ABIM Cardiology Rapid Review

Overview

Hypertension (HTN) Overview:

1. Definition: Persistent elevated blood pressure ≥130/80 mmHg.
2. Classification:
   • Normal: <120/80 mmHg.
   • Elevated: 120-129/<80 mmHg.
   • Stage 1 HTN: 130-139/80-89 mmHg.
   • Stage 2 HTN: ≥140/90 mmHg.

Diagnostic Workup:

1. Initial Steps:
   • Confirm HTN with multiple readings on different occasions.
   • Assess for white-coat HTN (ambulatory BP monitoring if needed).
2. Baseline Tests:
   • Electrolytes, kidney function (BUN, creatinine), fasting glucose, lipid profile, ECG, urinalysis.

Causes of HTN:

1. Primary HTN (95% cases): No identifiable cause, multifactorial.
2. Secondary HTN (5% cases):
   • Common causes: Renal artery stenosis, primary aldosteronism, pheochromocytoma, Cushing’s syndrome, OSA (Obstructive Sleep Apnea).

Treatment Targets:

1. Goal: <130/80 mmHg for most patients (individualize based on age/comorbidities).
2. Lifestyle changes (cornerstone):
   • DASH diet, weight loss, regular exercise, reduced sodium (<2.4g/day), smoking cessation.

Pharmacological Treatment:

1. First-line agents:
   • Thiazide diuretics, ACE inhibitors/ARBs, calcium channel blockers (CCBs).
2. Considerations:
   • Diabetes or CKD: Use ACE inhibitors or ARBs.
   • African-American patients: Prefer thiazides or CCBs.
3. Resistant HTN:
   • Triple therapy (including a diuretic) + consider secondary causes.

Hypertensive Emergencies:

1. Definition: Severe HTN (≥180/120 mmHg) with end-organ damage (e.g., stroke, MI, renal failure).
2. Management:
   • IV antihypertensives (labetalol, nitroprusside, nicardipine).
   • Gradual BP reduction (not >25% drop in first hour).

Special Populations:

1. Elderly: Balance between BP control and risk of falls.
2. Pregnancy:
   • First-line: Methyldopa, labetalol, nifedipine.
   • Avoid ACE inhibitors and ARBs.