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Hypertension
The diagnosis is confirmed by out-of-office measurement, treatment in most patients starts with two drugs in one pill (an ACE inhibitor or ARB with a calcium blocker or a diuretic), and when blood pressure is resistant or the patient is young — a secondary cause is sought.
Why it matters in the exam
The exam tests definitions and thresholds: 140/90 in the clinic, a 24-hour ambulatory average of 130/80 or more and a home average of 135/85 or more; white-coat hypertension (high in the clinic, normal at home) and masked hypertension (the reverse). Lines of treatment, treatment targets (usually a systolic of 120–129 if tolerated), and the definition of resistant hypertension are asked: uncontrolled despite three drugs at optimal doses including a diuretic — then spironolactone is added.
Secondary causes appear in every exam: primary aldosteronism (the most common endocrine cause, sometimes with hypokalaemia; screened by the aldosterone-to-renin ratio), renal artery stenosis (atherosclerotic in the elderly — medical treatment; fibromuscular dysplasia in young women — angioplasty), phaeochromocytoma (plasma or urine metanephrines), obstructive sleep apnoea, Cushing syndrome and coarctation of the aorta. ACE inhibitors and ARBs are forbidden in pregnancy.
Key points
- Diagnosis: 140/90 in clinic, confirmed by ambulatory (130/80) or home (135/85) readings.
- First line: ACE inhibitor or ARB with a calcium blocker or diuretic, in one pill.
- Resistant: uncontrolled on 3 drugs including a diuretic — add spironolactone.
- Suspect a secondary cause in the young, in resistance and with hypokalaemia; the most common is primary aldosteronism.
- In pregnancy: labetalol, nifedipine or methyldopa; no ACE inhibitor and no ARB.
Summary table
| Item | The rule | Details | Exam note |
|---|---|---|---|
| Diagnosis | 140/90 or more in clinic, confirmed out of office | Ambulatory: average 130/80 or more; home: 135/85 or more | White coat — high only in the clinic |
| First treatment | ACE inhibitor or ARB + calcium blocker or thiazide-like diuretic, as a single pill | Start with one drug in frail elderly patients or with mildly raised pressure | Never combine an ACE inhibitor with an ARB |
| Target | Systolic 120–129 if tolerated | More lenient target in the very old and frail | Check for orthostatic hypotension |
| Resistant hypertension | Uncontrolled on 3 drugs including a diuretic at optimal doses | Add spironolactone; check adherence and secondary causes | Exclude white coat effect and faulty measurement |
| Secondary causes | Aldosteronism, renal artery stenosis, phaeochromocytoma, sleep apnoea, Cushing, coarctation | Suspect in the young, in resistance and with hypokalaemia | Aldosterone/renin ratio; metanephrines |
| Pregnancy | Labetalol, nifedipine, methyldopa | ACE inhibitors and ARBs are forbidden | ACE inhibitor in a woman of childbearing age only with contraception |
A free exam question
A 40-year-old male is evaluated at the ER due to headaches, anxiety, and palpitations. His blood pressure is 210/100, pulse 110 regular. Pheochromocytoma is suspected. Which of the following is the next step in diagnosis?
- A. Urinary 5-hydroxyindole acetic acid (5-HIAA)
- B. Urinary catecholamines
- C. Urinary electrolytes
- D. Urinary protein quantity
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Sources
- ESC Guidelines for the management of elevated blood pressure and hypertension, 2024 — Diagnosis, treatment targets and drug strategy
- ESH Guidelines for the management of arterial hypertension, 2023 — Secondary hypertension and resistant hypertension
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Hypertension
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.