USMLE/COMLEX 2 - Hypertension Definitions & Etiologies

Here are key facts for USMLE Step 2 & COMLEX-USA Level 2 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 multiple readings in clinical and home settings.

• Accounts for 90–95% of cases.
• Multifactorial: genetics, obesity, salt sensitivity, sedentary lifestyle, alcohol/smoking, stress.

• Suspect in young patients (<30), sudden onset, resistant HTN, or target-organ damage out of proportion to severity.

• Caused by renal artery stenosis due to atherosclerosis or fibromuscular dysplasia.
• Clues: resistant HTN, abdominal bruit, recurrent flash pulmonary edema, or asymmetric kidney size.
• Diagnostic test: CT angiogram or Doppler US (initial); renal arteriography (gold standard).

• Suspect with HTN + unexplained hypokalemia.
• Screening: plasma aldosterone-to-renin ratio.
• Confirmatory testing: saline infusion or oral salt loading test.
• Imaging: CT adrenal glands.

• Paroxysmal HTN + triad: headache, sweating, palpitations.
• Labs: plasma or 24h urine metanephrines.
• Pre-op: alpha-blockade (phenoxybenzamine) before beta-blockade.

• HTN + central obesity + glucose intolerance + muscle weakness + striae.
• Diagnosis: low-dose dexamethasone suppression test, 24h urinary cortisol, or late-night salivary cortisol.

• HTN in upper extremities, low BP in lower, diminished femoral pulses.
• Diagnosis: echocardiography, CTA, or MRI.

• Common secondary cause in obese patients with daytime fatigue/snoring.
• Evaluate with polysomnography.

• White coat: elevated in office only.
• Masked HTN: normal in office, elevated at home.
• Use ambulatory BP monitoring to differentiate.

• Weight loss, DASH diet, reduced salt, exercise, smoking/alcohol cessation.

• Thiazide diuretics, ACE inhibitors, ARBs, CCBs.
• Choice depends on comorbidities (e.g., CKD → ACEi/ARB, Black patients → thiazide/CCB).

• Urgency: ≥180/≥120 without end-organ damage.
• Emergency: same BP but + target organ damage (e.g., encephalopathy, MI, AKI).
• Emergency requires IV meds and gradual BP reduction.

• Gestational HTN: >140/90 after 20 weeks without proteinuria.
• Pre-eclampsia: HTN + proteinuria or signs of end-organ damage.

• Black patients: start with thiazide or CCB unless CKD present.
• CKD/Proteinuria: start with ACEi or ARB regardless of race.

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• Salt-sensitive patients (e.g., elderly, African Americans) respond more to sodium reduction.
• DASH diet = high in fruits, vegetables, low-fat dairy, and low sodium.

• Defined as BP uncontrolled on 3 drugs, including a diuretic.
• Rule out secondary causes.

• Drugs: NSAIDs, stimulants, decongestants, OCPs, glucocorticoids, herbal agents.

• Heart: LV hypertrophy, heart failure, CAD.
• Brain: stroke, encephalopathy.
• Kidneys: CKD, proteinuria.
• Eyes: hypertensive retinopathy.

• Office BP + home or ambulatory monitoring confirms diagnosis and detects masked/white coat HTN.

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• Primary aldosteronism
• Diuretic overuse
• Cushing syndrome
• Renovascular disease (with renin-aldosterone activation)

• Systolic HTN more predictive of CV risk, especially in elderly (due to arterial stiffness).

• Common in young adults; generally lower CV risk but still requires follow-up.

• Safe meds: labetalol, nifedipine, methyldopa.
• ACEi/ARBs and diuretics are contraindicated.