, myocardial infarction, heart failure. Recommended the use of antihypertensive drugs in patients with grade 1(>140/90 mmHg), grade 2 (>160/100mmHg) and grade 3 (>180/110mmHg) even in the absence of other risk factors. A lower threshold for antihypertensive drug intervention is recommended in patients with diabetes, previous cardiovascular complications or chronic kidney disease. and suggested treatment of these patients, even when BP was in the high normal range (130–139/85–89 mmHg). Commonly prescribed and available drug classes are diuretics (thiazide, loop, potassium sparing), angiotensin converting enzyme inhibitors, angiotensin receptor blockers, aldosterone antagonists, beta blockers, alpha blockers, calcium channel blockers and direct vasodilators such as hydralazine.[1,3]
Management of hypertension in renal vascular disease Antihypertensive drug treatment can be used to control hypertension, but progression of renal artery stenosis may occur. As the definitive treatment revascularization is indicated to preserve renal function. Percutaneous transluminal renal angioplasty (PTRA) with stent implantation is the method of choice. Surgical revascularization is indicated if angioplasty fails or with multiple small arteries, or early branching of the main renal artery.[1,2,3]
Management of primary aldosteronism Surgical management should be provided for the patients with aldosterone producing adenomas and primary adrenal hyperplasia. Unilateral laparoscopic adrenalectomy is preferred over laparotomy, considering the laparotomy associated morbidity and mortality. Pharmacological treatment (spironolactone- mineralocorticoid receptor antagonist) can be given for those who are not treated surgically.[1,2,3]
Management of pheochromocytoma Surgical resection of the tumor is the definitive management, though it is associated with high rates of mortality. Control of blood pressure is also important in pheochromocytoma, treatment starts with α-blockers and after achieving adequate α-blockade, the patient can be treated with β-blockers to achieve heart rate control. Phenoxybenzamine (a nonselective blocker of α-receptors) is a preferred α-blocker; however, prazosin, terazosin, doxazosin can also be used. Metyrosine is also a very effective drug for blood pressure control, which acts by inhibiting tyrosine hydroxylase, thus causing depletion of adrenal stores of catecholamines. Persistent hypertension which in the immediate postoperative period is an important issue which can be due to the residual tumor, autonomic instability, pain, volume overload. However, coexisting essential hypertension is still most likely diagnosis if it persists longer. [4]
Management of thyroid dysfunction To manage hyperthyroidism, beta blockers and iodides are used as adjunctive treatment. Antithyroid drugs, radioactive iodine, and surgery are the main treatment modalities. For patients with hypothyroidism, thyroid hormone replacement therapy should be started in a lower dosage and increased gradually. Response should be monitored.[5,6]
Management of Cushing's syndrome Treatment varies according to the underlying primary cause of the syndrome. Transsphenoidal surgery is the primary therapy for Cushing disease where adrenalectomy for adrenal tumors. [1,3]
Management of sleep apnea Continuous positive airway pressure (CPAP) treatment has been reported to lower nighttime and daytime blood pressure in hypertensives with obstructed sleep apnea.[1,3]
Management of complications of hypertension Complications should be anticipated and have to detect and manage as soon as possible to limit/prevent the target organ damage.[1,2,3]
Management of resistant hypertension Resistant hypertension is defined as uncontrolled blood pressure on optimal doses of 3 antihypertensive agents, ideally one being a diuretic. The classic combined drug regimen recommended for these patients include a diuretic, a long-acting calcium channel blocker, an angiotensin-converting enzyme inhibitor, a beta blocker, and a mineralocorticoid receptor antagonist. Newest methods used to lower blood pressure safely are baroreflex activation and renal denervation.[1,2]
Treatment of associated co-morbid diseases and risk factors Associated diseases such as diabetes, dyslipidemia, ischemic heart disease, heart failure should be managed effectively with a proper clinic follow up.[1,3]
Management of hypertension in metabollic syndrome Lifestyle modification is the main way of management and antihypertensive drug therapy is indicated to control high blood pressure.[1,3]
Making appropriate referrals Appropriate referrals should be made to provide best treatment options for the individual patient, according to their underlying disease condition. Patients should be referred to endocrinologists, surgeons, nephrologists..etc.[1,3]
References
  1. MANCIA GIUSEPPE, FAGARD ROBERT, NARKIEWICZ KRZYSZTOF, REDóN JOSEP, ZANCHETTI ALBERTO, BöHM MICHAEL, CHRISTIAENS THIERRY, CIFKOVA RENATA, DE BACKER GUY, DOMINICZAK ANNA, GALDERISI MAURIZIO, GROBBEE DIEDERICK E., JAARSMA TINY, KIRCHHOF PAULUS, KJELDSEN SVERRE E., LAURENT STéPHANE, MANOLIS ATHANASIOS J., NILSSON PETER M., RUILOPE LUIS MIGUEL, SCHMIEDER ROLAND E., SIRNES PER ANTON, SLEIGHT PETER, VIIGIMAA MARGUS, WAEBER BERNARD, ZANNAD FAIEZ. 2013 ESH/ESC Guidelines for the management of arterial hypertension. Journal of Hypertension [online] 2013 July, 31(7):1281-1357 [viewed 06 July 2014] Available from: doi:10.1097/01.hjh.0000431740.32696.cc
  2. KUMAR N, CALHOUN DA, DUDENBOSTEL T. Management of patients with resistant hypertension: current treatment options. Integr Blood Press Control [online] 2013 Oct 22:139-51 [viewed 06 July 2014] Available from: doi:10.2147/IBPC.S33984
  3. CHOBANIAN A. V., BAKRIS G. L., BLACK H. R., CUSHMAN W. C., GREEN L. A., IZZO J. L., JONES D. W., MATERSON B. J., OPARIL S., WRIGHT J. T., ROCCELLA E. J.. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension [online] December, 42(6):1206-1252 [viewed 06 July 2014] Available from: doi:10.1161/​01.HYP.0000107251.49515.c2
  4. GARG MK, BRAR KS, MITTAL RAKESH, KHARB SANDEEP, GUNDGURTHI ABHAY. Medical management of pheochromocytoma: Role of the endocrinologist. Indian J Endocr Metab [online] 2011 December [viewed 10 July 2014] Available from: doi:10.4103/2230-8210.86976
  5. REID JR, WHEELER SF. Hyperthyroidism: diagnosis and treatment. Am Fam Physician [online] 2005 Aug 15, 72(4):623-30 [viewed 10 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16127951
  6. HUESTON WJ. Treatment of hypothyroidism. Am Fam Physician [online] 2001 Nov 15, 64(10):1717-24 [viewed 10 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11759078