Hypertension
Diagnose, classify, and manage hypertension — drug selection, titration, resistant/secondary HTN, and emergencies.
Learning Objectives
- 1.Classify blood pressure and confirm the diagnosis correctly.
- 2.Select and titrate first-line therapy, including compelling indications.
- 3.Recognize resistant and secondary hypertension and when to escalate.
- 4.Distinguish hypertensive urgency from emergency.
Overview
Hypertension is the most common condition you’ll manage and a major driver of ASCVD, heart failure, and kidney disease. The work is accurate measurement, the right drug at the right dose, and recognizing the minority who need more.
Why this matters
Most cardiovascular risk reduction in primary and cardiology practice comes from getting BP to goal. Poor technique and clinical inertia (not titrating) are the main reasons patients stay uncontrolled.
Classification & diagnosis
- •Normal <120/80; Elevated 120–129/<80; Stage 1 130–139 or 80–89; Stage 2 ≥140 or ≥90.
- •Confirm with proper technique and out-of-office readings (home/ambulatory) before labeling/treating.
- •Rule out white-coat and masked hypertension with home BP.
When to suspect secondary HTN
- •Resistant HTN, young onset, abrupt onset, or severe/accelerated course.
- •Clues: hypokalemia (hyperaldosteronism), snoring/daytime sleepiness (OSA), renal disease, episodic spells (pheo), bruit (renovascular).
- •Targeted workup based on the clue; refer/escalate when found.
First-line therapy & compelling indications
- •First-line classes: thiazide-type diuretic, ACE-i/ARB, dihydropyridine CCB.
- •Compelling indications steer choice: ACE-i/ARB for diabetes/CKD/HFrEF; beta-blocker for CAD/HFrEF (not first-line for HTN alone).
- •Stage 2 or BP far from goal: often start two agents (e.g., ACE-i/ARB + CCB or thiazide).
- •Lifestyle (sodium, weight, alcohol, activity, DASH) for everyone.
Titration & resistant HTN
- •Titrate at regular intervals to goal — don’t accept "close enough" (clinical inertia).
- •Resistant HTN = uncontrolled on 3 agents (including a diuretic) at adequate doses → add an MRA (e.g., spironolactone), confirm adherence, reconsider secondary causes.
Monitoring
- •Check potassium and creatinine after starting/titrating ACE-i/ARB/diuretic/MRA; monitor home BP logs.
Urgency vs emergency
- •Hypertensive urgency: very high BP WITHOUT acute target-organ damage → oral therapy, close follow-up; avoid rapid drops.
- •Hypertensive emergency: very high BP WITH acute target-organ damage (chest pain, dyspnea/pulmonary edema, neuro deficit, AKI, dissection) → emergent care.
Escalate
A hypertensive emergency (severe BP + acute organ damage) needs the acute pathway and physician involvement — not an office dose increase.
Common beginner mistakes
- •Treating a single in-office reading without confirmation/technique.
- •Clinical inertia — not titrating an uncontrolled patient.
- •Combining an ACE-i and an ARB (avoid).
- •Dropping BP too fast in asymptomatic severe hypertension.
Patient education
- •Home BP technique and logging; adherence; sodium and lifestyle; why control matters even when they feel fine.
Nurse / MA workflow connection
- •MA technique and nurse home-BP review feed your titration decisions; nurses flag crisis-range + symptoms.
Mini cases
A 45-year-old with resistant HTN on three agents, low potassium, BP still 150s/90s.
What’s the move?
Show answer
Resistant HTN with hypokalemia suggests primary aldosteronism — screen for it and consider adding an MRA (spironolactone), confirm adherence, and pursue the secondary-cause workup. Don’t just keep stacking agents blindly.
BP 200/120, no symptoms, normal exam, feels well.
Urgency or emergency?
Show answer
Hypertensive urgency (no acute target-organ damage). Use/adjust oral therapy with close follow-up and avoid a rapid drop — this is not an ED nitroprusside situation. Re-screen for symptoms/organ damage to be sure.