---

🩺 HYPERTENSION - Internal Medicine Notes

Made Easy | Exam Oriented | High Yield

---

📦 QUICK OVERVIEW BOX

🔑 Exam Rule: If SBP and DBP fall in different stages → assign the HIGHER category. e.g., 162/92 = Stage 3 HTN | 134/72 = Stage 1 HTN

---

1️⃣ CLASSIFICATION

ACC/AHA 2017 Guidelines (Most Current - Know This!)

Normal       <120  AND  <80
Elevated    120-129 AND  <80
Stage 1     130-139 OR  80-89
Stage 2      ≥140  OR   ≥90

JNC 7 Classification (Older but still tested!)

⚠️ Exam Trap: JNC 7 has "Prehypertension" as one category; ACC/AHA 2017 splits this into "Normal" + "Elevated" + "Stage 1". The ACC/AHA 2017 set the treatment threshold lower (≥130/80 vs ≥140/90).

---

2️⃣ EPIDEMIOLOGY - HIGH YIELD FACTS

• Worldwide prevalence is INCREASING (aging population + obesity)
• In USA - control rates are <50% despite effective medications
• In low/middle-income countries - control rates as low as 8-14%
• 3 main culprits for poor control: Unrecognized HTN + Patient non-adherence + Clinician inertia
• HTN is a major risk factor for: MI, Stroke, HF, Atrial Fibrillation, CKD, Dementia

Modifiable Risk Factors (Mnemonic: SLEEP AD)

• S - Sodium excess
• L - Lifestyle (sedentary)
• E - Excessive weight gain / obesity
• E - Ethanol (excess alcohol)
• P - Poor diet (low potassium, low fruit/vegetable)
• A - Activity (reduced physical activity)
• D - Dyslipidemia (associated modifiable)

---

3️⃣ PATHOPHYSIOLOGY

Primary (Essential) Hypertension (95% of all cases)

No identifiable single cause - multifactorial

Key Mechanisms:

RAAS Overactivity
    → Angiotensin II ↑ → Vasoconstriction + Aldosterone ↑
    → Aldosterone → Na+ & H2O retention → Volume ↑
    → BP ↑

Sympathetic Nervous System Overactivity
    → Heart rate ↑ + Cardiac output ↑
    → Vasoconstriction → SVR ↑
    → BP ↑

Impaired Renal Pressure Natriuresis
    → Kidneys fail to excrete Na+ at normal BP
    → Volume overload → BP ↑

Endothelial Dysfunction
    → Reduced Nitric Oxide (NO) → Vasodilation ↓
    → Increased Endothelin-1 → Vasoconstriction ↑

Structural Vascular Changes
    → Arteriolar hypertrophy → Increased SVR

Salt Sensitivity:

• Reduced glomerular filtration coefficient (Kf) → decreased natriuresis → salt-sensitive HTN
• Key in elderly, Black patients, diabetics, CKD patients

Secondary Hypertension (5% of all cases)

⭐ Always suspect secondary HTN in: Young patients, Resistant HTN, Hypokalemia, Abrupt onset

Causes (Mnemonic: CRAMP)

🔑 Exam Favorite: Primary Hyperaldosteronism = Most Common Cause of Secondary HTN

---

4️⃣ DIAGNOSIS & MEASUREMENT

Proper BP Measurement (Box 46.1 Rules)

• Patient sits quietly for ≥5 minutes before measurement
• Use appropriate cuff size (cuff covers 80% arm circumference)
• Arm supported at heart level
• Two readings on ≥2 separate occasions needed for diagnosis
• Use Korotkoff Phase V (disappearance of sounds) for diastolic

Types of Hypertension

ABPM (Ambulatory Blood Pressure Monitoring)

• Gold standard for confirming White Coat / Masked HTN
• Removes human error
• More predictive of outcomes than office BP

---

5️⃣ TARGET ORGAN DAMAGE (TOD)

Mnemonic: BRAIN-HEK

• B - Brain: Stroke, TIA, Encephalopathy, Dementia
• R - Retina: Retinopathy (Keith-Wagener-Barker classification)
• A - Aorta: Aortic dissection, Aortic aneurysm
• I - Ischemic Heart: LVH, MI, Heart failure
• N - —
• H - Heart: LVH, HFpEF, Diastolic dysfunction
• E - Eye: Papilledema (hypertensive emergency), hemorrhages
• K - Kidneys: CKD, Proteinuria, Nephrosclerosis

Keith-Wagener-Barker Retinal Changes

---

6️⃣ SECONDARY HYPERTENSION - DETAILED WORKUP

When to Suspect Secondary HTN:

1. Age <30 years
2. Resistant HTN (uncontrolled on ≥3 drugs)
3. Sudden onset or rapidly progressive
4. Hypokalemia (especially unexplained)
5. Abdominal bruit (renovascular)
6. Episodic symptoms (pheochromocytoma)

Investigation Summary

---

7️⃣ TREATMENT

Step 1: Lifestyle Modifications (MANDATORY in ALL patients)

Mnemonic: DASH-SW

• D - DASH Diet (fruits, vegetables, low-fat dairy, low sodium)
• A - Alcohol restriction (<20g/day women; <40g/day men)
• S - Sodium restriction (<2.4g/day)
• H - Heart rate/Physical activity (aerobic exercise ≥150 min/week)
• S - Smoking cessation
• W - Weight reduction (target BMI 18.5-24.9)

📊 Expected BP Reduction from Lifestyle:

• DASH diet alone: ↓8-14 mmHg
• Sodium restriction: ↓2-8 mmHg
• Weight loss (10kg): ↓5-10 mmHg
• Exercise: ↓4-9 mmHg
• Alcohol restriction: ↓2-4 mmHg

---

Step 2: Pharmacological Treatment

First-Line Drug Classes (Remember: ACE-D or ABCD)

⭐ Beta-blockers are NOT first-line for essential HTN (inferior for stroke prevention); reserved for post-MI, AF, HF

---

Drug of Choice by Compelling Indication (HIGH YIELD TABLE)

Drugs to AVOID

---

BP Treatment Targets (2017 ACC/AHA)

🔑 SPRINT Trial: Intensive treatment (<120 mmHg SBP) reduced cardiovascular events but was stopped early due to benefit; increased risk of AKI + electrolyte disturbances

---

8️⃣ HYPERTENSIVE URGENCY vs EMERGENCY

⭐ THE MOST IMPORTANT DISTINCTION - Exam loves this!

Target Organ Damage in Emergency (Mnemonic: PANE-S)

• P - Papilledema / Retinal hemorrhage
• A - Acute MI / Acute LVF / Acute aortic dissection
• N - Neurological (Hypertensive Encephalopathy, Stroke, Seizure)
• E - Eclampsia (in pregnancy)
• S - AKI (Serum creatinine rising)

IV Drugs for Hypertensive Emergency

⚠️ Classic Trap: In Aortic Dissection - NEVER use vasodilators alone (reflex tachycardia worsens shear force). Use BB FIRST (Esmolol/Labetalol) to control heart rate, THEN add vasodilator.

⚠️ Pheochromocytoma: Give Alpha-blocker FIRST (Phentolamine/Phenoxybenzamine), THEN beta-blocker. Never give BB first (causes paradoxical severe HTN from unopposed alpha stimulation)

Oral Drugs for Hypertensive Urgency

• Captopril (oral) - fast onset ACEI
• Clonidine (oral) - central alpha-2 agonist; useful for rapid control
• Labetalol (oral)
• Amlodipine (oral)
• Avoid Nifedipine sublingual - uncontrolled rapid BP drop → risk of stroke/MI

---

9️⃣ RESISTANT HYPERTENSION

Defined as: BP >140/90 despite ≥3 drugs at optimal doses (including a diuretic) OR requiring ≥4 drugs to achieve BP control

Causes of Pseudoresistance (Rule Out First!)

• White coat effect
• Poor technique / wrong cuff size
• Non-adherence to medications
• Inadequate drug doses

True Resistant HTN - Causes

1. Volume overload (most common) - inadequate diuretic use, excess salt
2. Drug interactions - NSAIDs, OCPs, decongestants, stimulants, licorice
3. Obstructive Sleep Apnea - commonly missed
4. Secondary HTN (see above)

Treatment of Resistant HTN

1. Maximize diuretic dose (chlorthalidone preferred over HCTZ)
2. Add Spironolactone (4th drug of choice - best evidence)
3. Consider Eplerenone, Amiloride
4. Renal Denervation (catheter-based - for well-defined resistant HTN)
5. Investigate for secondary causes

---

🔟 SPECIAL POPULATIONS

Hypertension in Elderly

• More likely to have Isolated Systolic HTN (arterial stiffness)
• More sensitive to volume depletion and postural hypotension
• Prefer CCB or Thiazide for initial therapy
• Target <130/80 mmHg (SPRINT evidence supports this even in elderly)
• Start low doses and titrate up slowly ("Start low, go slow")
• Risk of J-curve (too low DBP → coronary underperfusion) - monitor carefully

Hypertension in Pregnancy

⭐ ACEI and ARBs are ABSOLUTELY CONTRAINDICATED in pregnancy ⭐ Magnesium Sulfate - used for seizure prophylaxis and treatment in eclampsia (NOT an antihypertensive)

Hypertension in Black Patients

• Higher prevalence, earlier onset, more severe, greater end-organ damage
• More volume-dependent (low renin state) → Respond BETTER to CCBs and Thiazides
• Respond LESS to ACEI/ARB monotherapy as first-line
• Often require triple therapy
• CCB + Thiazide diuretic = preferred combination

Hypertension in Diabetes

• Target BP: <130/80 mmHg
• First-line: ACEI or ARB (renoprotective + reduce proteinuria)
• Add CCB or Thiazide as second drug
• AVOID: Thiazides + BB together (worsen insulin resistance/glucose control)

Hypertension in CKD

• Target: <130/80 mmHg
• Non-proteinuric CKD: Any first-line drug
• Proteinuric CKD: ACEI first-line (ARB if intolerant)
• Monitor potassium and creatinine closely when starting ACEI/ARB
• Do NOT combine ACEI + ARB (dual RAS blockade - increased AKI, hyperkalemia, no added CV benefit)

---

1️⃣1️⃣ ANTIHYPERTENSIVE DRUG SUMMARY TABLE

---

1️⃣2️⃣ HIGH-YIELD EXAM MNEMONICS SUMMARY

🔴 ABCD First Line Drugs

🔴 Compelling Contraindications - Exam Favourite

🔴 Side Effect Memory Tricks

• ACE inhibitors → Angioedema + Argh (cough)
• SpironoLACTONE → GYnecomastia (Spiro is "lactone" - anti-testosterone effect)
• Clonidine → Classic rebound (don't stop suddenly!)
• Hydralazine → Hydrala-LUPUS
• Thiazides → GLUCose ↑, URATE ↑, LDL ↑, Ca²⁺ ↑, K+ ↓ (think: Gout Loves U, Ca²⁺ Too)

---

1️⃣3️⃣ SPRINT TRIAL - KNOW THIS!

• SPRINT = Systolic Blood Pressure Intervention Trial
• Compared intensive target (<120 mmHg SBP) vs standard (<140 mmHg SBP)
• Stopped early due to benefit in intensive group
• Intensive therapy reduced: CV events, HF, death
• BUT increased: AKI, Electrolyte disturbances, Hypotension, Syncope
• Excluded: Diabetics, Stroke history, CKD with proteinuria, Age <50
• Harrison's & ACC/AHA 2017 use these findings to support <130/80 target

---

1️⃣4️⃣ ALLHAT TRIAL

• ALLHAT = Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial
• Compared: Chlorthalidone vs Amlodipine vs Lisinopril vs Doxazosin
• Chlorthalidone won - best for preventing strokes, HF
• Doxazosin arm stopped early (higher HF events)
• Showed CCBs and Diuretics as strong first-line choices
• In Black patients → Chlorthalidone and Amlodipine were most effective
• ALLHAT showed chlorthalidone reduced HFpEF by 50%

---

1️⃣5️⃣ ISOLATED TYPES - EXAM PEARLS

Isolated Systolic HTN (ISH)

• Most common in elderly >65 years
• Caused by arterial stiffness and atherosclerosis
• Wide pulse pressure (>60 mmHg)
• Predicts coronary disease in elderly
• Treat with: CCB, Thiazide, ACEI, ARB

White Coat HTN

• BP high in clinical setting, normal at home/ambulatory
• Confirm with ABPM (gold standard) or Home BP monitoring
• Not entirely benign - may progress to true HTN
• Consider lifestyle modification

Masked HTN

• Normal in office, high at ambulatory reading
• More dangerous than white coat HTN (increases CV risk)
• More common in smokers, DM, CKD

---

📝 QUICK REVISION TABLE - DRUGS IN SPECIAL CONDITIONS

---

⚡ FINAL HIGH-YIELD EXAM BUZZ POINTS

🔥 Exam One-Liners - Memorize These

1. Normal BP = <120/<80 mmHg (ACC/AHA 2017)
2. HTN Treatment threshold = ≥130/80 mmHg with CVD risk >10% (or always for Stage 2)
3. Most common cause Secondary HTN = Primary Hyperaldosteronism
4. Screener for Primary Hyperaldosteronism = Aldosterone:Renin Ratio (ARR)
5. Drug of choice in pregnancy = Methyldopa
6. Drug to treat eclamptic seizures = Magnesium Sulfate (NOT an antihypertensive)
7. ACEI side effect = Dry cough (due to bradykinin accumulation)
8. First dose hypotension = Alpha-blockers (Prazosin)
9. Rebound HTN on withdrawal = Clonidine
10. Drug-induced lupus = Hydralazine
11. Gynecomastia = Spironolactone
12. 4th drug for resistant HTN = Spironolactone
13. Hypertensive emergency → Target: Reduce BP by 20-25% in first hour
14. Don't use sublingual Nifedipine in urgency (uncontrolled drop → stroke/MI)
15. BB given BEFORE alpha-blocker in pheo = Paradoxical hypertensive crisis (classic trap!)
16. Chlorthalidone > HCTZ (longer half-life, better outcomes in ALLHAT)
17. SPRINT Trial target = <120 mmHg SBP (reduced CV events)
18. LVH treatment = Losartan (LIFE trial) - regresses LV mass better than Atenolol

---

---