ABIM - Hypertension Definitions & Etiologies

Here are key facts for ABIM from the Hypertension Overview tutorial, as well as points of interest at the end of this document that are not directly addressed in this tutorial but should help you prepare for the boards. See the tutorial notes for further details and relevant links.

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• Normal: <120/<80 mmHg
• Elevated: 120–129/<80 mmHg
• Stage 1: 130–139 or 80–89 mmHg
• Stage 2: ≥140 or ≥90 mmHg
• Use average of 2+ readings on 2+ separate visits for diagnosis.

• Accounts for 90–95% of adult cases.
• Etiology: multifactorial (genetic predisposition + lifestyle).
• Risk factors: obesity, excess sodium, sedentary lifestyle, smoking, alcohol, chronic stress, family history.

• Evaluate in:
• Onset <30 years without risk factors
• Abrupt onset or worsening
• Resistant hypertension (uncontrolled on ≥3 meds)
• Signs of end-organ damage out of proportion to BP

• Common causes:
• Renal artery stenosis (atherosclerosis or fibromuscular dysplasia)
• Primary aldosteronism (HTN + hypokalemia)
• Obstructive sleep apnea
• Pheochromocytoma (paroxysmal HTN)
• Cushing syndrome
• Coarctation of the aorta
• Medications (NSAIDs, decongestants, OCPs, steroids)

• Labs: BMP, UA, lipids, A1c, TSH
• ECG: assess for LVH or ischemia
• Assess for end-organ damage and secondary causes as indicated

• Initiate treatment if:
• Stage 1 HTN + ASCVD or 10-year risk ≥10%
• Stage 2 HTN (≥140/90 mmHg)
• BP goal: <130/80 mmHg for most patients

• DASH diet, sodium restriction (<1500 mg/day), aerobic exercise
• Weight loss (5–10% body weight), smoking cessation, limit alcohol

• Thiazide diuretics, ACE inhibitors/ARBs, CCBs
• Based on comorbidities:
• Black patients: CCB or thiazide
• CKD or proteinuria: ACEi or ARB
• CAD/post-MI: beta-blocker + ACEi/ARB
• Diabetes: ACEi/ARB preferred if albuminuria

• Hypertensive urgency: BP ≥180/≥120 without acute end-organ damage
• Manage with oral agents over 24–48 hrs
• Hypertensive emergency: same BP with damage (e.g., stroke, MI, AKI)
• Admit to ICU, give IV agents (e.g., labetalol, nicardipine)
• Lower MAP by ≤25% in first hour, avoid rapid correction

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• Uncontrolled BP on ≥3 drugs (including a diuretic)
• Causes:
• Poor adherence
• Inadequate dosing
• Secondary hypertension
• Drug interactions (e.g., NSAIDs)
• Evaluate with ambulatory BP monitoring

• White coat: high in office only
• Masked: normal in office, high at home
• Use ambulatory or home BP monitoring

• Suspect with HTN + unexplained hypokalemia
• Screen: aldosterone-renin ratio
• Confirm: saline suppression test
• Imaging: adrenal CT
• Management: surgery or spironolactone/eplerenone

• Clues: abdominal bruit, recurrent flash pulmonary edema, renal asymmetry
• Diagnosis:
• Initial: Doppler ultrasound
• Best: CT or MR angiography
• Gold standard: renal arteriography

• Classic triad: headache, palpitations, sweating
• Labs: plasma free metanephrines
• Management: alpha-blocker (phenoxybenzamine) → beta-blocker → surgery

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• Diabetes or CKD: initiate treatment at ≥130/80 mmHg
• Pregnancy:
• First-line: labetalol, nifedipine, methyldopa
• Avoid ACEi/ARBs, thiazides
• Elderly (>65): target <130/80, but avoid hypotension or falls

• Reassess BP and labs 4 weeks after starting or adjusting treatment
• Monitor for medication side effects, electrolyte changes
• Address adherence, cost, and polypharmacy