A previously healthy 61-year-old man comes to the physician because of a 6-month history of morning headaches. He also has fatigue and trouble concentrating on his daily tasks at work. He sleeps for 8 hours every night; his wife reports that he sometimes stops breathing for a few seconds while sleeping. His pulse is 71/min and blood pressure is 158/96 mm Hg. He is 178 cm (5 ft 10 in) tall and weighs 100 kg (220 lb); BMI is 31.6 kg/m2 . Which of the following is the most likely cause of this patient's hypertension?

Nocturnal upper airway obstruction

Proliferation of adrenal chromaffin cells

A 51-year-old man presents to the urgent care center with a blood pressure of 201/111 mm Hg. He is complaining of a severe headache and chest pain. Physical examination reveals regular heart sounds and clear bilateral lung sounds. Ischemic changes are noted on his electrocardiogram (ECG). What is the most appropriate treatment for this patient’s high blood pressure?

IV labetalol - lower mean arterial pressure no more than 25% over the 1st hour

Oral clonidine - gradually lower blood pressure over 24–48 hours

Oral beta-blocker - lower mean arterial pressure no more than 25% over the 1st hour

IV labetalol - lower mean arterial pressure no more than 50% over the 1st hour

IV labetalol - redose until blood pressure within normal limits

A 56-year-old Caucasian male presents to the clinic to establish care. He has never seen a physician and denies any known medical problems. Physical examination is notable for central obesity, but the patient has regular heart and lung sounds. He has a blood pressure of 157/95 mm Hg and heart rate of 92/min. He follows up 2 weeks later, and his blood pressure continues to be elevated. At this time, you diagnose him with essential hypertension and decide to initiate antihypertensive therapy. Per the Joint National Committee 8 guidelines for treatment of high blood pressure, of the following combinations of drugs, which can be considered for first-line treatment of high blood pressure in the Caucasian population?

ACE inhibitor, ARB, CCB, or thiazide

ACE inhibitor, angiotensin receptor blocker (ARB), beta-blocker (BB), or thiazide

ACE inhibitor, ARB, CCB, or loop diuretic

ACE inhibitor, ARB, alpha-blocker, or loop diuretic

ACE inhibitor, ARB, alpha-blocker, or direct vasodilator

Hypertension diagnosis and management for USMLE Step 3: High-Yield Internal Medicine Lessons

Diagnosis & Staging - The Pressure Check

Proper Measurement: Rest 5 min, no caffeine/exercise 30 min prior. Use correct cuff size on a bare arm, supported at heart level.
Diagnosis: Based on an average of ≥2 readings on ≥2 separate occasions.

Confirmatory blood pressure measurement workflow

Category	Systolic (SBP)		Diastolic (DBP)
Normal	<120	and	<80
Elevated	120-129	and	<80
Stage 1	130-139	or	80-89
Stage 2	≥140	or	≥90

Etiology & Complications - The Usual Suspects

Primary (Essential) Hypertension: >90% of cases; idiopathic, multifactorial (genetics, age, obesity, salt).
Secondary Hypertension: Suspect in young (<30), resistant, or acute-onset severe HTN.
- 📌 Mnemonic: CHAPS (Cushing's, Hyperaldosteronism, Aortic coarctation, Pheochromocytoma, Stenosis of renal arteries).

Secondary Cause	Classic Clue
Renal Artery Stenosis (RAS)	Abdominal bruit, ↑Creatinine with ACE-I
Primary Aldosteronism	HTN with hypokalemia, metabolic alkalosis
Pheochromocytoma	Paroxysmal HTN, palpitations, headache, sweating
Cushing's Syndrome	Central obesity, striae, hyperglycemia
Obstructive Sleep Apnea (OSA)	Snoring, daytime somnolence

- **Heart**: Left Ventricular Hypertrophy (LVH), Heart Failure
- **Brain**: Stroke, dementia
- **Kidney**: Chronic Kidney Disease (CKD)
- **Eyes**: Hypertensive retinopathy

⭐ In a young female with new-onset hypertension and an abdominal bruit, suspect fibromuscular dysplasia as the cause of renal artery stenosis.

Hypertension and Organ Damage

Treatment Algorithm - The Pressure Drop

The universal treatment goal is a blood pressure <130/80 mmHg.

Lifestyle Modification is foundational: Enforce DASH diet, aerobic exercise (150 min/week), sodium restriction (<1.5g/day), weight loss, and limited alcohol.
Pharmacotherapy: If lifestyle changes are insufficient, initiate a first-line agent. For most, this includes Thiazide diuretics, ACE inhibitors (ACEi)/ARBs, or long-acting Dihydropyridine Calcium Channel Blockers (CCBs).
📌 Mnemonic for major classes: A B C D (ACEi/ARB, Beta-blocker, CCB, Diuretic).

Choice of initial drug is heavily guided by compelling indications.

⭐ ACE inhibitors can cause a dry, non-productive cough due to bradykinin accumulation. Angiotensin II Receptor Blockers (ARBs) do not have this side effect and are the preferred alternative in such cases.

Special Cases & Crises - Code Red Pressure

Feature	Hypertensive Urgency	Hypertensive Emergency
Definition	BP >180/120 mmHg	BP >180/120 mmHg + acute end-organ damage
Goal	Gradual ↓BP	Lower MAP by ~25% in 1st hour
Timeline	24-48 hours	Immediate
Treatment	Oral agents (e.g., Clonidine)	IV agents (Labetalol, Nicardipine)

Special Populations:
- Pregnancy: Use safe agents. 📌 "Hypertensive Moms Love Nifedipine" (Hydralazine, Methyldopa, Labetalol, Nifedipine).
- CKD/Diabetes: ACE inhibitors or ARBs are first-line therapy.

⭐ ACE inhibitors and ARBs are teratogenic and absolutely contraindicated in pregnancy.

High‑Yield Points - ⚡ Biggest Takeaways

Diagnosis requires ≥2 readings on ≥2 occasions; ambulatory monitoring is the gold standard.

First-line agents include thiazides, ACE inhibitors/ARBs, and calcium channel blockers.

ACE inhibitors/ARBs are crucial for patients with CKD, diabetes, or heart failure.

Beta-blockers are reserved for compelling indications like post-MI or rate control.

Hypertensive emergency means end-organ damage, requiring immediate IV medication.

Always consider secondary hypertension in very young or resistant cases.

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