Hypertension Management

Key considerations: Secondary hypertension (renal artery stenosis, pheochromocytoma, Cushing, primary aldosteronism, coarctation), Hypertensive emergency with end-organ damage, Resistant hypertension (uncontrolled on 3+ drugs including diuretic)

Cannot miss

Secondary hypertension (renal artery stenosis, pheochromocytoma, Cushing, primary aldosteronism, coarctation)
Hypertensive emergency with end-organ damage
Resistant hypertension (uncontrolled on 3+ drugs including diuretic)

Likely diagnoses

Essential (primary) hypertension (90-95%)
White-coat hypertension
Masked hypertension

Red flags

SBP ≥180 or DBP ≥120 with end-organ damage
Hypokalemia (think aldosteronism)
Abdominal bruit (renal artery stenosis)
New onset in young patient (<30)

Workup

history: Duration, prior treatment, adherence; Family history of HTN, CVD; Diet (sodium, alcohol); Medications (NSAIDs, decongestants, OCPs, stimulants); Sleep apnea symptoms; exam: Accurate BP measurement (correct cuff, seated, both arms); Fundoscopic exam; Thyroid palpation; Cardiac and renal bruit auscultation; Peripheral pulses; labs: BMP (creatinine, potassium); Fasting glucose or A1c; Lipid panel; Urinalysis (proteinuria); TSH; ECG (LVH); imaging: Echocardiogram if LVH or CHF suspected; Renal US/Doppler if secondary cause suspected; bedside: Accurate BP measurement

Management

immediate: ; general: Target <130/80 for most patients (ACC/AHA 2017); Lifestyle: DASH diet, sodium <2300mg/day, exercise 150min/week, weight loss, limit alcohol; Start pharmacotherapy if BP ≥140/90 (or ≥130/80 with ASCVD risk ≥10%); specific: diagnosis: Stage 1 (130-139/80-89); steps: Lifestyle modifications; Add medication if 10-year ASCVD risk ≥10%; First-line: ACEi/ARB, CCB, or thiazide; diagnosis: Stage 2 (≥140/90); steps: Start 2 first-line agents; Combination pill improves adherence; Follow-up in 1 month, titrate to goal; diagnosis: Resistant Hypertension; steps: Verify adherence and technique; Add spironolactone 25-50mg (PATHWAY-2 trial); Screen for secondary causes; Consider referral

Disposition

admit: Hypertensive emergency with end-organ damage; discharge: All chronic hypertension management; Follow-up 2-4 weeks after medication change; consults: Nephrology/cardiology for resistant HTN; Endocrine if secondary cause suspected

Clinical pearls

ACEi/ARB: preferred if CKD, diabetes, proteinuria, or HFrEF
CCB (amlodipine): preferred in Black patients as first-line
Thiazides: preferred if volume overload or osteoporosis
Never combine ACEi + ARB — increased hyperkalemia and AKI risk without benefit

Source and review

2017 ACC/AHA Hypertension Guidelines; SPRINT Trial, NEJM 2015. Last reviewed: 2024-11-01