About This Page
This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- ACC/AHA 2017: Normal <120/80, Elevated 120-129/<80, Stage 1 130-139/80-89, Stage 2 >=140/>=90
- Diagnosis: >=2 readings on >=2 occasions or ABPM/home monitoring
- First-line: thiazide (chlorthalidone preferred), ACEi, ARB, or DHP CCB (amlodipine)
- Target <130/80 for most adults (SPRINT); <140/90 acceptable for low-risk >65
- Hypertensive emergency = BP >180/120 + end-organ damage: IV meds in ICU, reduce MAP 25% in first hour
Overview
Hypertension is defined by the 2017 ACC/AHA guideline as SBP >=130 or DBP >=80 mmHg. This threshold was lowered from the prior JNC 8 definition of >=140/90 based on SPRINT, which showed intensive BP control (target SBP <120) significantly reduced cardiovascular events and all-cause mortality. Primary (essential) HTN accounts for 90-95% of cases. It is the most important modifiable risk factor for cardiovascular disease, stroke, HF, CKD, and PAD.
Epidemiology
Nearly half of American adults (~116 million) have HTN under the 2017 definition. Only ~25% are controlled. Prevalence is highest among African Americans (~56%), who develop HTN earlier with more severe disease and target organ damage. Risk factors: age, obesity, inactivity, sodium >2300 mg/day, excess alcohol, family history, and stress.
Clinical Features
Symptoms
Most patients are asymptomatic — detected on routine screening
Headache (occipital, early morning — more common with severe HTN)
Visual changes, epistaxis, dizziness (suggest end-organ damage)
Chest pain, dyspnea (cardiac target organ damage)
Focal neurological deficits (hypertensive encephalopathy or stroke)
Signs
Elevated BP on >=2 occasions (proper technique: seated, rested 5 min, correct cuff, supported arm)
S4 gallop (LVH with diastolic dysfunction)
Hypertensive retinopathy: AV nicking, copper/silver wiring, flame hemorrhages, papilledema (grade IV = malignant)
Abdominal bruit (renal artery stenosis)
Radio-femoral delay (coarctation of the aorta)
Investigations
First-line
BP measurementOffice BP >=130/80 on >=2 occasions. Confirm with ABPM (gold standard) or home monitoring. ABPM also identifies white coat HTN and masked HTN
BMPCreatinine (eGFR), electrolytes (hypokalemia may suggest primary aldosteronism), glucose, calcium
Lipid panel + HbA1cCV risk assessment using 10-year ASCVD calculator
UrinalysisProteinuria or hematuria = renal target organ damage
Second-line
ECGLVH (Sokolow-Lyon or Cornell criteria), strain pattern
Urine albumin-to-creatinine ratioScreen in diabetes, CKD, or sustained HTN. UACR >30 mg/g is abnormal
EchocardiogramIf clinical suspicion for LVH, HF, or valvular disease — more sensitive than ECG for LVH
Specialist
Secondary HTN workupIf resistant HTN, onset <30, sudden onset, hypokalemia, or renal bruit. Tests: plasma aldosterone/renin ratio (primary aldosteronism), renal artery imaging (RAS), plasma free metanephrines (pheo), overnight dexamethasone suppression (Cushing), TSH, sleep study (OSA)
1
Lifestyle (all stages)
- DASH diet (fruits, vegetables, whole grains, low-fat dairy)
- Sodium <1500 mg/day ideal, or at least 1000 mg/day reduction
- Aerobic exercise: 150 min/week moderate or 75 min/week vigorous
- Weight loss: BMI 18.5-24.9; each 1 kg lost = ~1 mmHg SBP reduction
- Alcohol: <=2 drinks/day men, <=1/day women
- Smoking cessation (reduces CV risk, not direct BP effect)
2
When to start pharmacotherapy
- Stage 1 (130-139/80-89): lifestyle first; add drug if ASCVD risk >=10% or known CVD/diabetes/CKD
- Stage 2 (>=140/>=90): lifestyle + drug immediately; 2-drug combo if BP >=160/100 or >20/10 above goal
- Target: <130/80 for most adults
3
First-line drug classes
- Thiazide: chlorthalidone 12.5-25 mg preferred (longer acting, better data) or HCTZ 25-50 mg
- ACEi: lisinopril 10-40 mg, enalapril 5-20 mg BID, ramipril 2.5-10 mg
- ARB: losartan 50-100 mg, valsartan 80-320 mg (if ACEi intolerant; never combine ACEi + ARB)
- DHP CCB: amlodipine 2.5-10 mg (long-acting, once daily)
4
Compelling indications
- CKD with proteinuria or diabetic nephropathy: ACEi or ARB (renoprotective)
- HFrEF: ACEi/ARB/ARNi + BB + MRA + SGLT2i
- Post-MI: ACEi + BB
- African Americans without CKD/diabetes: CCB or thiazide first-line (ACEi/ARB less effective as monotherapy per ALLHAT)
- Pregnancy: labetalol, nifedipine, or methyldopa (ACEi/ARBs CONTRAINDICATED — teratogenic)
5
Hypertensive emergency (>180/120 + end-organ damage)
- ICU with arterial line monitoring
- IV agents: nicardipine, clevidipine, labetalol, nitroprusside, or fenoldopam
- Reduce MAP by no more than 25% in first hour, then to 160/100 over 2-6 h, then normal over 24-48 h
- Aortic dissection: target SBP <120 and HR <60 within 20 min — IV esmolol/labetalol FIRST, then vasodilator
- Acute ischemic stroke: treat only if >185/110 and tPA planned, or >220/120 without tPA eligibility
Complications
- Cardiovascular: LVH, CAD, HF (HFrEF and HFpEF), aortic dissection, PAD
- Cerebrovascular: Ischemic stroke, hemorrhagic stroke, TIA, vascular dementia
- Renal: Hypertensive nephrosclerosis, CKD, ESRD
- Ophthalmic: Hypertensive retinopathy (grades I-IV)
- Hypertensive emergency: Encephalopathy, acute pulmonary edema, aortic dissection, eclampsia, AKI, MAHA
USMLE Step 2 CK Exam Tips
- 1ACC/AHA 2017: HTN = >=130/80. This is the Step 2 CK threshold, not the older >=140/90
- 2SPRINT: SBP <120 reduced CV events and mortality but excluded diabetics
- 3Hypokalemia + HTN = think primary aldosteronism (most common secondary cause). Screen with aldosterone/renin ratio
- 4Young patient + HTN + radio-femoral delay + rib notching = coarctation of aorta
- 5Paroxysmal HTN + headache + palpitations + diaphoresis = pheochromocytoma. Screen with plasma free metanephrines
- 6ACEi/ARBs absolutely contraindicated in pregnancy — switch to labetalol or nifedipine
- 7Hypertensive emergency vs urgency: the distinction is end-organ damage, NOT the absolute BP number
- 8Aortic dissection: reduce HR FIRST with BB (esmolol) before vasodilator (prevents reflex tachycardia)
practicetest your knowledge on hypertensionApply what you've learnt with USMLE Step 2 CK-style questions from the iatroX Q-Bank — cardiovascular and beyond.
open q-bank