Hypertension Management
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Direct answer
Hypertension is diagnosed when clinic blood pressure is 140/90 mmHg or above, confirmed by repeat visits, home readings or ambulatory monitoring, and Indian practice treats to below 140/90 mmHg for most patients. Management begins with lifestyle change — salt restriction, exercise, weight reduction, alcohol moderation — and most patients need drug therapy, starting with an angiotensin receptor blocker or ACE inhibitor, a calcium channel blocker or a thiazide-like diuretic, alone or in early combination. The India Hypertension Control Initiative supports protocol-driven, single-pill combination treatment under the national non-communicable disease programme.
What you must remember
- Diagnosis requires elevated readings on separate occasions: clinic 140/90 mmHg or above, or 24-hour ambulatory daytime average at or above 135/85; grade severity and assess total cardiovascular risk, not the numbers alone.
- Lifestyle prescription: salt below about 5 g daily (Indian intakes are far higher, much hidden in pickles and packaged food), 150 minutes of moderate activity weekly, weight reduction and tobacco cessation.
- First-line classes are the A-C-D trio — ACE inhibitor or angiotensin receptor blocker, calcium channel blocker (amlodipine), and thiazide-like diuretic — with combination therapy preferred for pressures 20/10 mmHg or more above target.
- Screen every hypertensive patient for target-organ damage and risk: urine protein, serum creatinine with electrolytes, fasting glucose and lipids, ECG, and fundoscopy — and seek secondary causes in the young (under 30) or suddenly resistant case.
- Secondary-cause reflexes: obstructive sleep apnoea and renal disease are commonest, then renal artery stenosis, phaeochromocytoma (episodic headache, sweating, palpitations) and primary aldosteronism — check potassium before blaming essential resistance.
- Hypertensive emergency (severe hypertension with acute target-organ damage — encephalopathy, dissection, pulmonary oedema, eclampsia) needs controlled intravenous lowering; urgency without organ damage is managed with oral agents and early review, not rapid falls.
- Beta-blockers are not first-line uncomplicated therapy but are preferred with ischaemic heart disease or heart failure, and combination ACE inhibitor with angiotensin receptor blocker is avoided.
Common confusion
The commonest error is treating the white-coat phenomenon: a single high clinic reading never starts lifelong therapy without out-of-office confirmation. Candidates also chase an imagined emergency in asymptomatic severe hypertension and lower pressure too fast, risking cerebral hypoperfusion — organ damage, not the number, defines the emergency. Finally, do not reflexively add drugs before checking adherence and the secondary-cause screen; resistant hypertension is defined on three drugs including a diuretic at full dose.
Exam-focused takeaway
FMGE hypertension questions test the threshold, the target and the first drug: 140/90 diagnoses, most Indians are treated to below it, and the answer to "first-line" is the A-C-D trio with early single-pill combination, as promoted by the India Hypertension Control Initiative. Learn the emergency-versus-urgency split by organ damage and the young-patient trigger for secondary screening. Stems pairing hypokalaemia with resistant hypertension point to primary aldosteronism, and episodic triads point to phaeochromocytoma — both recycled favourites.
Frequently asked questions
What is the usual treatment target in Indian practice?
Below 140/90 mmHg for most patients, tighter where tolerated in selected high-risk groups.
Which drug classes are first line?
An ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or a thiazide-like diuretic — combined early when blood pressure is well above target.
What separates a hypertensive emergency from urgency?
Acute target-organ damage — encephalopathy, dissection, pulmonary oedema, eclampsia — defines the emergency needing intravenous therapy; urgency is managed orally.
When should secondary hypertension be suspected?
In patients under 30, with resistant or suddenly severe hypertension, or with clues such as hypokalaemia, abdominal bruits or daytime somnolence.
What is the India Hypertension Control Initiative?
A programme partnership, under the national NCD programme, promoting standardised protocols and single-pill combination therapy to raise blood-pressure control rates across Indian districts.