Conclusion

ing rather than screening reduces the need for time-consuming and anxiety-provoking further investigation. The suggested practice is not to screen for secondary hypertension without a clear indication and a strategy for positive, negative and intermediate probability results.

In this case, there is little indication to screen for haemodynamically significant renal artery stenosis as renal function is normal despite use of an ACE inhibitor. MRA may reveal radiographic renal artery stenosis, but stenting of the renal arteries is associated with an uncertain risk-benefit ratio. Without other clear clinical pointers, the only other screening test to be considered would be a plasma aldosterone concentration to renin activity ratio. However, as the specificity of a positive screening test for surgically curable hypertension is so low, it may be more pragmatic to prescribe a trial of an aldosterone antagonist. This may be particularly appropriate in this case, as the patient has already suffered a myocardial infarction and a recent trial demonstrated that the use of eplerenone was associated with a 15% reduction in death following myocardial infarction associated with left ventricular failure.8

Suggested practice would be to ensure that the current treatment plan is acceptable to the patient and that non-adherence is not a significant problem. ABPM may identify an element of white coat hypertension. If not, a fifth hypotensive agent—probably an aldos-terone antagonist—would be introduced to see if this lowered blood pressure further toward 130/80 mmHg. It is suggested to ask specifically about symptoms of OSA. Also, ensure that lipid lowering and glycaemic control are optimized, both of which may also reduce the risk of a further vascular event.

Screening for secondary hypertension will produce false-positive tests because of the high sensitivity and relatively low specificity of some of the tests outlined above. Selective test-

Blood Pressure Health

Blood Pressure Health

Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

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