PANCE - Hypertension Definitions & Etiologies

Here are key facts for PANCE 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 HTN: 130–139 or 80–89 mmHg
• Stage 2 HTN: ≥140 or ≥90 mmHg
• Diagnosis requires 2+ readings on 2+ separate visits.

• 90–95% of adult cases.
• Multifactorial: genetic predisposition, obesity, high salt diet, sedentary lifestyle, alcohol/smoking, stress.

• Clues: young onset, resistant HTN, or target organ damage out of proportion to BP.
• Common causes:
• Renovascular disease: renal artery stenosis (fibromuscular dysplasia or atherosclerosis).
• Primary aldosteronism: HTN + hypokalemia.
• Pheochromocytoma: episodic HTN, sweating, headache.
• Cushing syndrome: central obesity, purple striae, glucose intolerance.
• Coarctation of the aorta: arm-leg BP discrepancy, diminished femoral pulses.
• Obstructive sleep apnea: fatigue, snoring.
• Medications: NSAIDs, decongestants, OCPs, steroids.

• Labs:
• Basic metabolic panel, CBC, lipid panel, TSH, UA, ECG, A1c
• Look for:
• End-organ damage (LVH, proteinuria)
• Secondary causes if clinically suspected

• Start pharmacologic treatment at:
• ≥130/80 mmHg in patients with ASCVD or 10-year risk ≥10%
• ≥140/90 mmHg in low-risk patients
• BP Goal: <130/80 mmHg for most patients

• Weight loss, DASH diet, sodium restriction, aerobic exercise, smoking cessation, alcohol moderation.

• Thiazide diuretics
• ACE inhibitors / ARBs
• Calcium channel blockers
• Initial choice depends on comorbidities:
• Black patients: CCB or thiazide
• CKD or proteinuria: ACEi or ARB
• Diabetes: ACEi/ARB preferred
• Post-MI or heart failure: beta blocker + ACEi/ARB

• Emergency: BP ≥180/≥120 + end-organ damage (e.g., stroke, MI, encephalopathy, AKI)
• Treat with IV antihypertensives (labetalol, nicardipine)
• Urgency: same BP, but no damage
• Treat with oral meds and close outpatient follow-up

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• Uncontrolled BP on ≥3 meds (including a diuretic)
• Evaluate for:
• Noncompliance
• Secondary causes
• Drug interactions
• Consider ambulatory BP monitoring

• White coat: elevated in office, normal at home.
• Masked: normal in office, elevated at home.
• Confirm with ambulatory BP monitoring.

• Common in African Americans, elderly, post-menopausal women.
• Responds well to sodium reduction and thiazide diuretics.

• First-line: labetalol, nifedipine, methyldopa.
• Avoid: ACEi, ARBs, diuretics.
• Monitor for pre-eclampsia: new-onset HTN + proteinuria or end-organ damage after 20 weeks.

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• Screening test for primary aldosteronism.
• High ratio = suggests diagnosis, confirm with saline suppression test.

• Common in young females, renovascular HTN.
• String-of-beads pattern on angiography.

• Labs: plasma or 24h urine metanephrines
• Pre-op: alpha-blocker (phenoxybenzamine), then beta-blocker

• Low-dose dexamethasone suppression test
• 24-hour urinary free cortisol
• Late-night salivary cortisol