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Home , Hypertension, Secondary hypertension

COVER ARTICLE PROBLEM-ORIENTED DIAGNOSIS

Diagnosing Secondary EDWARD ONUSKO, M.D., Clinton Memorial Hospital, Wilmington, Ohio

Secondary hypertension is elevated pressure that results from an underlying, iden- tifiable, often correctable cause. Only about 5 to 10 percent of hypertension cases are thought to result from secondary causes. The ABCDE mnemonic can be used to help deter- mine a secondary cause of hypertension: Accuracy of diagnosis, obstructive , Aldosteronism, presence of renal (suggesting ), renal parenchymal (Bad kidneys), excess , Coarctation of the , Cushing’s syndrome, Drugs, Diet, excess , and Endocrine disorders. An algorithm showing the general strategy to help screen for factors involved in is presented. Routine urinalysis, complete blood cell count, blood chemistry profile (, , , fasting glucose, fasting lipid levels), and a 12-lead electrocardiogram are recommended for all patients with hypertension. (Am Fam Physi- cian 2003;67:67-74. Copyright© 2003 American Academy of Family Physicians)

atients with hypertension other risk factors for cardiovascular dis- have some underlying mech- orders (e.g., mellitus, hyperlipi- anism that elevates their demia); and detection of secondary . Conceptu- causes of hypertension. Physicians can ally, it is useful to think of use the mnemonic ABCDE to help deter- Ppatients with hypertension as having mine secondary causes in the patient either (systemic with elevated blood pressure (Table 1). hypertension of unknown cause) or sec- ondary hypertension (hypertension that Diagnosis: ABCDE results from an underlying, identifiable, A: ACCURACY, APNEA, ALDOSTERONISM often correctable cause).1 Although only Accuracy. The first, most practical step about 5 to 10 percent of hypertension in evaluating an elevated blood pressure cases are thought to result from sec- reading is to investigate its accuracy. A Members of various family practice depart- ondary causes, hypertension is so com- blood pressure cuff that is too small, tight- ments develop articles mon that secondary hypertension proba- fitting sleeves that are not removed, or a for “Problem-Oriented bly will be encountered frequently by the that is noncompressible Diagnosis.” This is one practitioner.2-4 because of calcification (sometimes seen in a series from the The sixth report of the Joint National in the elderly) can cause falsely elevated Department of Family Practice at the Univer- Committee on Prevention, Detection, readings. White-coat hypertension (blood sity of Cincinnati Col- Evaluation, and Treatment of High Blood pressure that is elevated in the physician’s lege of Medicine. Pressure (JNC-VI)5 defines four goals for office but normal at other times) accounts Guest coordinator of the evaluation of the patient with ele- for about 20 percent of patients with ele- the series is Susan vated blood pressure: detection and con- vated readings.3 JNC-VI recommends Montauk, M.D. firmation of hypertension; detection of confirming high blood pressure readings target disease (e.g., renal damage, outside of the office setting. congestive failure); identification of Apnea. (OSA), a repetitive mechanical obstruction of the upper airway during sleep, is an indepen- 6 The first, most practical step in evaluating an elevated blood dent for hypertension. At least one half of patients with OSA have pressure reading is to investigate its accuracy. hypertension.7 Treatment of OSA with or nasal continuous positive air-

JANUARY 1, 2003 / VOLUME 67, NUMBER 1 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 67 TABLE 1 Findings That Suggest Secondary Hypertension

Findings Disorder suspected Further diagnostic studies

Snoring, daytime , Obstructive sleep apnea Sleep study Hypernatremia, Aldosteronism Ratio of plasma to plasma activity, CT scan of adrenal glands Renal insufficiency, atherosclerotic Renal parenchymal Creatinine clearance, renal , , disease ultrasonography elevated and creatinine levels, Systolic/diastolic abdominal Renovascular disease Magnetic resonance angiography, (Capoten)-augmented radioisotopic renography, renal arteriography Use of sympathomimetics, perioperative Excess catecholamines Confirm patient is normotensive setting, acute , in absence of high catecholamines. Decreased or delayed femoral , Coarctation of aorta Doppler or CT imaging of aorta abnormal , , weakness, Cushing’s syndrome -suppression test , amenorrhea, moon facies, dorsal hump, purple striae, truncal obesity, hypokalemia Use of drug in Table 2 Drug side effect Trial off drug, if possible High intake, excessive Diet side effects Trial of dietary modification intake, obesity Erythropoietin use in renal disease, Erythropoietin side Trial off drug, if possible in COPD effect Paroxysmal hypertension, , Urinary metabolites diaphoresis, , tachycardia (, metanephrines, normetanephrines) Plasma free metanephrines Fatigue, , hair loss, diastolic TSH levels hypertension, muscle weakness Heat intolerance, weight loss, TSH levels palpitations, , tremor, tachycardia stones, osteoporosis, , Serum , parathyroid lethargy, muscle weakness levels Headaches, fatigue, visual problems, Growth hormone level enlargement of hands, feet, tongue

CT = computed tomography; COPD = chronic obstructive pulmonary disease; TSH = thyroid-stimulating hormone.

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way pressure reduces hypertension in these patients.8 Daytime somnolence, obesity, snor- Increased urinary excretion of potassium signals hyperal- ing, lower-extremity edema (secondary to the dosteronism, which should be suspected in all hypertensive right-sided congestive that occurs patients with unprovoked hypokalemia. after repetitive anoxic insults to the myo- cardium during sleep), morning headaches, and nocturia suggest OSA.9 There is a high incidence of OSA in patients with chronic tions of hypertensive persons, the incidence of obstructive pulmonary disease (COPD). A renovascular hypertension is less than 1 per- formal sleep study usually is needed for diag- cent.14 However, identification of this rela- nosis of OSA and determination of corrective tively small population can be important interventions. because surgery or can reverse the Aldosteronism. Primary hypertension, especially if performed early is defined as overproduction of aldosterone enough to prevent permanent renal damage. independent of its usual regulator, the renin- Magnetic resonance angiography (MRA) is angiotensin system.10 The resulting retention of a noninvasive imaging modality with a sensi- excess salt and water suppresses renin levels (as tivity of 100 percent and a specificity of 70 to opposed to elevating renin levels, which causes 90 percent compared with renal arteriography secondary hyperaldosteronism). Increased uri- for detection of .2,15 MRA nary excretion of potassium signals hyperal- best delineates the proximal renal vasculature dosteronism, which should be suspected in all and is therefore useful as an initial diagnostic hypertensive patients with unprovoked (i.e., tool for patients suspected of having athero- not -induced) hypokalemia.11 The next sclerotic renal artery stenosis, which usually diagnostic test should be demonstration of an involves the proximal renal artery.16 Patients elevated ratio of plasma aldosterone levels to suspected of having FMD, which tends to .12 involve the distal renal artery, should undergo conventional angiography or computed B: BRUITS, BAD KIDNEYS tomographic angiography.16 (RENAL PARENCHYMAL DISEASE) Another initial diagnostic test is the captopril Bruits. Renovascular hypertension is (Capoten)-augmented radioisotopic reno- defined as hypertension resulting from com- gram.17 This test is based on the fact that a kid- promised arterial supply to the kidneys. About ney that is receiving an inadequate blood sup- 65 percent of renovascular disease is sec- ply will activate the renin-angiotensin system. ondary to in the renal , Therefore, a single dose of the angiotensin-con- usually seen after age 50 in patients at risk for verting enzyme (ACE) inhibitor captopril will arterial compromise (e.g., smokers, patients abruptly reduce renal function in the ischemic with diabetes, patients with known athero- kidney. A scan is considered positive if there is sclerotic disease).13 The remainder of patients delayed or decreased uptake of the radioisotope will demonstrate in the stenotic kidney compared with the non- (FMD) and will tend to be younger (25 to 50 stenotic one, so this test is not as useful if steno- years of age) at the time of diagnosis.13 sis is present bilaterally.2 About one half of patients with renovascu- Duplex ultrasound scanning is another diag- lar hypertension will have an abdominal bruit nostic option, but it can be limited by its depen- identifiable on .13 Bruits dence on operator skill and experience. Renal heard in both and are more arteriography remains the gold standard for suggestive of renovascular hypertension than defining the vessel anatomy but does not always systolic bruits alone.14 In unselected popula- correlate with postprocedural outcomes (i.e.,

JANUARY 1, 2003 / VOLUME 67, NUMBER 1 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 69 surgical correction of the renal artery stenosis sion and hypertension in pheochromocy- often does not resolve the hypertension).13 toma, OSA, and other discussed in Bad Kidneys. Renal parenchymal disease this article. Acute stress induces catechol- can be a cause or consequence of hyperten- amine release and often contributes to preop- sion. Progressive renal damage is caused by erative or postoperative hypertension. Over- the mechanical and humoral effects of the-counter or prescription glomerular hypertension. The renal damage can have sympathomimetic effects, as do decreases the kidneys’ ability to excrete salt nonprescription weight-loss preparations and excess fluid (resulting in a low renin state, containing (ma huang).19,20 The as opposed to the high renin state found in hypertensive effects of and ampheta- renovascular hypertension), and the hyper- mines also are sympathomimetic. tension worsens. As renal damage progresses, . Coarctation of the hyperparathyroidism develops and erythro- aorta is a congenital narrowing of the aortic poietin production increases, exacerbating the lumen, most often occurring just distal to the hypertension.5,18 Thus, a vicious cycle of wors- origin of the left subclavian artery. Patients ening renal function and hypertension begins. with less severe forms of the disorder may not Aggressive treatment of hypertension (par- be diagnosed until young adulthood but have ticularly with ACE inhibitors) in patients with a high incidence of premature .21 Diag- renal parenchymal disease can lower the nostic clues include decreased lower-extrem- blood pressure and slow the disease’s progres- ity (femoral) pulses with upper-extremity sion, although it is difficult to effectively con- hypertension, dyspnea on exertion, and chest trol hypertension in chronic renal disease. radiographic findings of notched ribs (from Early treatment of hypertension and diabetes, dilated collateral vessels) and dilation of the the two most common causes of end-stage aorta above and below the constriction (the renal disease, can lower the incidence of long- “3” sign).22 term renal complications.18 Cushing’s Syndrome. Cushing’s syndrome Diagnosis is based on loss of renal cortical can cause hypertension via the mineralocorti- function (demonstrated by elevated serum coid effects of excess and is creatinine levels and decreased creatinine best screened for with a dexamethasone-sup- clearance), although it may be impossible to pression test.23 tell if the renal dysfunction is primary or sec- ondary to the hypertension.2 D: DRUGS, DIET Drugs. Many prescription and nonprescrip- C: CATECHOLAMINES, COARCTATION, tion drugs can cause or exacerbate hyperten- CUSHING’S SYNDROME sion (Table 2). Immunosuppressive agents Catecholamines. Excess catecholamine lev- such as cyclosporine (Sandimmune), tacro- els play a role in causing white-coat hyperten- limus (Prograf), and increase blood pressure in up to 80 percent of solid- organ transplant recipients.5 Nonsteroidal The Author anti-inflammatory drugs (NSAIDs) and EDWARD ONUSKO, M.D., is associate director of the family practice residency pro- cyclooxygenase-2 (COX-2) inhibitors elevate gram at Clinton Memorial Hospital, Wilmington, Ohio. He also is associate professor blood pressure via their antiprostaglandin of clinical family medicine at the University of Cincinnati College of Medicine. He grad- effects on the kidneys. , in the dosages uated from Case Western Reserve University School of Medicine in Cleveland, Ohio, and completed a residency in family medicine at University Hospitals of Cleveland. most often used in oral contraceptive pills (30 to 35 mcg), appears to have only a mild Address correspondence to Edward Onusko, M.D., Clinton Memorial Hospital, 825 W. Locust St., Wilmington, OH 45177 (e-mail: [email protected]). Reprints are hypertensive effect and no increased risk for not available from the author. overall mortality or myocardial (if

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smokers over age 35 are excluded).24 The pressure than in systolic blood pressure.7 Con- lower doses of estrogen used in postmeno- versely, hyperthyroidism induces increased pausal hormone-replacement regimens actu- and compensatory decreased ally can have some antihypertensive effect.25 vascular tone, causing a greater increase in sys- in , smokeless tobacco, and tolic blood pressure.7 A thyroid-stimulating cigars causes transient (30 minutes or less) hormone level is the best diagnostic increases in blood pressure, although trans- test for thyroid disorders. dermal nicotine preparations do not appear to Hyperparathyroidism (primary or sec- have this effect.26 Because patients who smoke ondary to chronic renal insufficiency) is a often have a just before coming into potentially reversible cause of hypertension. the physician’s office, blood pressure should Its incidence in hypertensive patients is about be rechecked after 30 minutes if initial read- 1 percent, compared with a 0.1 percent inci- ings are elevated. Although caffeine can raise dence in the general population.29 However, blood pressure acutely, tolerance develops only 30 to 40 percent of patients with hyper- rapidly, and there appears to be no direct rela- parathyroidism have hypertension, and tionship between caffeine intake and chronic parathyroidectomy does not reliably resolve hypertension.27 Chronic overuse of alcohol is hypertension in patients with this disorder.29 a potentially reversible cause of hypertension.4 It is unclear how hyperparathyroidism Diet. Excess consumption of dietary increases blood pressure, because there is no sodium is linked to chronic hypertension, direct correlation with parathyroid hormone although the lower limit of “excess” can be dif- or calcium levels. ficult to define. Blacks, the elderly, patients with diabetes, and patients with essential hypertension appear to be particularly sensi- TABLE 2 5 tive to dietary sodium intake. Low intake of Drugs That Can Raise Blood Pressure potassium, calcium, and magnesium can have a similar but less pronounced effect.5 Dietary Drug class Drug examples patterns that cause obesity also can cause hypertension. Sustained weight reduction Immunosuppressive agents Cyclosporine (Sandimmune), lowers blood pressure—often to normal lev- (Prograf), corticosteroids els—in at least one half of obese patients.28 A Nonsteroidal anti-inflammatory (Motrin), naproxen (Naprosyn), loss of 5 to 10 percent of body weight can sig- drugs (Feldene) nificantly reduce blood pressure. COX-2 inhibitors (Celebrex), rofecoxib (Vioxx), valdecoxib (Bextra) E: ERYTHROPOIETIN, ENDOCRINE DISORDERS Estrogens 30- to 35-mcg estrogen oral contraceptives Erythropoietin. Elevated erythropoietin lev- Weight-loss agents (Meridia), phentermine els can be endogenous (as in response to the (Adipex), ma huang (ephedra) chronic of COPD) or exogenous Nicotine, (administered to alleviate the seen in (Florinef) chronic renal failure). High erythropoietin Antiparkinsonian (Parlodel) levels can elevate blood pressure either via a polycythemia/hyperviscosity mechanism or Monoamine oxidase inhibitors (Nardil) by direct pressor effects.7 Anabolic Testosterone Endocrine Disorders. Hypothyroidism can Sympathomimetics (Novafed) cause decreased cardiac output with a com- pensatory increase in vascular tone, resulting COX-2 = cyclooxygenase-2. in a more prominent rise in diastolic blood

JANUARY 1, 2003 / VOLUME 67, NUMBER 1 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 71 -induced hypertension has an can vary depending on the types of cate- incompletely understood neurohumoral cholamines being produced, the amount and mechanism (possibly initiated by inadequate frequency of their release into the circulation, establishment of blood supply to the develop- and other factors. The usual screening test has ing placenta) and occasionally can develop in been urinary measurement of catecholamine the immediate . metabolites (vanillylmandelic acid, meta- Pheochromocytoma is another endocrine nephrines, normetanephrines).30 Determina- cause of hypertension. The classic symptoms tion of plasma free metanephrines might be include , diaphoresis, palpitations, the test of first choice for diagnosis of this and paroxysmal hypertension. The syndrome tumor, although availability of this test at

Evaluation for Secondary Causes of Hypertension

Suspected hypertension

Test accuracy of reading (check cuff size, repeat office readings, out-of-office readings).

Confirmed hypertension Normotensive White-coat hypertension

Screening history Screening physical examination Screening laboratory tests (Table 4)

Risk factors for secondary hypertension present (Table 3)?

No Yes

Treat hypertension and assess response. Screening results suggest a Screening results do not specific cause (Table 1). suggest a specific cause.

Identify and treat suspected Consider more aggressive evaluation for cause and assess response. secondary hypertension (see “Further diagnostic studies” in Table 1).

FIGURE 1. General strategy for diagnosing a secondary cause of hypertension.

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hospital and reference laboratories is lim- ited.31 Pheochromocytoma is very rare, and The classic symptoms of pheochromocytoma include routine screening in hypertensive patients is headache, diaphoresis, palpitations, and paroxysmal not recommended. hypertension. Acromegaly (elevated growth hormone) is a rare endocrine cause of hypertension.

Recommendations treatment recommendations by the National A more aggressive evaluation for secondary Education Program (NCEP-III) causes of hypertension should be considered are based on these findings.36 in certain clinical situations (Table 3).5,32,33 A diagnostic algorithm for secondary hyperten- The author thanks Edna Layman, Judy Scroggy, and sion is presented in Figure 1.34,35 However, the staff of the Health Resources Center at Clinton Memorial Hospital in Wilmington, Ohio, for assis- there is little objective evidence that following tance in the prepration of the manuscript. these recommendations would significantly benefit patients. Despite this uncertainty, it The author indicates that he does not have any con- would seem reasonable for the physician to flicts of interest. Sources of funding: none reported. follow the recommendations in the JNC-VI (Table 4) for routine , physical REFERENCES examination, and laboratory testing. Doing so 1. O’Rorke JE, Richardson WS. Evidence based manage- would screen for most of the secondary causes ment of hypertension: what to do when blood pres- of hypertension discussed in this article, along sure is difficult to control. BMJ 2001;322:1229-32. 2. Wofford MR, King DS, Wyatt SB, Jones DW. Sec- with signs of target organ disease and comor- ondary hypertension: detection and management bid factors. Although it is not one of the JNC- for the primary care provider. J Clin Hypertens VI recommendations, obtaining fasting low- 2000;2:124-31. 3. Setaro JF. An update on the diagnostic evaluation density lipoprotein cholesterol levels and of the hypertensive patient. J Clin Hypertens 2000; levels makes sense, because recent 2:25-32.

TABLE 3 TABLE 4 Risk Factors for Secondary Hypertension Routine Screening Laboratory Tests for Hypertension Poor response to therapy (resistant hypertension) Worsening of control in previously stable Urinalysis hypertensive patient Complete blood count Stage 3 hypertension (systolic blood pressure Blood chemistries (potassium, sodium, creatinine, > 180 mm Hg or diastolic blood pressure fasting glucose) >110 mm Hg) Fasting lipid profile (LDL, HDL, , total Onset of hypertension in persons younger than cholesterol) age 20 or older than age 50 12-lead electrocardiogram Significant hypertensive target organ damage Lack of family LDL = low-density lipoprotein; HDL = high-density Findings on history, physical examination, or lipoprotein. laboratory testing that suggest a secondary Information from Joint National Committee. The sixth cause (Table 1) report of the Joint National Committee on Preven- tion, Detection, Evaluation, and Treatment of High Information from references 5,32, and 33. Blood Pressure. Arch Intern Med 1997;157:2413-46.

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4. Oparil S, Calhoun DA. Managing the patient with diovascular medicine. 5th ed. Philadelphia: Saun- hard-to-control hypertension. Am Fam Physician ders, 1997:963-87. 1998;57:1007-14. 22. Steiner RM. Radiology of the heart. In: Braunwald 5. The sixth report of the Joint National Committee E, ed. Heart disease: a textbook of cardiovascular on Prevention, Detection, Evaluation, and Treat- medicine. 5th ed. Philadelphia: Saunders, 1997: ment of High Blood Pressure. Arch Intern Med 204-39. 1997;157:2413-46. 23. Fitzgerald PA. Endocrinology. In: Tierney LM, ed. 6. Silverberg DS, Oksenberg A. Essential and sec- Current and treatment, 2001. ondary hypertension and sleep-disordered breath- 40th ed. New York: Lange/McGraw-Hill, 2001: ing: a unifying hypothesis. J Hum Hypertens 1088-160. 1996;10:353-63. 24. Oral contraception. In: Speroff L, Glass RH, Kase 7. Kaplan NM. Other forms of secondary hyperten- NG, eds. Clinical gynecologic endocrinology and sion. In: Kaplan NM, Lieberman E, eds. Clinical infertility. 6th ed. Philadelphia: Lippincott Williams hypertension. 7th ed. Baltimore: Williams & & Wilkins, 1999:867-945. Wilkins, 1998:395-406. 25. Menopause and the perimenopausal transition. In: 8. Stradling JR, Partlett J, Davies RJ, Siegwart D, Speroff L, Glass RH, Kase NG, eds. Clinical gyneco- Tarassenko L. Effect of short term graded with- logic endocrinology and infertility. 6th ed. Philadel- drawal of nasal continuous positive airway pressure phia: Lippincott Williams & Wilkins, 1999:643-724. on systemic blood pressure in patients with obstruc- 26. Kaplan, NM. Treatment of hypertension: nondrug tive sleep apnea. Blood Press 1996;5:234-40. therapy. In: Kaplan NM, Lieberman E, eds. Clinical 9. Victor LD. Obstructive sleep apnea. Am Fam Physi- hypertension. 7th ed. Baltimore: Williams & cian 1999;60:2279-86. Wilkins, 1998:323-44. 10. Gordon RD. hypertension. 27. Basic and physiologic effects of the Lancet 1994;344:240-3. methylxanthines. In: Spiller GA, ed. Caffeine. Boca 11. Ganguly A. . N Engl J Med Raton, Fla.: CRC Press, 1998:225-31. 1998;339:1828-34. 28. Alexander D. Obesity and coronary heart disease. In: 12. Gordon RD, Stowasser M, Tunny TJ, Klemm SA, Alpert MA, Alexander JK, eds. The heart and lung in Rutherford JC. High incidence of primary aldo- obesity. Armonk, N.Y.: Futura, 1998:213-38. steronism in 199 patients referred with hyperten- 29. Dluhy RG, Williams RH. Endocrine hypertension. In: sion. Clin Exp Pharmacol Physiol 1994;21:315-8. Williams RH, Wilson JD, eds. Williams Textbook of 13. Kaplan NM. Renal vascular hypertension. In: endocrinology. 9th ed. Philadelphia: Saunders, Kaplan NM, Lieberman E, eds. Clinical hyperten- 1998:729-49. sion. 7th ed. Baltimore: Williams & Wilkins, 1998: 30. Williams GH. Approach to the patient with hyper- 301-21. tension. In: Braunwald E, ed. Harrison’s Principles 14. Pohl M. Renal artery stenosis, renal vascular hyper- of internal medicine. 15th ed. New York: McGraw- tension, and ischemic nephropathy. In: Schrier RW, Hill, 2001:211-4. Gottschalk CW, eds. Diseases of the kidney. 6th ed. 31. Lenders JW, Pacak K, Walther MM, Linehan WM, Boston: Little, Brown, 1997:1367-423. Mannelli M, Friberg P, et al. Biochemical diagnosis 15. Cohen DL, Townsend RR. How to manage complex of pheochromocytoma: which test is best? JAMA hypertension. Emerg Med 2001;33:20-9. 2002;187:1427-34. 16. Yucel EK. MRA of the aorta, visceral and peripheral 32. guideline: Hypertension diagnosis and arteries. In: Higgins CB, Hricak H, Helms CA, eds. treatment. Retrieved November 2002, from www. Magnetic resonance imaging of the body. 3d ed. icsi.org/guide/HTN.pdf. Philadelphia: Lippincott-Raven, 1997:1383-99. 33. Krijnen P, van Jaarsveld BC, Steyerberg EW, Man in 17. Aitchison F, Page A. Diagnostic imaging of renal ‘t Veld AJ, Schalekamp MA, Habbema JD. A clini- artery stenosis. J Hum Hypertens 1999;13:595- cal prediction rule for renal artery stenosis. Ann 603. Intern Med 1998;129:705-11. 18. Kaplan NM. Renal parenchymal hypertension. In: 34. Hall WD. A rational approach to the treatment of Kaplan NM, Lieberman E, eds. Clinical hyperten- hypertension in special populations. Am Fam Physi- sion. 7th ed. Baltimore: Williams & Wilkins, 1998: cian 1999;60:156-62. 281-99. 35. Oparil S. Arterial hypertension. In: Cecil RL, Gold- 19. Phenylpropanolamine and other OTC alpha-adren- man L, Bennett JC, eds. Cecil Textbook of medicine. ergic agonists. Med Lett Drugs Ther 2000;42:113. 21st ed. Philadelphia: Saunders, 2000:258-73. 20. Morelli V, Zoorob RJ. Alternative therapies: part I. 36. Executive summary of the third report of the Depression, diabetes, obesity. Am Fam Physician National Cholesterol Education Program (NCEP) 2000;62:1051-60. Expert Panel on Detection, Evaluation, and Treat- 21. Perloff JK. Congenital heart disease in adults. In: ment of High Blood Cholesterol in Adults (Adult Braunwald E, ed. Heart disease: a textbook of car- Treatment Panel III). JAMA 2001;285:2486-97.

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