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Background: Secondary hypertension is relatively uncommon with a 10% incidence rate. Objective: To describe a case of secondary hypertension caused by metabolic disorder. Case Illustration: A 28-year-old man came to the emergency department of Pupuk Kaltim Hospital with dyspnea on effort since three days before admission. He had persistent hypertension uncontrolled with triple antihypertensive drugs since four years ago. BP was 169/103 mmHg, heart rate 135-145 bpm, temperature 37.9° C. He had alopecia areata, exophthalmos, icteric, bilateral rales, systolic murmur at lower sternal border, and bilateral pitting edema. ECG showed AFib with Ashman phenomenon. CXR revealed cardiomegaly and flattened cardiac waist. LVEF is preserved with concentric LVH and LA dilatation. Abdominal sonogram revealed congestive hepatopathy. fT4 was increased while TSH was reduced. H2FPEF score estimated 38.7% probability of HFpEF. Burch Wartofsky score was 60 (thyroid storm). He was assessed with thyroid heart disease. Medication included intravenous furosemide and digoxin, warfarin, hydrochlorothiazide, ramipril, spironolactone, propranolol, and methimazole. Blood pressure successfully managed with five antihypertensive agents. Discussion: Renovascular hypertension is unlikely (absence of paraumbilical bruit and normal renal function). It is difficult to obtain plasma renin and aldosterone level but his electrolyte profile (no sodium retention and potassium excretion) is unsuitable for primary hyperaldosteronism. Aortic coarctation is unlikely (absence of differential hypertension and rib notching). No clinical signs of hypercortisolism are found. Pheochromocytoma is unlikely (no suprarenal tumor via abdominal ultrasound). Obstructive sleep apnea is eliminated as well (no history of excessive snoring, no hypercarbia). Conclusion: Clinical suspicion for secondary hypertension is necessary to ensure therapeutic precision.
Oetama et al. (Wed,) studied this question.