Hypertension PEARLS - Essential Hypertension, Hypertensive emergencies, Secondary hypertension (Smarty PANCE)
Define an elevated blood pressure
120-129 and < 80
Define stage 1 hypertension
130-139 or 80-89
Causes leg edema
CCB
Cuff bladder should be ____% of arm width?
Cuff bladder should be 40% of arm width
Cuff bladder should be ____% of arm circumference?
Cuff bladder should be 80% of arm circumference
Diagnosis of hypertensive emergencies
Diagnosis is by BP measurement, ECG, urinalysis, ophthalmic exam, and serum BUN and creatinine measurements
What is essential (primary) hypertension?
Essential hypertension, also known as primary hypertension, is elevated blood pressure that occurs without a single, identifiable secondary cause. ● It is the most common form of hypertension, accounting for the vast majority of cases ● Its etiology is a complex interplay of genetic, behavioral (e.g., diet quality, physical activity), and environmental factors across the lifespan
Recommended treatment for stage 1 HTN in all patients requiring treatment, including those with diabetes?
For all patients, including those with diabetes: Initial treatment should be with either: ● ACE inhibitor or ARB ● Long-acting calcium channel blockers (most often a dihydropyridine such as amlodipine) ● Thiazide-like diuretic (chlorthalidone or indapamide)
What are the AAP guidelines for high blood pressure (BP) screening in children and adolescents
For children without risk factors or conditions associated with HTN, BP is measured beginning at three years of age during annual health supervision visits
What are the preferred IV agents and BP goal for a hypertensive emergency due to acute aortic dissection?
Goal: Rapidly lower Systolic BP to ≤120 mm Hg within 20 minutes ● Preferred Agents: Start with an IV beta-blocker like esmolol or labetalol to control heart rate before using a vasodilator. Vasodilators (e.g., nicardipine, nitroprusside) may be added for BP control only after beta-blockade is established
Causes lupus like syndrome and pericarditis
Hydralazine
What are the most common causes of primary aldosteronism?
The two most common causes are: ● Bilateral adrenal hyperplasia: This is the most frequent cause and is responsible for approximately two-thirds of cases of primary aldosteronism. ● Aldosterone-producing adenoma: This is a benign, aldosterone-secreting tumor on one of the adrenal glands, which accounts for about one-third of cases.
What is the workup for secondary hypertension?
The workup is guided by clinical suspicion, history, and physical exam findings. Screening tests for common causes include: ● Primary Aldosteronism: Check plasma aldosterone concentration and plasma renin activity to calculate the aldosterone-to-renin ratio ● Obstructive Sleep Apnea (OSA): Use a screening tool such as the STOP-Bang or Berlin Questionnaire. A polysomnography is the confirmatory test ● Chronic Kidney Disease (CKD): Order serum electrolytes, serum creatinine with eGFR, urinalysis, and a urine albumin-to-creatinine ratio ● Renovascular Hypertension: Listen for an abdominal bruit. Initial imaging can include renal duplex Doppler ultrasound, magnetic resonance angiography (MRA), or CT angiography (CTA) ● Pheochromocytoma/Paraganglioma: Order 24-hour urinary fractionated metanephrines or plasma free metanephrines ● Cushing Syndrome: Perform an overnight 1-mg dexamethasone suppression test or a 24-hour urinary free cortisol excretion test
For historical context, what were the main treatment targets of the JNC 8 guidelines?
These are outdated guidelines, superseded by the 2025 AHA/ACC guidelines which recommend a universal target of <130/80 mmHg for most adults The JNC 8 targets were: For patients ≥ 60 years old: Reduce BP to <150/90 mm Hg. For patients < 60 years old: Reduce BP to <140/90 mm Hg. For patients of any age with diabetes or chronic kidney disease: Reduce BP to <140/90
A patient's BP is 145/90 mmHg despite taking lisinopril, amlodipine, and chlorthalidone at optimal doses. Their eGFR is 65 mL/min/1.73 m². What is this condition, and what is the recommended next step in medical therapy?
This is Resistant Hypertension, defined as BP above goal despite treatment with 3 antihypertensive agents, including a diuretic. ● Evaluation: First, exclude pseudoresistance (e.g., nonadherence) and screen for secondary causes. ● Next Step: Assuming true resistant hypertension, the next step is to add a mineralocorticoid receptor antagonist (MRA), such as spironolactone.
Define hypertensive urgency
This is an Outdated Term! It is now "Severe Hypertension" (formerly Urgency) = BP >180/120 mmHg WITHOUT acute TOD -> (this replaces the term "hypertensive urgency")
A 60-year-old female with type 2 diabetes has an average office BP of 136/86 mmHg. Her calculated 10-year PREVENT™ risk is 12%. What is the recommended initial treatment?
This patient has Stage 1 Hypertension in a high-risk individual (due to both diabetes and a PREVENT™ risk ≥7.5%). The initial treatment plan is: ● Initiate lifestyle modifications AND pharmacologic therapy with a single first-line agent ● If the patient also has albuminuria (≥30 mg/g), an ACE inhibitor or ARB is specifically recommended to delay the progression of diabetes-related kidney disease ● The treatment goal is a BP of <130/80 mm Hg
A 50-year-old male has an average office BP of 152/94 mmHg confirmed on multiple visits. He has no other medical conditions. What is the recommended initial treatment according to the 2025 guidelines?
This patient has Stage 2 Hypertension. The initial treatment plan is: ● Immediately initiate lifestyle modifications AND pharmacologic therapy. ● Therapy should begin with two first-line agents from different classes, with a preference for a single-pill combination (SPC) to improve adherence. ● The treatment goal is a BP of <130/80 mm Hg.
What are the preferred IV agents for a hypertensive emergency with acute pulmonary edema or acute coronary syndrome?
● Acute Pulmonary Edema: Preferred agents include clevidipine, nitroglycerin, and nitroprusside. Beta-blockers are contraindicated in this setting ● Acute Coronary Syndromes: Preferred agents include esmolol, labetalol, nicardipine, and nitroglycerin
What are the preferred IV agents for a hypertensive emergency in eclampsia or preeclampsia?
● Preferred Agents: Hydralazine, labetalol, and nicardipine are recommended for rapid BP lowering in pregnant individuals ● Contraindicated Agents: ACE inhibitors, ARBs, renin inhibitors, and nitroprusside are contraindicated in pregnancy and should be avoided
What two types of BP meds are considered most effective in Black adults
2025 AHA/ACC guideline removes race-based first-line distinctions. Thiazides and CCBs remain effective options in Black patients but are not exclusive recommendations
According to the 2025 guidelines, what is the BP treatment target for a patient with hypertension AND diabetes? What about a patient with hypertension AND chronic kidney disease?
The target is the same for both: <130/80 mm Hg! ● The 2025 guidelines establish a single, overarching blood pressure treatment goal of <130/80 mm Hg for ALL adults with hypertension, including those with comorbidities like diabetes or chronic kidney disease
How do the 2025 ACC/AHA guidelines define and differentiate "Severe Hypertension" and "Hypertensive Emergency"?
Both conditions involve a BP >180/120 mmHg. The crucial difference is the presence of acute Target Organ Damage (TOD), which is assessed by looking for conditions like encephalopathy, myocardial infarction, acute heart failure, aortic dissection, or hypertensive retinopathy (e.g., papilledema). ● Severe Hypertension (formerly Urgency): BP >180/120 mmHg WITHOUT acute TOD. ● Hypertensive Emergency: BP >180/120 mmHg WITH acute TOD.
Define a normal blood pressure
< 120/80
Define stage 2 hypertension
> 140/90
Associated with cough and hperkalemia and is contraindicated in pregnancy
Ace inhibitors
What is the recommended treatment for a Hypertensive Emergency?
Admit to intensive care unit (ICU)—The goal for BP reduction depends on the clinical situation: ● For a compelling condition like aortic dissection, SBP should be rapidly reduced to <120 mm Hg during the first hour ● For emergencies without a compelling condition, SBP should be reduced by no more than 25% within the first hour, then stabilized to 160/100 mmHg over the next 2 to 6 hours ● Short-acting, titratable IV agents like nicardipine, clevidipine, or labetalol are appropriate choices.
Treats HTN and BPH
Alpha blockers
How does Primary Aldosteronism cause secondary hypertension?
In primary aldosteronism, aldosterone production is inappropriately high and is not properly regulated by the renin-angiotensin system. This excess aldosterone leads to hypertension through the following mechanism: ● Sodium Retention: The increased aldosterone causes the kidneys to retain excess sodium. ● Volume Expansion: Water follows the retained sodium, leading to intravascular volume expansion. ● Hypertension: The increased volume in the blood vessels raises blood pressure, causing hypertension. This process results in the classic lab findings of suppressed plasma renin activity and increased potassium excretion, which may lead to hypokalemia.
What is the recommended treatment for Severe Hypertension (BP >180/120 mmHg without acute target organ damage)?
Manage the patient in the outpatient setting ● Reinstitute or intensify the patient's oral antihypertensive medications and arrange for close follow-up ● Rapid, aggressive BP lowering with parenteral (IV) or as-needed oral medications is NOT recommended and may be harmful
A 48-year-old woman with no comorbidities has a single office BP reading of 152/84 mmHg. Is this sufficient to diagnose hypertension?
No, this single reading is not enough for a formal diagnosis of hypertension. ● A single blood pressure reading is considered inadequate for clinical decision-making due to the potential for variability. ● A formal diagnosis requires an average of at least two readings taken on at least two separate occasions showing a BP of ≥130 mmHg systolic or ≥80 mmHg diastolic. ● To confirm the diagnosis and rule out white-coat hypertension, out-of-office BP measurements using either Home Blood Pressure Monitoring (HBPM) or 24-hour Ambulatory Blood Pressure Monitoring (ABPM) are recommended. ● The appropriate next step for this patient would be to have her return for another BP check and/or begin home blood pressure monitoring to confirm if her BP is persistently elevated.
What class of antihypertensive is contraindicated in asthma or reactive airway disease?
Non-cardioselective β-blockers (e.g., propranolol, nadolol) should be avoided in patients with reactive airway disease ● Clinical Pearl: If a patient has a compelling indication for a β-blocker (like heart failure or coronary artery disease), a cardioselective β-blocker (e.g., metoprolol succinate, bisoprolol) is preferred in patients with bronchospastic airway disease
Appropriate alcohol intake for men and women?
Reduce alcohol intake ● Men ≤2 drinks/day ● Women ≤1 drink/day
When should you suspect secondary hypertension?
Screening is recommended when there is clinical suspicion, such as in cases of: ● Resistant hypertension (refractory to antihypertensive medications) ● Abrupt onset of hypertension ● Onset of hypertension at age <30 years ● Target organ damage that is disproportionate to the degree of hypertension ● Unprovoked or excessive hypokalemia
Define secondary hypertension
Secondary hypertension is defined as a systolic BP ≥ 130, diastolic BP ≥ 80, or both with an identifiable and often correctable cause ● Found in approximately 5% to 25% of adult patients with hypertension.
Which diuretic can cause hyperkalemia
Spironolactone
Name the lifestyle modifications to prevent and treat hypertension?
The 2025 AHA/ACC guidelines strongly recommend several lifestyle changes for all adults. These include: ● Weight Management: Maintaining a healthy weight or achieving weight loss for those with overweight or obesity ● Heart-Healthy Diet: Following a heart-healthy eating pattern, such as the DASH (Dietary Approaches to Stop Hypertension) plan ● Sodium Reduction: Reducing dietary sodium intake, aiming for <2,300 mg/day (≈ 1 tsp salt) with an ideal limit of <1,500 mg/day for most adults ● Potassium Intake: Increasing dietary potassium intake, ideally from dietary sources ● Physical Activity: Adopting a structured exercise program that includes aerobic and/or resistance training (≥ 150 min/week moderate or 75 min/week vigorous) ● Alcohol Reduction: Reducing or eliminating alcohol intake. For those who drink, the recommendation is to limit intake to ≤1 drink/day for women and ≤2 drinks/day for men ● Stress Management: Adopting stress management practices
According to the 2025 guidelines, what is required to formally diagnose hypertension in an adult?
The diagnosis of hypertension requires the following: ● An average office blood pressure of ≥130 mm Hg systolic or ≥80 mm Hg diastolic. ● This BP level must be based on an average of at least two readings taken on at least two separate occasions ● It is also recommended to confirm the diagnosis with out-of-office BP measurements, using either Ambulatory Blood Pressure Monitoring (ABPM) or Home Blood Pressure Monitoring (HBPM), to rule out white-coat hypertension
What is the initial management for a patient with confirmed Stage 1 Hypertension (e.g., average BP 135/85 mmHg)?
The first step is to determine the patient's 10-year risk for cardiovascular disease (CVD) using the PREVENT™ calculator. ● If 10-year PREVENT™ risk is <7.5% (and no clinical CVD, diabetes, or CKD), the recommendation is to start lifestyle modifications and reassess blood pressure in 3-6 months - If BP remains ≥130/80 mmHg after that period, then initiate medication. ● If 10-year PREVENT™ risk is ≥7.5% (or the patient has existing clinical CVD, diabetes, or CKD), the recommendation is to start one BP-lowering medication in addition to lifestyle modifications.
Causes of secondary hypertension?
The most common causes include Obstructive Sleep Apnea (OSA), primary aldosteronism, Chronic Kidney Disease (CKD), renovascular disease, and drug/alcohol-induced hypertension
If the blood pressure goal is not met after 1 month of treatment, what is the next step?
The next step is to consider intensification of therapy while also optimizing medication adherence. This can include titrating the dosage of the current medication or adding another agent from a different first-line class
What is the overarching blood pressure treatment goal for adults according to the 2025 ACC/AHA guidelines?
The overarching blood pressure treatment goal is <130/80 mm Hg for all adults with hypertension, including those with comorbidities! ● Note on Individualization: This goal may be individualized based on a clinician-patient assessment for those who require institutional care, are frail, or have a limited predicted lifespan
Once a patient's blood pressure goal is met and they are stable, when is the next reassessment?
The patient should be reassessed in 3 to 6 months
After starting or intensifying a blood pressure medication, when should the patient be reassessed?
The patient should have a follow-up evaluation at 1 month. Follow-up should then continue at monthly intervals until the blood pressure goal is achieved.
Recommended treatment for stage 2 HTN?
Two first-line agents from different classes, ideally in a single-pill combination (SPC)
According to the US Preventive Services Task Force (USPSTF) guidelines who should be screened for HTN?
US Preventive Services Task Force (USPSTF) guidelines: all individuals 18 years or older should be screened for elevated blood pressure
