1.10 Hypertensive Crises & Dyslipidemia

ABIM Internal Medicine Exam

Track your progress as you read

Finished sections get a check mark.

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

1.10 Hypertensive Crises & Dyslipidemia

Key Takeaways Explain This Topic AI

Lipid disorders appear as a named subsection under both Cardiovascular Disease and Endocrinology, Diabetes, and Metabolism.

Hypertensive emergency requires acute target-organ damage; the same blood pressure without organ injury is urgency and is managed with oral agents.

Mean arterial pressure should be reduced by no more than approximately 25% in the first hour in most hypertensive emergencies to avoid cerebral and renal hypoperfusion.

Aortic dissection and eclampsia are exceptions requiring rapid reduction to a specified systolic target rather than a graded 25% reduction.

Ezetimibe and PCSK9-directed therapy are added to maximally tolerated statin therapy in very high-risk atherosclerotic disease when LDL cholesterol remains above threshold.

Last updated: August 2026

1. Hypertensive Crises: Urgency vs. Emergency

A hypertensive crisis is defined as a severe acute elevation in blood pressure, typically Systolic BP >= 180 mmHg and/or Diastolic BP >= 120 mmHg .

Hypertensive Urgency vs. Hypertensive Emergency

Hypertensive Urgency: Severe BP elevation (>=180/>=120 mmHg) in an otherwise stable patient WITHOUT evidence of acute target organ damage . Managed with oral antihypertensive medications (e.g., Captopril, Clonidine, Labetalol, Amlodipine) with a goal of gradual BP reduction over 24 to 48 hours in the outpatient setting. Rapid IV reduction is contraindicated as it precipitates cerebral or myocardial ischemia.

Hypertensive Emergency: Severe BP elevation WITH acute, life-threatening target organ damage :

Neurologic: Hypertensive encephalopathy, acute ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage.

Cardiovascular: Acute aortic dissection, acute coronary syndrome, acute cardiogenic pulmonary edema.

Renal: Acute kidney injury with hematuria/proteinuria (malignant nephrosclerosis).

Obstetric: Eclampsia or severe preeclampsia.

Ophthalmologic: Grade IV hypertensive retinopathy (papilledema, flame hemorrhages, cotton-wool spots).

Blood Pressure Lowering Targets in Hypertensive Emergency

General Rule: Reduce Mean Arterial Pressure (MAP) by maximum 20% to 25% within the first hour , then if stable, reduce BP toward 160/100-110 mmHg over the next 2 to 6 hours , and cautiously toward normal over the subsequent 24 to 48 hours in the ICU.

CRITICAL EXCEPTIONS TO THE GENERAL RULE:

Acute Aortic Dissection: Rapid, immediate reduction of Systolic BP to < 120 mmHg and Heart Rate < 60 bpm within 20 minutes using IV Esmolol/Labetalol + Nitroprusside.

Acute Ischemic Stroke:

Eligible for IV Thrombolysis (Alteplase/Tenecteplase): Lower BP carefully to < 185/110 mmHg before administering thrombolytic, and maintain < 180/105 mmHg for at least 24 hours post-thrombolysis.

NOT receiving Thrombolysis/Thrombectomy: Permissive hypertension up to 220/120 mmHg is allowed to maintain penumbral perfusion, unless BP exceeds 220/120 mmHg (lower by 15% in first 24 hours) or other acute end-organ damage coexists.

Eclampsia / Severe Preeclampsia: Rapidly reduce SBP to < 140 mmHg using IV Hydralazine, IV Labetalol, or oral Nifedipine, combined with IV Magnesium Sulfate for seizure prophylaxis.

Intravenous Antihypertensive Agents

Nicardipine: Dihydropyridine CCB infusion (5-15 mg/h); excellent for encephalopathy, stroke, and renal failure.

Clevidipine: Ultra-short-acting lipid-emulsion CCB (half-life 1-2 min; 1-32 mg/h); precise titration.

Labetalol: Combined alpha-1 and non-selective beta blocker (1:7 alpha-to-beta ratio IV; 20 mg IV bolus followed by 40-80 mg q10min or infusion); safe in pregnancy and aortic dissection; avoid in acute decompensated HF or severe asthma.

Esmolol: Ultra-short beta-1 blocker (onset 1 min; 500 mcg/kg load, then 50-300 mcg/kg/min); agent of choice for aortic dissection.

Sodium Nitroprusside: Potent arterial and venous nitric oxide donor. Risk of Cyanide/Thiocyanate toxicity (altered mental status, metabolic lactic acidosis) with prolonged infusions (>48h), high doses (>2 mcg/kg/min), or renal/hepatic impairment.

Nitroglycerin: Potent venodilator (reduces preload); drug of choice for acute pulmonary edema and ACS; headache and tachyphylaxis within 24-48h.

2. Dyslipidemia: 2018 AHA/ACC Guidelines & Statin Benefit Groups

Lipid management centers on ASCVD risk reduction through matching statin intensity to absolute risk, supplemented by targeted non-statin therapies.

The 4 Statin Benefit Groups

Statin Benefit Group Patient Population Recommended Statin Intensity Primary LDL-C Target / Goal

1. Secondary Prevention: Clinical ASCVD ACS, history of MI, stable angina, coronary revascularization, stroke/TIA, PAD High-Intensity Statin (if age <=75y). Moderate-intensity if age >75y or intolerant >=50% reduction in LDL-C and LDL-C < 55-70 mg/dL . If Very High-Risk ASCVD and LDL-C >=70 mg/dL on max statin, add Ezetimibe ; add PCSK9 inhibitor if still >=70 mg/dL

2. Severe Hypercholesterolemia Baseline LDL-C >= 190 mg/dL (4.9 mmol/L) High-Intensity Statin (no risk score calculation needed) Target >=50% reduction in LDL-C. If LDL remains >=100 mg/dL on max statin, add Ezetimibe +/- PCSK9 inhibitor

3. Diabetes Mellitus in Adults Age 40 to 75 years with Type 1 or Type 2 DM and LDL-C 70–189 mg/dL Moderate-Intensity Statin (High-Intensity if multiple ASCVD risk factors or 10-year risk >=20%) Target 30-49% reduction in LDL-C (>=50% for high-intensity)

4. Primary Prevention in Adults without DM Age 40 to 75 years, LDL-C 70–189 mg/dL, stratified by 10-year Pooled Cohort Equations (PCE) risk - Low Risk (<5%): Lifestyle; - Borderline (5 to <7.5%): Moderate statin if risk enhancers present; - Intermediate (7.5 to <20%): Moderate statin (target 30-49% reduction); - High Risk (>=20%): High-Intensity statin (target >=50% reduction) If treatment decision is uncertain in Intermediate or Borderline risk, measure Coronary Artery Calcium (CAC) score

Coronary Artery Calcium (CAC) Scoring in Decision-Making:

CAC = 0: Statin therapy can be safely withheld or delayed (reassess in 3-5 years), unless the patient is a current cigarette smoker, has diabetes mellitus, or has a strong family history of premature ASCVD.

CAC = 1 to 99 (or <75th percentile): Favors initiating moderate-intensity statin therapy.

CAC >= 100 (or >=75th percentile): Strong indication for statin initiation regardless of estimated risk.

Statin Intensity Definitions

High-Intensity Statins (Lowers LDL-C by >= 50%):

• Atorvastatin 40 to 80 mg daily
• Rosuvastatin 20 to 40 mg daily

Moderate-Intensity Statins (Lowers LDL-C by 30% to 49%):

• Atorvastatin 10 to 20 mg daily
• Rosuvastatin 5 to 10 mg daily
• Simvastatin 20 to 40 mg daily
• Pravastatin 40 to 80 mg daily
• Lovastatin 40 mg daily

Low-Intensity Statins (Lowers LDL-C by < 30%):

Pravastatin 10 to 20 mg daily, Lovastatin 20 mg daily.

3. Non-Statin Pharmacotherapies

Ezetimibe (10 mg daily): Inhibits Niemann-Pick C1-Like 1 (NPC1L1) protein at the enterocyte brush border, blocking dietary and biliary cholesterol absorption. Lowers LDL-C by 15-20%. First-line add-on to maximally tolerated statin therapy in secondary prevention and severe hypercholesterolemia (IMPROVE-IT trial).

PCSK9 Inhibitors (Evolocumab 140 mg SC q2w / 420 mg monthly; Alirocumab 75-150 mg SC q2w): Fully human monoclonal antibodies that bind and neutralize Proprotein Convertase Subtilisin/Kexin type 9, preventing LDL receptor lysosomal degradation and dramatically upregulating hepatocyte LDL clearance. Lowers LDL-C by 50% to 60% . Proven to reduce cardiovascular death, MI, and stroke in very high-risk ASCVD (FOURIER and ODYSSEY OUTCOMES trials).

Bempedoic Acid (Nexletol 180 mg daily): Inhibits ATP-citrate lyase (ACL), an enzyme upstream of HMG-CoA reductase in hepatic cholesterol synthesis. Because it is a prodrug activated only in the liver (lacks activating enzyme in skeletal muscle), it does not cause statin-associated muscle symptoms (SAMS) . Lowers LDL-C by 15-25% and reduces MACE in statin-intolerant patients (CLEAR Outcomes trial). Side effects: Hyperuricemia (gout), tendon rupture.

Inclisiran (Leqvio): Small interfering RNA (siRNA) that inhibits intracellular PCSK9 translation in hepatocytes, administered subcutaneously on day 1, day 90, and then every 6 months . Lowers LDL-C by ~50%.

Icosapent Ethyl (Vascepa 2 g PO BID with meals): Highly purified ethyl ester of eicosapentaenoic acid (EPA). Indicated for patients with established ASCVD or diabetes with >=2 additional cardiovascular risk factors who have fasting triglycerides 135–499 mg/dL despite statin therapy . Reduces cardiovascular death, MI, and stroke by 25% (REDUCE-IT trial). Side effects: Increased risk of atrial fibrillation/flutter and minor bleeding.

Management of Severe Hypertriglyceridemia (Triglycerides >= 500 mg/dL): Primary objective is preventing acute pancreatitis . First-line therapy: Fibrates (Fenofibrate 54-160 mg daily; avoid Gemfibrozil with statins due to glucuronidation inhibition causing severe rhabdomyolysis), prescription Omega-3 fatty acids, strict dietary fat restriction (<15-20% of total daily calories), and complete alcohol abstinence.