Study guide
1.9 Hypertension: Classification, Diagnosis & Secondary Causes
ABIM Internal Medicine Exam
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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy
0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan
2 Chapter 1: Cardiovascular Disease (14% of Exam)
1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection
3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)
2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia
4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)
3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV
5 Chapter 4: Infectious Disease (9% of Exam)
4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections
6 Chapter 5: Pulmonary Disease (9% of Exam)
5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule
7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)
6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease
8 Chapter 7: Hematology (6% of Exam)
7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation
9 Chapter 8: Medical Oncology (6% of Exam)
8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care
10 Chapter 9: Nephrology & Urology (6% of Exam)
9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria
11 Chapter 10: Neurology (4% of Exam)
10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders
12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)
11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health
13 Chapter 12: Dermatology (3% of Exam)
12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease
14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)
13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications
15 Chapter 14: Geriatric Syndromes (3% of Exam)
14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings
16 Chapter 15: Allergy & Immunology (2% of Exam)
15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders
17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology
16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design
18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)
17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity
19 Chapter 18: Perioperative Medicine & Medical Consultation
18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications
20 Chapter 19: Ophthalmology (1% of Exam)
19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease
21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)
20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders
1.9 Hypertension: Classification, Diagnosis & Secondary Causes
Key Takeaways Explain This Topic AI
Hypertension is a 5% blueprint subsection cross-listed between Cardiovascular Disease and Nephrology and Urology, making it the single largest topic on the exam.
Essential hypertension, renal and renovascular causes, coarctation of the aorta, hypertensive urgency and emergency, and undifferentiated hypertension are the enumerated blueprint topics.
Ambulatory or home blood pressure monitoring is required to confirm the diagnosis and to identify white-coat and masked hypertension.
Resistant hypertension is uncontrolled pressure on three agents including a diuretic, or controlled pressure requiring four agents, and warrants secondary evaluation.
Adrenal vein sampling is required before adrenalectomy in most patients with primary aldosteronism because an incidentally imaged nodule may not be the source of excess aldosterone.
Last updated: August 2026
Hypertension and dyslipidemia are the two most prevalent modifiable risk factors for atherosclerotic cardiovascular disease (ASCVD), heart failure, stroke, and chronic kidney disease. This section provides an in-depth, board-focused synthesis of the ACC/AHA guidelines for blood pressure classification, secondary hypertension workup, hypertensive crises management, statin benefit groups, and non-statin lipid-lowering therapies.
- 1. Hypertension: Classification & Diagnostic Criteria
- 2017 ACC/AHA Blood Pressure Categories
Blood pressure classification is based on the average of >=2 careful readings obtained on >=2 separate occasions:
Normal BP: Systolic < 120 mmHg AND Diastolic < 80 mmHg.
Elevated BP: Systolic 120–129 mmHg AND Diastolic < 80 mmHg.
Stage 1 Hypertension: Systolic 130–139 mmHg OR Diastolic 80–89 mmHg.
Stage 2 Hypertension: Systolic >= 140 mmHg OR Diastolic >= 90 mmHg.
Out-of-Office Blood Pressure Monitoring
Ambulatory Blood Pressure Monitoring (ABPM; Gold Standard): 24-hour mean >= 125/75 mmHg, Daytime (awake) mean >= 130/80 mmHg, or Nighttime (asleep) mean >= 110/65 mmHg diagnostic of HTN. Identifies non-dipping status (<10% nocturnal BP dip), which confers heightened cardiovascular and stroke risk.
Home Blood Pressure Monitoring (HBPM): Mean >= 130/80 mmHg diagnostic of HTN.
Phenotypes:
White-Coat Hypertension: Elevated office BP (>=130/80) but normal out-of-office BP (<130/80 on ABPM/HBPM). No drug therapy indicated; manage with lifestyle and annual ABPM.
Masked Hypertension: Normal office BP (<130/80) but elevated out-of-office BP (>=130/80). Carries cardiovascular risk equivalent to sustained HTN; requires pharmacologic therapy.
Initial Pharmacotherapy & Target Goals
Treatment Thresholds:
Stage 1 HTN (130-139/80-89) + 10-year ASCVD risk <10%: 3 to 6 months of non-pharmacologic lifestyle modification.
Stage 1 HTN + 10-year ASCVD risk >=10%, or Stage 2 HTN (>=140/90 mmHg): Immediate pharmacotherapy + lifestyle.
Stage 2 HTN with BP >20/10 mmHg above target (e.g., >=150/90 mmHg): Initiate two first-line antihypertensive agents of different classes (e.g., CCB + ACEi/ARB or Thiazide-like diuretic + ACEi/ARB).
Target Blood Pressure Goal: < 130/80 mmHg for all adult populations with confirmed hypertension, including elderly patients and those with diabetes, CKD, or CAD (supported by the SPRINT trial).
First-Line Antihypertensive Classes
Thiazide-Like Diuretics: Chlorthalidone (12.5-25 mg daily) or Indapamide preferred over Hydrochlorothiazide (HCTZ 25-50 mg daily) due to longer half-life (40-60 hours) and superior clinical trial evidence in preventing CV events (ALLHAT trial). Adverse effects: Hypokalemia, hyponatremia, hyperuricemia (precipitates gout flares), hyperglycemia, hypercalcemia.
Dihydropyridine CCBs: Amlodipine (2.5-10 mg daily) , Nifedipine ER. Potent vasodilators. Adverse effects: Dose-dependent peripheral dependent edema (pre-capillary arteriolar vasodilation; reduced by adding an ACEi/ARB which induces post-capillary venodilation), reflex tachycardia, gingival hyperplasia.
ACE Inhibitors / ARBs: Lisinopril, Enalapril / Losartan, Valsartan. First-line for diabetes with albuminuria, CKD with proteinuria, and HFrEF. Adverse effects: Hyperkalemia, acute rise in serum creatinine (up to 30% increase is hemodynamically expected and acceptable), dry cough (ACEi, due to substance P and bradykinin accumulation), angioedema. Strictly contraindicated in pregnancy and bilateral renal artery stenosis. Never combine an ACEi and an ARB (increases renal failure and hyperkalemia without CV benefit; ONTARGET trial).
Compelling Indications:
Black Adults without CKD/HF: Initial therapy should include a Thiazide-like diuretic and/or a CCB (superior BP lowering and stroke reduction compared to ACEi monotherapy; ALLHAT trial).
Chronic Kidney Disease with Albuminuria (UACR >=300 mg/g or 30-299 mg/g): ACE inhibitor or ARB is Class 1 to slow renal progression.
2. Secondary Hypertension: Diagnostic Workup
Secondary hypertension accounts for ~10% of adult hypertension. Screen when patients present with: Resistant Hypertension (uncontrolled BP despite >=3 antihypertensive medications of different classes at maximal doses, one of which is a diuretic; or controlled on >=4 medications), sudden onset <30 years, abrupt loss of BP control in a previously stable patient, or unprovoked hypokalemia.
Etiology Clinical Clues Initial Screening Test Confirmatory / Localization Test Definitive Management
Primary Aldosteronism (Conn Syndrome / Bilateral Hyperplasia) Resistant HTN, spontaneous or diuretic-induced hypokalemia, metabolic alkalosis Plasma Aldosterone Concentration (PAC) to Plasma Renin Activity (PRA) Ratio (ARR) : ARR > 20 (with PAC > 15 ng/dL) Confirmatory: 24h urinary aldosterone during oral sodium load or IV saline suppression test. Localization: Adrenal CT scan + Adrenal Venous Sampling (AVS) Unilateral adenoma: Laparoscopic adrenalectomy. Bilateral hyperplasia: MRA ( Spironolactone or Eplerenone )
Renal Artery Stenosis (RAS) Flash pulmonary edema, refractory HTN, abdominal bruit, unexplained rise in serum Cr >30% after starting ACEi/ARB Renal Duplex Ultrasonography , CT Angiography, or MR Angiography of renal arteries Renal catheter angiography Fibromuscular Dysplasia (FMD) in young women: Percutaneous balloon angioplasty without stent. Atherosclerotic RAS in older men: Medical therapy (stenting has no benefit over GDMT; ASTRAL/CORAL)
Pheochromocytoma / Paraganglioma Paroxysmal "5 Ps": Pressure (severe HTN), Pain (headache), Perspiration (diaphoresis), Palpitations, Pallor Plasma free metanephrines (high sensitivity) or 24-hour urine fractionated metanephrines Abdominal/pelvic CT or MRI, 123I-MIBG scan, or 68Ga-DOTATATE PET Preoperative: Alpha-blockade FIRST (Phenoxybenzamine or Doxazosin for 10-14 days) , followed by Beta-blockade for reflex tachycardia. Surgical adrenalectomy. (Never start Beta-blocker before Alpha-blocker!)
Cushing Syndrome Central obesity, moon facies, buffalo hump, purple abdominal striae, proximal muscle weakness 24-hour urinary free cortisol , late-night salivary cortisol, or 1-mg overnight dexamethasone suppression test Serum ACTH level, High-dose dexamethasone test, Pituitary MRI / Adrenal CT Transsphenoidal resection of pituitary adenoma or adrenalectomy
Obstructive Sleep Apnea (OSA) Loud snoring, witnessed apneas, daytime somnolence, resistant HTN, obesity In-lab Polysomnography or Home Sleep Apnea Testing (AHI >= 5 events/hour) Sleep study severity quantification Nocturnal Continuous Positive Airway Pressure (CPAP), weight loss
Coarctation of the Aorta Upper extremity HTN with diminished/delayed femoral pulses ( brachial-femoral pulse delay ), lower extremity SBP >20 mmHg lower than arms 12-lead ECG (LVH), Chest X-ray ( rib notching on ribs 3-8, 'figure-of-3' aortic sign), Echocardiogram CT Angiography or MR Angiography of the chest Percutaneous balloon angioplasty +/- stent or surgical resection