Cardiovascular Disorders

Hypertension

Clinical Overview and Exam Mastery Guide. Focus areas include blood pressure staging, first-line therapy, special populations, resistant hypertension, and hypertensive crisis.

Core Goal
BP below 130/80 mmHg
Primary HTN
Around 90 to 95 percent
Emergency Threshold
At least 180 / 120 + organ injury
Resistant HTN Step
Add spironolactone

Blood Pressure Severity Snapshot

Normal Elevated Stage 1 Stage 2 Crisis risk zone Evaluate organ damage Target <130 / 80 for most

Color bands and markers help rapid staging and urgency recognition.

1. What Is Hypertension?

Hypertension is a chronic elevation in blood pressure that increases risk of cardiovascular disease, stroke, heart failure, kidney disease, and death. It is often asymptomatic until complications appear.

ACC/AHA Class Blood Pressure
Normal Below 120 / 80 mmHg
Elevated 120 to 129 / below 80
Stage 1 130 to 139 or 80 to 89
Stage 2 At least 140 or at least 90
Blood pressure is interpreted as systolic (top number) over diastolic (bottom number).

2. Primary vs Secondary Hypertension

Primary (Essential)

  • Accounts for around 90 to 95 percent of cases
  • No single identifiable cause
  • Linked to genetics, age, and lifestyle

Secondary

  • CKD, renal artery stenosis, hyperaldosteronism
  • Pheochromocytoma, obstructive sleep apnea
  • Drug-induced: NSAIDs, steroids, oral contraceptives
Exam clue: resistant hypertension should trigger evaluation for secondary causes.

3. Risk Factors

Age Obesity High sodium intake Sedentary lifestyle Diabetes Dyslipidemia Smoking Family history

4. Complications of Uncontrolled Hypertension

Brain

Stroke

Heart

Myocardial infarction, heart failure

Kidney

Chronic kidney disease

Eye

Retinopathy

Vasculature

Peripheral arterial disease

Theme

Target-organ damage

5. Treatment Goals

For most patients, target BP is below 130/80 mmHg. Patients with diabetes, CKD, or established ASCVD typically require strict sustained control and closer follow-up.

6. Non-Pharmacologic Management

Core Interventions

  • Weight reduction
  • DASH diet
  • Sodium restriction
  • Regular exercise
  • Limit alcohol
  • Smoking cessation

Exam Message

  • Recommended for all BP stages
  • Can significantly lower systolic pressure
  • May delay medications in early disease

7. Pharmacologic Management - First-Line Drug Classes

Core First-Line Options

  • Thiazide diuretics
  • ACE inhibitors
  • ARBs
  • Calcium channel blockers

Beta Blockers

Not first-line in uncomplicated hypertension unless there is a compelling indication such as CAD or heart failure.

A. Thiazide Diuretics

Examples: hydrochlorothiazide, chlorthalidone.

  • Often effective in Black patients
  • May cause hypokalemia
  • May increase uric acid and glucose

B. ACE Inhibitors

Examples: lisinopril, enalapril.

  • Renal protection and reduced proteinuria in diabetes
  • Adverse effects: dry cough, hyperkalemia, angioedema
  • Contraindicated in pregnancy

C. ARBs

Examples: losartan, valsartan.

  • Alternative when ACE inhibitor is not tolerated
  • Renal and cardiovascular protection remains strong
  • No ACE inhibitor cough effect

D. Calcium Channel Blockers

  • DHP (amlodipine): vasodilation, peripheral edema
  • Non-DHP (diltiazem, verapamil): lower heart rate
  • Avoid non-DHP agents in HFrEF

8. Special Populations

Population Preferred Approach Important Avoidance
Black patients Thiazide or CCB often preferred first-line Individualize combination strategy
CKD ACE inhibitor or ARB preferred Monitor potassium and renal function
Diabetes ACE inhibitor or ARB preferred Track renal outcomes and albuminuria
Pregnancy Labetalol, methyldopa, nifedipine Avoid ACEI, ARB, and direct renin inhibitors

9. Resistant Hypertension

Defined as blood pressure above goal despite three medications, including a diuretic.

Next step: add spironolactone and reassess secondary causes, adherence, and sodium intake.

10. Hypertensive Crisis

Hypertensive Urgency

  • At least 180 / 120 without acute organ damage
  • Usually treated with oral medication adjustments

Hypertensive Emergency

  • At least 180 / 120 with organ damage
  • Requires IV therapy and monitored care
  • Typical IV options: nicardipine, labetalol, nitroprusside
Lower blood pressure gradually in emergency settings to avoid ischemic injury.

Urgency vs Emergency Decision Diagram

BP at least 180 / 120 Confirm and assess symptoms No target-organ damage Hypertensive urgency Target-organ damage present Hypertensive emergency Oral meds / close follow-up Do not over-correct rapidly IV therapy + monitored care Lower BP gradually

Management Recap Drill

Step 1: Confirm BP classification and repeat accurate measurement.
Step 2: Start lifestyle modification for all patients.
Step 3: Stage 1 with high ASCVD risk or Stage 2 -> start medication.
Step 4: Use first-line classes: thiazide, ACEI, ARB, CCB.
Step 5: If uncontrolled, add second agent from a different class.
Step 6: If still uncontrolled on three agents including diuretic, add spironolactone.
Step 7: At least 180/120 with organ damage -> IV emergency protocol with gradual reduction.

Treatment Escalation Flow Diagram

Classify BP ACC/AHA staging Lifestyle for all DASH, sodium, exercise Medication trigger Stage 2 or high-risk Stage 1 First-line class Thiazide / ACEI / ARB / CCB Not at goal? Add second class from different group Still uncontrolled on 3 meds incl. diuretic Resistant HTN: add spironolactone and re-evaluate causes/adherence

Guideline References

ACC/AHA Guideline Publication

https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065

ACC Guideline Hub

https://www.acc.org/guidelines/hubs/high-blood-pressure

11. Common Exam Traps

ACE inhibitor plus ARB combination is generally not recommended.
Beta blockers are not first-line for uncomplicated hypertension.
ACE inhibitors are contraindicated in pregnancy.
Thiazides can increase uric acid.
Do not lower BP too rapidly in hypertensive emergency.

12. Quick Revision Summary

Must Remember

  • First-line: thiazide, ACEI, ARB, CCB
  • Goal: below 130/80 mmHg for most patients
  • Lifestyle intervention is mandatory

High-Yield Management Triggers

  • Resistant HTN -> add spironolactone
  • Emergency HTN -> IV therapy and gradual BP reduction
  • Secondary workup in resistant or atypical cases