Hypertension: Clinical Review

HTN

Hypertension

Final Clinical Review

Core Concepts

This section establishes the foundational knowledge. Hover or click the interactive pathophysiology cards below to flip them and reveal core mechanisms. Remember: HTN is a vascular disease first.

Definition & Key Concept

SBP (Clinic) ≥ 140

AND/OR

DBP (Clinic) ≥ 90

*Based on multiple clinic readings

💡 First Principles Important!

"Hypertension is a vascular disease first, pressure problem second."

Etiology Breakdown

Primary (Essential) No identifiable cause

90–95%

Secondary Renal, endocrine, vascular

5–10%

Core Pathophysiology (Click to Reveal)

🩸

↑ Peripheral Resistance

Flip

Structural narrowing or active vasoconstriction of small arteries increases total peripheral resistance.

🧪

RAAS Activation

Flip

Overactive Renin-Angiotensin-Aldosterone System leads to sodium/water retention and vasoconstriction.

⚡

Sympathetic Overdrive

Flip

Increased catecholamines cause elevated heart rate, cardiac output, and sustained vasoconstriction.

🧬

Endothelial Dysfunction

Flip

Imbalance favoring vasoconstrictors (Endothelin) over vasodilators (Nitric Oxide) in the vascular wall.

Severity Classification Dashboard

Clinical Evaluation

Interact with the flowchart steps to expand details. Use the interactive checklist below to review required investigations. Pay close attention to the hover-reveal pearls for secondary hypertension.

Interactive Evaluation Flow

Patient presents with an elevated screening BP (≥140/90). Ensure proper cuff size and resting state before recording.

Do not diagnose on a single reading unless crisis. Repeat measurements over visits or use ABPM (Gold Standard) to rule out white coat effect.

Check for acute symptoms: severe headache, chest pain, dyspnea, visual changes.

YES → Emergency (Admit)

NO → Urgency/Chronic (OPD)

Evaluate for secondary causes if criteria are met (see interactive list), otherwise proceed to essential HTN management.

Hover to Reveal Secondary HTN Clues

• Age <30 or >55 onset Think: Renovascular / Coarctation
• Resistant HTN (≥3 drugs) Think: Undiagnosed Secondary
• Unprovoked Hypokalemia Think: Primary Aldosteronism
• Episodic headache, sweating Think: Pheochromocytoma

Investigation Panels (Click to Check)

Basic Panel (Routine for all)

✓ CBC

✓ RFT & Electrolytes

✓ Urine Routine

✓ Lipid Profile

Advanced Panel (If indicated)

✓ ECG

Check for LVH

✓ Fundoscopy

Retinopathy grading

✓ USG Kidneys

Renal size/parenchyma

Complications & Crises

Hover over target organs to reveal specific manifestations. Click on the Fundoscopy grades to expand critical clinical correlations associated with malignant and accelerated hypertension.

Target Organ Damage (TOD)

🧠

Brain

Stroke (Ischemic/Hemorrhagic)
Encephalopathy
PRES

🫀

Heart

LVH & Heart Failure
Myocardial Infarction
Cardiomegaly

🩸

Kidney

Chronic Kidney Disease
Proteinuria
Nephrosclerosis

👁️

Eye

Retinopathy
Hemorrhages
Papilledema

🛤️

Vessels

Atherosclerosis
Aortic Dissection
Peripheral Artery Dz

🚨 Crisis Spectrum (BP ≥180/120)

Type	Acute Damage	Action
Urgency	❌ None	Oral drugs, OPD F/U
Emergency	✅ Present	ICU, IV Titration
Accelerated	✅ Retina (Gr III)	Admit, controlled drop
Malignant	✅ Retina (Gr IV)	Immediate emergency care

Fundoscopy Grading (Click to Expand)

Grade I: Minor arteriolar narrowing.
Grade II: AV nicking (arterioles compress venules where they cross). Indicates chronic HTN.

Presence of flame-shaped hemorrhages, cotton wool spots (soft exudates), or hard exudates.

Diagnostic of Accelerated HTN

Swelling of the optic disc due to high intracranial pressure secondary to severe hypertension.

Diagnostic of Malignant HTN (Emergency)

Management Strategy

Navigate through the tabs below to explore lifestyle modifications, core pharmacology, emergency protocols, and special case considerations.

Lifestyle Modifications (Mandatory Baseline)

🧂

Salt Restriction

<5 g/day

⚖️

Weight Loss

BMI 18.5-24.9

🏃

Exercise

150 min/week

🍷

Alcohol Limit

Moderate/None

First-Line Pharmacotherapy (A-C-D)

A

ACE Inhibitors / ARBs

e.g., Ramipril / Losartan. Compelling indication for Diabetics, Heart Failure, CKD with proteinuria.

SE: Cough (ACEi), Hyperkalemia

C

Calcium Channel Blockers

e.g., Amlodipine. Excellent for elderly and Afro-Caribbean patients. Potent vasodilators.

SE: Pedal edema, Flushing

D

Thiazide-like Diuretics

e.g., Indapamide, Chlorthalidone. Good add-on or primary therapy. Reduces plasma volume.

SE: Hypokalemia, Hyponatremia, Hyperuricemia

⚠️ Strict Emergency Principles

• 1. ICU Admission is mandatory for continuous monitoring.
• 2. Use IV titratable drugs (short half-life).
• Crucial: Do NOT drop BP by more than 25% in the first hour. Rapid drops risk severe cerebral/myocardial ischemia due to shifted autoregulation curves.

Common IV Agents

Labetalol

Combined α & β blocker. Good general choice.

Nicardipine

Dihydropyridine CCB. Excellent cerebral vasodilator.

Nitroprusside

Direct NO donor. Potent, rapid. (Risk of cyanide toxicity).

Special Clinical Scenarios

White Coat HTN

High BP in clinic, normal at home. Often anxiety-induced.

Action: Confirm with ABPM

Masked HTN

Normal clinic BP, but high at home/work. Carries high cardiovascular risk.

Action: Monitor target organs

Resistant HTN

Uncontrolled despite ≥3 optimal drugs (must include a diuretic).

Action: Screen for secondary causes

Isolated Systolic HTN

High SBP, normal DBP. Very common in elderly due to arterial stiffness.

Action: CCBs or Thiazides preferred

Active Recall Flashcards

Click on a card to flip it and reveal the answer. These high-yield facts are crucial for rapid recall during rounds or exams.

Interactive Clinical Quiz

Test your decision-making against these scenario-based questions. Select an answer to receive immediate feedback.

Q 1/4 Score: 0

Final Synthesis

Your one-page cheat sheet. Review these clinical pearls and the logical decision-making pipeline before stepping onto the ward.

💎 Golden Clinical Pearls

• 1.
  Pacing the Drop: In emergencies, dropping BP too fast causes ischemic strokes or MIs. Autoregulation curves are shifted rightward in chronic HTN.
• 2.
  The Eye Never Lies: Fundoscopy is the ONLY non-invasive way to directly visualize human microvasculature. Don't skip it.
• 3.
  Age Extremes: New onset severe HTN in a 25yo or an 80yo is secondary until proven otherwise.

Actionable Takeaways

Most HTN = Essential Exclude secondary, then focus on adherence, lifestyle, and combo therapy.

Secondary HTN = Curable Be suspicious. Finding a renal artery stenosis or adenoma can cure the patient.

Accelerated = Admit Grade III retinopathy means the vessels are leaking. Admit and control carefully.

Malignant = ICU Papilledema means cerebral edema. Start IV antihypertensives immediately.

Deterministic Evaluation Logic

A mental framework representing the structured clinical approach.

function evaluateHypertension(patient) {
  if (patient.BP >= "140/90") {
    let confirmed = confirmWithABPM(patient);
    if (confirmed) {
      if (patient.BP >= "180/120") {
        if (hasOrganDamage(patient)) {
           return manageEmergency(rx: 'IV_drugs', admit: 'ICU');
        } else {
           return manageUrgency(rx: 'Oral_drugs', fup: '24hrs');
        }
      }
      if (isHighRiskForSecondary(patient)) {
         workupSecondaryCauses(patient);
      }
      return initiateChronicCare(rx: selectFirstLine());
    }
  }
  return "NORMOTENSIVE";
}