Hypertension: Complete Diagnosis, Staging & Modern Treatment Guidelines (2025)

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--- # 🔶 **HYPERTENSION — COMPLETE CLINICAL REFERENCE** --- ## **1. Definition** * **Hypertension (HTN)** = persistently elevated **SBP ≥140 mmHg and/or DBP ≥90 mmHg** (clinic, ≥2 readings on ≥2 occasions). * **ACC/AHA (US) definition:** ≥130/80 mmHg. * **Types:** * **Primary (essential)** – 90–95%, multifactorial. * **Secondary** – 5–10%, due to identifiable cause (renal, endocrine, vascular, drugs). --- ## **2. Pathophysiology** Hypertension develops due to **↑ systemic vascular resistance**, **↑ sympathetic activity**, **RAAS overactivation**, **endothelial dysfunction**, and/or **renal sodium retention**. Key mechanisms: * **↑ SNS** → tachycardia, vasoconstriction. * **RAAS activation** → Ang II–mediated vasoconstriction + aldosterone → Na⁺/water retention. * **Endothelial dysfunction** → ↓ NO, ↑ endothelin. * **Vascular remodeling** → stiffness → isolated systolic HTN. * **Nephron loss** → impaired natriuresis. --- ## **3. Causes & Triggers** ### **Primary HTN** Genetic predisposition + lifestyle (salt, obesity, alcohol, stress). ### **Secondary HTN** * **Renal causes:** CKD, renovascular HTN (RAS), glomerulonephritis, polycystic kidney. * **Endocrine:** * Primary hyperaldosteronism * Pheochromocytoma * Cushing * Hyperthyroid/hypothyroid * Acromegaly * **Vascular:** Coarctation of aorta. * **Drugs:** OCPs, NSAIDs, steroids, cocaine, cyclosporine, tacrolimus, decongestants, erythropoietin. * **OSA (obstructive sleep apnea)**. --- ## **4. Clinical Features** ### **Usually asymptomatic** HTN is often detected incidentally. ### **Symptoms when severe / accelerated** * Headache (occipital, morning) * Blurred vision, floaters * Epistaxis * Dyspnea, chest pain * Neuro deficits (possible stroke) ### **Signs of target-organ damage** * **Brain:** stroke, TIA, hypertensive encephalopathy * **Heart:** LVH, HF, CAD, arrhythmias * **Kidney:** proteinuria, CKD * **Eye:** hypertensive retinopathy (Grade I–IV) * **Vascular:** PAD, aortic aneurysm/dissection --- ## **5. Investigations / Diagnosis** ### **Basic tests for all:** * BP in **both arms**, confirm with **home/ambulatory BP** if needed * CBC * Fasting glucose / HbA1c * Lipid profile * RFTs (creatinine, eGFR) + electrolytes * Urinalysis (protein, RBCs) * ECG (look for LVH) * Fundus exam ### **Tests for secondary HTN (selective):** * Aldosterone–renin ratio (hyperaldosteronism) * Plasma free metanephrines (pheochromocytoma) * Renal Doppler (RAS) * Thyroid function tests * Sleep study for OSA --- ## **6. Differential Diagnosis** * White-coat HTN * Masked HTN * Anxiety disorders * Pain-induced BP rise * Hyperthyroidism * Cushing syndrome * Pheochromocytoma * Coarctation of aorta --- # **7. Management (Complete & Stepwise)** --- ## **A. Non-pharmacologic (for all patients)** * **Salt restriction <5 g/day** * **Weight loss:** every 1 kg loss = ↓1 mmHg * **DASH diet** * **Regular exercise:** 150 min/week * **Reduce alcohol** * **Stop smoking** * **Manage stress, sleep, OSA** --- ## **B. Pharmacologic Treatment** (Initial therapy depends on comorbidities, BP level, age, and ethnicity.) ### **First-line drugs** 1. **ACE inhibitors** (enalapril, lisinopril) 2. **ARBs** (losartan, telmisartan) 3. **Calcium channel blockers** (amlodipine, diltiazem) 4. **Thiazide diuretics** (chlorthalidone, HCTZ) ### **Second-line** * β-blockers (metoprolol, carvedilol) * α-blockers (prazosin) * Centrally acting (clonidine, methyldopa) * Direct vasodilators (hydralazine, minoxidil) ### **Targets** * **General population:** <130/80 mmHg * **CKD/DM:** <130/80 mmHg * **Elderly:** individualize (<140/90) --- # 🔶 **8. DRUGS — FULL INDIVIDUAL PHARMACOLOGY** --- ## **1. ACE Inhibitors (e.g., Enalapril)** **Indication:** HTN, HF, diabetic nephropathy. **MOA:** Blocks conversion of Ang I → Ang II; ↓ aldosterone; ↑ bradykinin. **Dose:** * Enalapril: **5–20 mg/day** (adult) **PK:** Renal excretion. **Adverse effects:** Cough, hyperkalemia, hypotension, angioedema, ↑creatinine. **Contraindications:** Pregnancy, bilateral RAS. **Drug interactions:** K⁺-sparing diuretics, NSAIDs. **Monitoring:** K⁺, creatinine, BP. **Counselling:** Report swelling of lips/tongue; avoid potassium supplements. --- ## **2. ARBs (Losartan)** **Indication:** HTN, proteinuric CKD. **MOA:** Blocks AT₁ receptor. **Dose:** Losartan **50–100 mg/day**. **PK:** Hepatic metabolism. **AEs:** Hyperkalemia, dizziness (no cough). **Contra:** Pregnancy, bilateral RAS. **Interactions:** NSAIDs, K⁺ drugs. **Monitoring:** BP, K⁺, renal function. --- ## **3. Calcium Channel Blockers (Amlodipine)** **Indication:** HTN, angina. **MOA:** Blocks L-type Ca²⁺ channels → vasodilation. **Dose:** **5–10 mg/day**. **AEs:** Pedal edema, headache, flushing. **Contra:** Severe AS, cardiogenic shock. **Monitoring:** Edema, BP. **Counselling:** Edema improves with leg elevation. --- ## **4. Thiazide Diuretics (Chlorthalidone)** **Indication:** First-line HTN. **MOA:** Inhibits Na-Cl transporter (DCT). **Dose:** **12.5–25 mg/day**. **AEs:** Hypokalemia, hyponatremia, hyperuricemia, hypercalcemia, ↑glucose. **Contra:** Gout (relative), sulfa allergy. **Monitoring:** Electrolytes, uric acid, glucose. --- ## **5. Beta-blockers (Metoprolol)** **Indication:** HTN + CAD, HF, arrhythmias. **MOA:** β₁ blockade → ↓HR, ↓CO. **Dose:** **25–100 mg/day**. **AEs:** Bradycardia, fatigue, bronchospasm. **Contra:** Asthma, severe bradycardia, AV block. **Monitoring:** HR, BP. **Counselling:** Do not stop abruptly. --- ## **6. Hydralazine** **Indication:** Resistant HTN, pregnancy HTN. **MOA:** Direct arteriolar vasodilator. **Dose:** **25–100 mg/day**. **AEs:** Reflex tachycardia, fluid retention, lupus-like syndrome. **Monitoring:** HR, ANA if long-term. --- ## **7. Clonidine** **Indication:** Resistant HTN, hypertensive urgency. **MOA:** α2-agonist (central). **Dose:** **0.1–0.3 mg/day**. **AEs:** Rebound HTN, sedation, dry mouth. **Counselling:** Do not stop abruptly. --- # **9. Hypertensive Emergency** **BP >180/120 with acute organ damage.** Use IV labetalol, nicardipine, nitroprusside. Goal: reduce MAP by **≤25% in first hour**. --- # **10. Hypertensive Urgency** BP >180/120 **without** acute organ damage. Use oral captopril, clonidine; gradual ↓ over 24–48 hrs. ---