Cardiovascular Health and Hypertension
Core concepts
Anchor on the ACC/AHA 2017 framework: normal <120/<80, elevated 120–129/<80, stage 1 130–139/80–89, stage 2 ≥140/90. Confirm with out-of-office measurement (home or ambulatory) before committing to a diagnosis when feasible. Treatment thresholds differ by 10-year ASCVD risk: stage 1 with risk <10% favors lifestyle; ≥10% or clinical CVD/diabetes favors pharmacotherapy.
First-line agents are thiazide-type diuretics, ACE inhibitors/ARBs, and dihydropyridine CCBs. Match drug to comorbidity: ACEi/ARB for diabetes with albuminuria or CKD; avoid ACEi/ARB in pregnancy and bilateral renal artery stenosis; beta-blockers are not first-line for uncomplicated hypertension but are indicated post-MI, in heart failure with reduced EF, and for rate control.
For lipids, use the pooled cohort equations to drive statin intensity (moderate vs. high). Know the four statin benefit groups and that diabetes age 40–75 warrants at least moderate-intensity statin. Heart failure: distinguish HFrEF (four pillars: ARNI/ACEi/ARB, beta-blocker, MRA, SGLT2 inhibitor) from HFpEF (SGLT2 inhibitors now favored).
Traps
- White-coat and masked hypertension - a normal office reading does not exclude hypertension.
- Resistant hypertension workup: confirm adherence, add spironolactone, then screen for primary aldosteronism.
- Secondary causes: young onset, hypokalemia, sleep apnea, renal disease, pheochromocytoma (paroxysmal symptoms).
- Aspirin for primary prevention is now rarely routine - weigh bleeding risk.
Rule of thumb
When a stem pairs hypertension with a comorbidity, pick the drug that treats both: diabetes + albuminuria → ACEi/ARB; HFrEF → guideline quadruple therapy; post-MI → beta-blocker plus statin.