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Hypertension Hub

Hypertension affects nearly half of American adults and is the most important modifiable risk factor for stroke, heart attack, heart failure, and kidney disease. This module covers BP classification, measurement technique, first-line medications, hypertensive urgency vs. emergency, and the DASH diet.

Cardiology APPsPA/NP StudentsNursesMAsMedical StudentsClinic Staff

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📊Hypertension

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Pre-Test — Hypertension

~2 min

Answer a few quick questions before starting to measure your learning gain.

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Overview

Learning Objectives

1.Classify blood pressure using the 2017 ACC/AHA guidelines
2.Demonstrate proper blood pressure measurement technique
3.Distinguish white coat hypertension from masked hypertension
4.Identify first-line antihypertensive medication classes and compelling indications
5.Recognize the difference between hypertensive urgency and emergency
6.Understand the DASH diet and lifestyle modifications
7.Communicate with Spanish-speaking patients about blood pressure management

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APP Lesson: Hypertension Foundations

Audience: New cardiology APPs, PA/NP students, and clinicians new to cardiology.

Why Hypertension Is a Priority

›Hypertension (HTN) affects approximately 47% of US adults and is a leading cause of stroke, MI, heart failure, chronic kidney disease, and aortic dissection. Despite its prevalence, control rates remain poor — only about 25% of patients with hypertension have adequate blood pressure control.
›In cardiology practice, virtually every patient you encounter will have hypertension as a primary or comorbid condition. Understanding how to classify, measure, treat, and escalate hypertension is foundational knowledge.

2017 ACC/AHA Blood Pressure Classification

›Normal BP: Systolic <120 mmHg AND diastolic <80 mmHg. No pharmacological therapy needed. Healthy lifestyle encouraged.
›Elevated BP: Systolic 120–129 mmHg AND diastolic <80 mmHg. Lifestyle modification recommended. Reassess in 3–6 months.
›Stage 1 Hypertension: Systolic 130–139 mmHg OR diastolic 80–89 mmHg. Lifestyle modification; consider pharmacotherapy if 10-year ASCVD risk ≥10% or clinical CVD is present.
›Stage 2 Hypertension: Systolic ≥140 mmHg OR diastolic ≥90 mmHg. Lifestyle modification and pharmacotherapy recommended.
›Hypertensive Crisis: Systolic >180 mmHg and/or diastolic >120 mmHg. Subdivide into urgency (no end-organ damage) vs. emergency (end-organ damage).
›Key change from prior JNC 7 guidelines: The threshold for Stage 1 HTN was lowered from 140/90 to 130/80 mmHg in 2017. This significantly expanded the diagnosed population but focuses earlier intervention on high-risk patients.

Proper Blood Pressure Measurement

›Accurate BP measurement is deceptively difficult. Errors in technique are extremely common and lead to misclassification, over- and under-treatment.
›Preparation: Patient should be seated quietly for 5 minutes before measurement. No caffeine or tobacco for 30 minutes prior. Bladder should be empty. No talking during measurement.
›Positioning: Patient seated with back supported, feet flat on floor (not dangling). Arm at heart level, supported. No crossing of legs.
›Cuff size: Critical. An undersized cuff overestimates BP; an oversized cuff underestimates it. The cuff bladder should encircle 80% of the arm circumference.
›Technique: Place cuff on bare arm, 2–3 cm above the antecubital fossa. Take 2–3 readings, 1 minute apart. Average the readings. Document which arm and note any significant difference between arms (>10–15 mmHg difference warrants further evaluation).
›Ambulatory BP monitoring (ABPM): Gold standard for diagnosing white coat and masked hypertension. Records BP over 24 hours during normal daily activities.
›Home BP monitoring: A useful adjunct. Patient records BP at home — helps identify white coat HTN and assess response to therapy. Instruct proper technique.

White Coat and Masked Hypertension

›White coat hypertension: BP is elevated in the clinic setting but normal outside the clinic. Affects 15–30% of patients with apparent stage 1–2 HTN. Associated with slightly increased cardiovascular risk compared to truly normal BP, but less than sustained HTN. ABPM or home BP monitoring can confirm.
›Masked hypertension: BP appears normal in the clinic but is elevated outside (at home, at work). More dangerous than white coat HTN — associated with increased target organ damage and cardiovascular events. ABPM is the best tool to identify.
›Clinical pearl: When in-clinic BP is elevated but the patient appears low-risk and says their home readings are normal, consider ABPM or structured home monitoring before initiating pharmacotherapy.

First-Line Antihypertensive Drug Classes

›Thiazide diuretics (e.g., hydrochlorothiazide, chlorthalidone): First-line for most uncomplicated HTN. Chlorthalidone has superior evidence. Watch for hyponatremia, hypokalemia, and gout.
›ACE inhibitors (e.g., lisinopril, ramipril): First-line for patients with diabetes, CKD with proteinuria, heart failure, or post-MI. Do not use in bilateral renal artery stenosis or pregnancy. Main side effect: dry cough (~10% of patients).
›Angiotensin receptor blockers — ARBs (e.g., losartan, valsartan): Equivalent to ACEi with better tolerability (no cough). Same indications. Do not combine ACEi + ARB.
›Calcium channel blockers — CCBs: Dihydropyridine type (amlodipine, nifedipine): Peripheral vasodilators, good for isolated systolic HTN and older adults. Non-dihydropyridine type (diltiazem, verapamil): Rate-lowering, useful in AFib with HTN but avoid in systolic HF and with beta-blockers (AV block risk).
›Beta-blockers (e.g., metoprolol, carvedilol, atenolol): Not first-line for uncomplicated HTN per ACC/AHA 2017, but compelling indications include heart failure with reduced EF, post-MI, and AFib rate control.
›RAAS combination caution: Do not combine ACEi + ARB or ACEi/ARB + direct renin inhibitor (aliskiren) — increased risk of hypotension, renal failure, and hyperkalemia.

Compelling Indications for Specific Drug Classes

›Diabetes + CKD with proteinuria: ACEi or ARB (nephroprotective).
›Heart failure with reduced EF (HFrEF): ACEi/ARB/ARNI + beta-blocker + MRA + SGLT2i.
›Post-MI: Beta-blocker + ACEi/ARB (reduce remodeling and mortality).
›Isolated systolic hypertension in elderly: Thiazide or dihydropyridine CCB.
›Recurrent stroke prevention: Thiazide or ACEi (PROGRESS trial).
›Gout: Avoid thiazides; losartan has mild uricosuric properties.
›Pregnancy: Safe options include labetalol, hydralazine, nifedipine. ACEi/ARB are contraindicated (teratogenic).
›Bilateral renal artery stenosis: Avoid ACEi/ARB — can precipitate acute renal failure.

Hypertensive Urgency vs. Emergency

›Hypertensive urgency: BP severely elevated (>180/120) WITHOUT signs of acute end-organ damage. Patient may be asymptomatic or have headache. Management: oral medications, gradual BP reduction over 24–48 hours. Does not require ICU admission. Identify and address precipitants (missed medications, pain, anxiety).
›Hypertensive emergency: Severely elevated BP WITH evidence of acute end-organ damage. This is a true medical emergency requiring hospital admission, IV antihypertensives, and intensive monitoring.
›End-organ damage in hypertensive emergency: Hypertensive encephalopathy (confusion, headache, seizure), hemorrhagic or ischemic stroke, acute MI, acute aortic dissection, acute decompensated heart failure, hypertensive retinopathy with papilledema, eclampsia/HELLP, acute kidney injury.
›Key distinction: The height of the BP does not define emergency — the presence or absence of end-organ damage does. A patient with BP 200/120 and no symptoms may be urgency. A patient with BP 170/110, confusion, and papilledema is an emergency.

DASH Diet Basics

›The DASH (Dietary Approaches to Stop Hypertension) diet is one of the most studied dietary patterns for blood pressure reduction. The DASH diet reduces SBP by 8–14 mmHg in studies.
›Emphasize: fruits, vegetables, whole grains, low-fat dairy, fish, nuts, and legumes.
›Reduce: sodium (target <2,300 mg/day; ideally <1,500 mg for higher-risk patients), saturated fats, red meat, sweets, and sugary beverages.
›Sodium restriction alone reduces SBP by ~5–6 mmHg in hypertensive patients.
›Combined lifestyle approach: DASH diet + weight loss + regular exercise + sodium restriction + alcohol limitation can reduce BP by 10–20 mmHg — equivalent to one antihypertensive medication.

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Clinical Cheat Sheet

2017 ACC/AHA BP Classification

•Normal: <120/<80 mmHg
•Elevated: 120–129/<80 mmHg
•Stage 1 HTN: 130–139/80–89 mmHg
•Stage 2 HTN: ≥140/≥90 mmHg
•Hypertensive Crisis: >180/>120 mmHg
•Urgency = no end-organ damage | Emergency = end-organ damage

Proper BP Measurement

•Seat quietly 5 min before measurement
•No caffeine or tobacco 30 min prior
•Back supported, feet flat, arm at heart level
•Correct cuff size (encircles 80% of arm)
•Cuff on bare arm, 2–3 cm above antecubital
•Average 2–3 readings, 1 min apart
•Check both arms at first visit

First-Line Medications

•Thiazides: Uncomplicated HTN; chlorthalidone preferred
•ACEi/ARB: DM, CKD proteinuria, HFrEF, post-MI
•Dihydropyridine CCB (amlodipine): Elderly, isolated systolic HTN
•Beta-blockers: HFrEF, post-MI, AFib rate control (not first-line alone)
•Do NOT combine ACEi + ARB
•ACEi/ARB contraindicated in pregnancy and bilateral RAS

Hypertensive Emergency Signs

•Confusion or altered mental status
•Severe headache with nausea/vomiting
•Vision changes or papilledema
•Chest pain (ACS or dissection)
•Acute shortness of breath
•Focal neurologic deficits (stroke)
•Acute kidney injury
•Eclampsia / HELLP in pregnancy

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Nurse Assessment Checklist

Ensure accurate BP measurement and gather relevant history for hypertension evaluation and follow-up.

BP Measurement Protocol

Patient seated quietly for at least 5 minutes before measuring
No caffeine or tobacco in the 30 minutes prior
Select appropriate cuff size
Arm at heart level, back supported, feet flat
No talking during measurement
Record 2–3 readings, 1 minute apart
Average readings and document
Note which arm was used
If first visit, check both arms

Symptoms to Ask About

Headache — location, severity, how long?
Visual changes or blurry vision?
Dizziness or lightheadedness?
Nausea or vomiting?
Chest pain or pressure?
Shortness of breath?
Confusion or difficulty speaking?
Nosebleed (epistaxis)?

Medication Adherence

Which BP medications is the patient taking?
Are they taking them every day?
Any missed doses — how many?
Any side effects (cough from ACEi, swelling, dizziness)?
Any new medications — OTC, supplements, NSAIDs?
Any new use of decongestants (pseudoephedrine) or stimulants?

Escalate Immediately If

BP >180/120 mmHg
Any neurologic symptom (confusion, weakness, slurred speech)
Severe headache with vision changes
Chest pain or severe shortness of breath
Patient appears altered or unwell
Pregnancy with elevated BP (preeclampsia concern)

Report to Provider

Current and prior BP readings (today and trend)
Symptoms and their onset
Medication adherence and any side effects
Home BP readings if available
Recent labs (BMP, potassium, creatinine)
Relevant history: DM, CKD, heart failure, stroke

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Patient Education Handout

What is High Blood Pressure?

Blood pressure is the force of blood pushing against the walls of your arteries.
High blood pressure (hypertension) means this pressure is too high for too long.
Normal blood pressure is less than 120/80. High blood pressure starts at 130/80 or higher.
High blood pressure usually has no symptoms. That is why it is called the "silent killer."
Over time, high blood pressure damages your heart, brain, kidneys, and blood vessels.

Why It Matters

Uncontrolled high blood pressure raises your risk of:
•Heart attack
•Stroke
•Heart failure
•Kidney damage
•Vision loss
The good news: controlling your blood pressure greatly reduces these risks.

Your Blood Pressure Goal

Your doctor will give you a personal blood pressure goal.
For most people, the goal is less than 130/80.
Check your blood pressure at home or at the pharmacy regularly.
Bring your home readings to your appointments.

DASH Diet — Eating for Your Heart

Eat more: fruits, vegetables, whole grains, low-fat dairy, beans, nuts, and fish.
Eat less: salt (sodium), red meat, fried foods, sugary drinks, and processed snacks.
Use less salt when cooking. Do not add extra salt at the table.
Read food labels. Choose foods with less than 600 mg of sodium per serving.
The DASH diet can lower blood pressure by up to 14 points on its own.

Other Lifestyle Changes That Help

Be active: Walk 30 minutes most days. Even 10 minutes at a time adds up.
Lose weight if needed: Even losing 5–10 pounds can lower blood pressure.
Limit alcohol: No more than 1 drink per day for women, 2 for men.
Quit smoking: Smoking raises blood pressure and damages blood vessels.
Manage stress: Try deep breathing, prayer, walking, or talking to someone you trust.

Your Blood Pressure Medicines

Take your medicine every day, even when you feel fine.
High blood pressure has no symptoms — you cannot feel when it is high.
Do not stop your medicine without talking to your doctor.
Tell your doctor if you have side effects like cough, dizziness, or swelling.
Do not take ibuprofen or naproxen — these can raise blood pressure.

When to Seek Urgent Help

Call 911 immediately if you have:
•Sudden severe headache
•Confusion or trouble speaking
•Vision changes
•Chest pain or shortness of breath
•Sudden weakness or numbness
These may be signs of a stroke or hypertensive emergency.

This handout is for education only and does not replace medical advice from your healthcare team.

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Spanish / Communication Phrases

Interpreter Notice: These phrases are for basic communication and rapport only. Use a certified medical interpreter for diagnosis, treatment decisions, medication changes, consent, discharge instructions, and all complex clinical conversations.

Your blood pressure is very high today.

Su presión arterial está muy alta hoy.

Do you have a headache?

¿Tiene dolor de cabeza?

Are you taking your blood pressure medicine?

¿Está tomando su medicina para la presión?

Have you missed any doses?

¿Se le ha olvidado tomar alguna dosis?

Do you check your blood pressure at home?

¿Se toma la presión en su casa?

Please sit still and relax for 5 minutes.

Por favor, siéntese tranquilo y relájese por cinco minutos.

Try to eat less salt.

Trate de comer menos sal.

Do you have any chest pain or trouble breathing?

¿Tiene dolor en el pecho o dificultad para respirar?

Are you having any vision changes?

¿Tiene algún cambio en la visión?

We need an interpreter to explain your blood pressure plan.

Necesitamos un intérprete para explicar su plan para la presión.

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Sim Patient Case

Cardiology ClinicInteractive

Patient

[EN] 61-year-old Spanish-speaking female with no prior hypertension diagnosis. Referred from primary care for BP elevation. [ES] Mujer de 61 años, hispanohablante, sin diagnóstico previo de hipertensión. Referida desde atención primaria por elevación de presión arterial.

Chief Complaint

[EN] "I have a terrible headache and my vision is blurry. I haven't taken my blood pressure medicine in a week." [ES] "Tengo un dolor de cabeza terrible y mi visión está borrosa. No he tomado mi medicina para la presión en una semana."

Vitals

BP (right arm)

178/104 mmHg

BP (left arm)

174/100 mmHg

88 bpm

16 breaths/min

SpO2

98%

Temp

98.4°F

Goal

[EN] Classify BP, identify urgency vs. emergency, assess for end-organ damage, choose appropriate management, and plan patient education. [ES] Clasifique la presión arterial, identifique si es urgencia o emergencia, evalúe el daño a órganos diana, elija el manejo apropiado y planifique la educación del paciente.

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Knowledge Check Quiz

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Disclaimer: This content is for educational purposes only. It is not medical advice, does not replace clinical judgment, and is not a substitute for institutional protocols or certified medical interpreters. No patient health information (PHI) should be entered into this application.