📋 Clinical Guideline: Assessment & Management
This algorithm synthesizes all the physiology we have learned into a practical, step-by-step guide for managing hypertension.
Step 1: Initial Assessment (Triage)
- Confirm the reading: Take 2-3 readings. Rule out White Coat HTN with ambulatory monitoring.
- Rule out Hypertensive Emergency: Check for chest pain, dyspnea, neurological deficits, papilledema, or aortic dissection.
If present → Admit to ICU. Lower BP by 20-25% in the first hour using IV agents (Labetalol, Nicardipine). Do NOT drop to normal immediately.
Step 2: Identify the Physiological Phenotype
- High BP + High HR (>85): High Cardiac Output. Suspect Hyperthyroidism, Anemia, Sympathetic overdrive, or Pheochromocytoma.
- High BP + Normal/Slow HR: High TPR or High Volume. Suspect Essential HTN, Renal Artery Stenosis, or Hyperaldosteronism.
- Wide Pulse Pressure (e.g., 180/70): Stiff arteries (loss of elastin). Suspect Isolated Systolic HTN (Aging).
- Edema + Bounding pulses: High Preload (Volume overload). Suspect Heart Failure or Kidney Failure.
Step 3: Basic Labs & Secondary Workup
- Baseline: BMP (Creatinine, eGFR, Potassium), Glucose, Lipid panel, Urinalysis, ECG.
- If Low K⁺ + High BP: Check Aldosterone/Renin Ratio (ARR) → Suspect Conn's Syndrome.
- If Spiking BP + Sweating: Check 24-hour urine Metanephrines → Suspect Pheochromocytoma.
- If Cushingoid features: Check 24-hour urine Cortisol → Suspect Cushing's.
Step 4: Non-Pharmacological Management (The "Physiological Reset")
| Intervention | Physiological Target | BP Reduction |
|---|---|---|
| Sodium Restriction (< 2g/day) | Reduces volume & unloads Na/K pump | ~5-10 mmHg |
| DASH Diet (Fruits/Veggies) | Increases NO & Potassium (Vasodilation) | ~10-12 mmHg |
| Weight Loss (BMI < 25) | Reduces sympathetic tone | ~5-20 mmHg |
| Aerobic Exercise (150 min/wk) | Increases NO, lowers HR | ~5-8 mmHg |
Step 5: Pharmacological Management (Matching Drugs to Physiology)
💊 Step 1 (Mild HTN): Start 1 drug based on phenotype.
- High HR / Sympathetic: Beta-Blocker (Metoprolol).
- Edema / High Volume: Diuretic (Chlorthalidone).
- High TPR / Stiff Vessels: CCB (Amlodipine) or ACEi/ARB (Lisinopril).
💊 Step 2 (Moderate HTN): Dual Therapy. Best combo: ACEi/ARB + CCB or ACEi/ARB + Diuretic.
💊 Step 3 (Resistant HTN): Triple Therapy. Add Spironolactone (Mineralocorticoid Receptor Antagonist) to block aldosterone.
Drug Class Cheat Sheet
| Drug Class | Physiological Target | Best For |
|---|---|---|
| Thiazide Diuretic | Volume / Preload | Elderly, Edema, High Salt intake |
| ACE Inhibitor / ARB | RAAS / TPR | Younger, Diabetics, CKD |
| CCB (Amlodipine) | Vascular Calcium / TPR | Isolated Systolic HTN, African-American patients |
| Beta-Blocker | Cardiac Output / HR | High HR, Angina, Heart Failure (not first-line for pure HTN) |
Final Target Goals
- General Adults: < 130/80 mmHg.
- Elderly (>65): < 130/80 if tolerated. Avoid dropping diastolic below 60 (compromises coronary perfusion).
- Do NOT drop BP too fast: The autoregulatory curve has shifted to the right. A sudden drop to 120/70 can cause stroke or kidney injury.