Mechanism-defined secondary hypertension enables precision diagnosis and treatment: an evidence review
- 1Department of Pharmacology, Government Erode Medical College and Hospital
- 2Department of Internal Medicine, Eastern Railway Production Unit Hospital
- 3Department of Physical Therapy, Neighborhood PT PC
Abstract
Background: Secondary hypertension is under-recognised despite the availability of mechanism-based diagnostic tests and, for several aetiologies, potentially curative or highly targeted therapy. The clinically important question is not only which causes exist, but how reliably mechanisms translate into diagnosis and cause-directed treatment.
Objectives: To systematically synthesise evidence across the principal causes of secondary hypertension using a mechanism → diagnosis → therapy framework; to compare diagnostic performance and cause-directed treatment effects; and to examine concordance between contemporary society guidelines and real-world implementation.
Methods: This systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020, with diagnostic accuracy reporting informed by PRISMA-DTA. MEDLINE (PubMed), Embase, CENTRAL, Web of Science Core Collection, Scopus, ClinicalTrials.gov, and the WHO ICTRP were searched from inception to 30 June 2025, supplemented by citation searching. The formal search identified 580 records; after removal of 168 duplicates, 412 records were screened, 106 full-text reports were assessed, and 58 included evidence records were represented across 63 publications. The review was not prospectively registered in PROSPERO. Screening, extraction and structured appraisal were performed by a single reviewer (the first author); therefore, no dual-reviewer agreement statistic was applicable. Risk of bias was appraised with RoB 2, ROBINS-I, QUADAS-2, and AMSTAR 2 as appropriate, and certainty was summarised using GRADE. A targeted post-search surveillance update through 31 July 2026 was used only to contextualise major newly available guidelines and Phase 3 trial reports and did not alter the original PRISMA counts.
Results: Primary aldosteronism (PA) is best understood as a continuum of renin-independent aldosterone excess: in Brown et al. [The unrecognized prevalence of primary aldosteronism: a cross-sectional study. Ann Intern Med . (2020) 173 :10–20], biochemically overt autonomous aldosterone production was present in 11.3%, 15.7%, 21.6%, and 22.0% across normotensive, stage 1, stage 2, and resistant-hypertension strata, respectively. In unilateral PA, the PASO cohort distinguished complete biochemical success after adrenalectomy (94%; 656/699) from complete clinical success (37%; 259/705), with partial clinical improvement in a further 47%. PATHWAY-2 established spironolactone as the most effective fourth-line drug in resistant hypertension; CORAL, ASTRAL, STAR, and DRASTIC did not support routine revascularisation for stable atherosclerotic renal-artery stenosis; plasma-free metanephrines remained highly sensitive for phaeochromocytoma/paraganglioma; and PA testing in eligible patients with resistant hypertension remained only 1.6%–2.1%. Post-search Phase 3 trials of selective aldosterone synthase inhibition showed approximately 9 mm Hg placebo-corrected office systolic blood pressure reductions, but cardiovascular-outcome benefit has not been established, and electrolyte/renal monitoring remains necessary.
Conclusions: Across secondary hypertension, a limited set of pathophysiological effector pathways maps to specific diagnostic tests and cause-directed treatments. The strongest opportunities for clinical gain are earlier recognition of high-yield phenotypes, accurate aetiological subtyping, and implementation of established testing pathways; emerging aldosterone synthase inhibitors expand blood-pressure-lowering options but should not yet be interpreted as proven cardiovascular-outcome therapies.
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BibTeX
@article{choudhary2026mechanismdefined,
title = {{Mechanism-defined secondary hypertension enables precision diagnosis and treatment: an evidence review}},
author = {Arbind Kumar Choudhary and Anamitra Hait and Maheshkumar Baladaniya},
journal = {Frontiers in Cardiovascular Medicine},
year = {2026},
month = oct,
doi = {10.3389/fcvm.2026.1958980},
url = {https://www.frontiersin.org/articles/10.3389/fcvm.2026.1958980/full},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Mechanism-defined secondary hypertension enables precision diagnosis and treatment: an evidence review
AU - Arbind Kumar Choudhary
AU - Anamitra Hait
AU - Maheshkumar Baladaniya
PY - 2026
DA - 2026/10/14
JO - Frontiers in Cardiovascular Medicine
DO - 10.3389/fcvm.2026.1958980
UR - https://www.frontiersin.org/articles/10.3389/fcvm.2026.1958980/full
AB - Background: Secondary hypertension is under-recognised despite the availability of mechanism-based diagnostic tests and, for several aetiologies, potentially curative or highly targeted therapy. The clinically important question is not only which causes exist, but how reliably mechanisms translate into diagnosis and cause-directed treatment. Objectives: To systematically synthesise evidence across the principal causes of secondary hypertension using a mechanism → diagnosis → therapy framework; to compare diagnostic performance and cause-directed treatment effects; and to examine concordance between contemporary society guidelines and real-world implementation. Methods: This systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020, with diagnostic accuracy reporting informed by PRISMA-DTA. MEDLINE (PubMed), Embase, CENTRAL, Web of Science Core Collection, Scopus, ClinicalTrials.gov, and the WHO ICTRP were searched from inception to 30 June 2025, supplemented by citation searching. The formal search identified 580 records; after removal of 168 duplicates, 412 records were screened, 106 full-text reports were assessed, and 58 included evidence records were represented across 63 publications. The review was not prospectively registered in PROSPERO. Screening, extraction and structured appraisal were performed by a single reviewer (the first author); therefore, no dual-reviewer agreement statistic was applicable. Risk of bias was appraised with RoB 2, ROBINS-I, QUADAS-2, and AMSTAR 2 as appropriate, and certainty was summarised using GRADE. A targeted post-search surveillance update through 31 July 2026 was used only to contextualise major newly available guidelines and Phase 3 trial reports and did not alter the original PRISMA counts. Results: Primary aldosteronism (PA) is best understood as a continuum of renin-independent aldosterone excess: in Brown et al. [The unrecognized prevalence of primary aldosteronism: a cross-sectional study. Ann Intern Med . (2020) 173 :10–20], biochemically overt autonomous aldosterone production was present in 11.3%, 15.7%, 21.6%, and 22.0% across normotensive, stage 1, stage 2, and resistant-hypertension strata, respectively. In unilateral PA, the PASO cohort distinguished complete biochemical success after adrenalectomy (94%; 656/699) from complete clinical success (37%; 259/705), with partial clinical improvement in a further 47%. PATHWAY-2 established spironolactone as the most effective fourth-line drug in resistant hypertension; CORAL, ASTRAL, STAR, and DRASTIC did not support routine revascularisation for stable atherosclerotic renal-artery stenosis; plasma-free metanephrines remained highly sensitive for phaeochromocytoma/paraganglioma; and PA testing in eligible patients with resistant hypertension remained only 1.6%–2.1%. Post-search Phase 3 trials of selective aldosterone synthase inhibition showed approximately 9 mm Hg placebo-corrected office systolic blood pressure reductions, but cardiovascular-outcome benefit has not been established, and electrolyte/renal monitoring remains necessary. Conclusions: Across secondary hypertension, a limited set of pathophysiological effector pathways maps to specific diagnostic tests and cause-directed treatments. The strongest opportunities for clinical gain are earlier recognition of high-yield phenotypes, accurate aetiological subtyping, and implementation of established testing pathways; emerging aldosterone synthase inhibitors expand blood-pressure-lowering options but should not yet be interpreted as proven cardiovascular-outcome therapies.
SN - 2297-055X
ER -