MBBS Year
1st Year
Subject
What Is Usually Asked
Regulation of blood pressure, renin-angiotensin-aldosterone system
Resource HubAll Years (1st-Final)Medical Topic AuthorityHypertension
Hypertension: Notes, PPT and PYQs for MBBS
Hypertension is a persistent elevation of systemic arterial blood pressure, most commonly defined as 140/90 mmHg or above on repeated measurement. It is a major risk factor for stroke, coronary artery disease, heart failure and chronic kidney disease. It is examined in Physiology in 1st Year, Pathology and Pharmacology in 2nd Year, Community Medicine in 3rd Year, and General Medicine and Obstetrics in Final Year.
SME-reviewed. Updated 2026.
Open in GeckoMed for PPT slides and notesQuick Summary: What You Need to Know for University Exams
- Hypertension is diagnosed on repeated, properly measured readings, not a single reading.
- About 90 to 95% of cases are primary (essential); the rest are secondary to an identifiable cause.
- It is often asymptomatic, which is why it is called the "silent killer".
- Main target organs: heart, brain, kidneys, eyes and blood vessels.
- First-line drug classes: ACE inhibitors or ARBs, calcium channel blockers and thiazide or thiazide-like diuretics.
- ACE inhibitors and ARBs are contraindicated in pregnancy.
- Hypertensive emergency means severe hypertension with acute target organ damage.
Hypertension Across MBBS Subjects
| MBBS Year | Subject | What Is Usually Asked |
|---|---|---|
| 1st Year | Physiology | Regulation of blood pressure, renin-angiotensin-aldosterone system |
| 2nd Year | Pathology | Hypertensive vascular disease, arteriolosclerosis, hypertensive heart disease |
| 2nd Year | Pharmacology | Classification of antihypertensives, mechanisms, adverse effects |
| 3rd Year | Community Medicine | Epidemiology, risk factors, prevention, screening |
| 3rd Year | Ophthalmology | Hypertensive retinopathy |
| Final Year | General Medicine | Evaluation, secondary causes, management, emergencies |
| Final Year | Obstetrics and Gynaecology | Hypertensive disorders of pregnancy |
MBBS Year
2nd Year
Subject
What Is Usually Asked
Hypertensive vascular disease, arteriolosclerosis, hypertensive heart disease
MBBS Year
2nd Year
Subject
What Is Usually Asked
Classification of antihypertensives, mechanisms, adverse effects
MBBS Year
3rd Year
Subject
What Is Usually Asked
Epidemiology, risk factors, prevention, screening
MBBS Year
3rd Year
Subject
What Is Usually Asked
Hypertensive retinopathy
MBBS Year
Final Year
Subject
What Is Usually Asked
Evaluation, secondary causes, management, emergencies
MBBS Year
Final Year
Subject
What Is Usually Asked
Hypertensive disorders of pregnancy
Definition and Classification
Definition: Hypertension is a sustained rise in systemic arterial blood pressure to levels that increase the risk of target organ damage. In most guidelines used in India, this is a systolic pressure of 140 mmHg or more and/or a diastolic pressure of 90 mmHg or more on repeated measurement.
Classification by Blood Pressure Level (International Society of Hypertension, 2020)
| Category | Systolic (mmHg) | Column 3 | Diastolic (mmHg) |
|---|---|---|---|
| Normal | Below 130 | and | Below 85 |
| High-normal | 130 to 139 | and/or | 85 to 89 |
| Grade 1 hypertension | 140 to 159 | and/or | 90 to 99 |
| Grade 2 hypertension | 160 or more | and/or | 100 or more |
Category
Normal
Systolic (mmHg)
Below 130
Column 3
and
Diastolic (mmHg)
Below 85
Category
High-normal
Systolic (mmHg)
130 to 139
Column 3
and/or
Diastolic (mmHg)
85 to 89
Category
Grade 1 hypertension
Systolic (mmHg)
140 to 159
Column 3
and/or
Diastolic (mmHg)
90 to 99
Category
Grade 2 hypertension
Systolic (mmHg)
160 or more
Column 3
and/or
Diastolic (mmHg)
100 or more
The 2017 American College of Cardiology and American Heart Association guideline uses a lower threshold, defining Stage 1 hypertension from 130/80 mmHg.
Classification by Cause
| Type | Proportion | Key Feature |
|---|---|---|
| Primary (essential) | About 90 to 95% | No single identifiable cause |
| Secondary | About 5 to 10% | Due to an identifiable, sometimes curable, cause |
Type
Primary (essential)
Proportion
About 90 to 95%
Key Feature
No single identifiable cause
Type
Secondary
Proportion
About 5 to 10%
Key Feature
Due to an identifiable, sometimes curable, cause
Other Important Terms
| Term | Meaning |
|---|---|
| White coat hypertension | Raised in clinic, normal at home or on ambulatory monitoring |
| Masked hypertension | Normal in clinic, raised outside it |
| Isolated systolic hypertension | Raised systolic with normal diastolic pressure; common in elderly people |
| Resistant hypertension | Uncontrolled despite three drugs of different classes, including a diuretic, at optimal doses |
| Hypertensive urgency | Severe hypertension without acute target organ damage |
| Hypertensive emergency | Severe hypertension with acute target organ damage |
Term
White coat hypertension
Meaning
Raised in clinic, normal at home or on ambulatory monitoring
Term
Masked hypertension
Meaning
Normal in clinic, raised outside it
Term
Isolated systolic hypertension
Meaning
Raised systolic with normal diastolic pressure; common in elderly people
Term
Resistant hypertension
Meaning
Uncontrolled despite three drugs of different classes, including a diuretic, at optimal doses
Term
Hypertensive urgency
Meaning
Severe hypertension without acute target organ damage
Term
Hypertensive emergency
Meaning
Severe hypertension with acute target organ damage
Aetiology (Causes and Risk Factors)
Risk Factors for Primary Hypertension
- Increasing age and family history
- High salt intake
- Obesity and physical inactivity
- Excess alcohol intake
- Diabetes mellitus and dyslipidaemia
- Psychosocial stress
Causes of Secondary Hypertension
| Category | Examples | Clues |
|---|---|---|
| Renal parenchymal | Chronic kidney disease, glomerulonephritis, polycystic kidney disease | Abnormal urine, raised creatinine |
| Renovascular | Renal artery stenosis (atherosclerosis, fibromuscular dysplasia) | Renal bruit, worsening renal function with ACE inhibitors |
| Endocrine | Primary hyperaldosteronism (Conn's syndrome) | Hypokalaemia |
| Endocrine | Phaeochromocytoma | Episodic headache, sweating, palpitations |
| Endocrine | Cushing's syndrome, thyroid disorders, acromegaly | Features of the underlying disease |
| Vascular | Coarctation of the aorta | Radio-femoral delay, weak femoral pulses |
| Drugs | NSAIDs, corticosteroids, oral contraceptives | Drug history |
| Others | Obstructive sleep apnoea, pregnancy | Snoring and daytime sleepiness; onset in pregnancy |
Category
Renal parenchymal
Examples
Chronic kidney disease, glomerulonephritis, polycystic kidney disease
Clues
Abnormal urine, raised creatinine
Category
Renovascular
Examples
Renal artery stenosis (atherosclerosis, fibromuscular dysplasia)
Clues
Renal bruit, worsening renal function with ACE inhibitors
Category
Endocrine
Examples
Primary hyperaldosteronism (Conn's syndrome)
Clues
Hypokalaemia
Category
Endocrine
Examples
Phaeochromocytoma
Clues
Episodic headache, sweating, palpitations
Category
Endocrine
Examples
Cushing's syndrome, thyroid disorders, acromegaly
Clues
Features of the underlying disease
Category
Vascular
Examples
Coarctation of the aorta
Clues
Radio-femoral delay, weak femoral pulses
Category
Drugs
Examples
NSAIDs, corticosteroids, oral contraceptives
Clues
Drug history
Category
Others
Examples
Obstructive sleep apnoea, pregnancy
Clues
Snoring and daytime sleepiness; onset in pregnancy
Pathophysiology
Basic equation: Blood pressure = Cardiac output × Total peripheral resistance
Flowchart
- Genetic predisposition combined with environmental factors such as high salt intake and obesity
- Increased sympathetic activity and activation of the renin-angiotensin-aldosterone system
- Sodium and water retention and vasoconstriction
- Rise in cardiac output and/or peripheral resistance
- Structural changes in arterioles maintain the raised resistance
- Sustained hypertension damages target organs
(Examiner may ask you to draw the renin-angiotensin-aldosterone system flowchart.)
Pathology of Hypertensive Vascular Disease
| Lesion | Seen In | Features |
|---|---|---|
| Hyaline arteriolosclerosis | Long-standing, benign hypertension | Homogeneous pink hyaline thickening of arteriolar walls; kidneys show benign nephrosclerosis |
| Hyperplastic arteriolosclerosis | Severe (malignant) hypertension | Concentric "onion-skin" thickening of arteriolar walls, often with fibrinoid necrosis |
| Hypertensive heart disease | Long-standing hypertension | Concentric left ventricular hypertrophy |
Lesion
Hyaline arteriolosclerosis
Seen In
Long-standing, benign hypertension
Features
Homogeneous pink hyaline thickening of arteriolar walls; kidneys show benign nephrosclerosis
Lesion
Hyperplastic arteriolosclerosis
Seen In
Severe (malignant) hypertension
Features
Concentric "onion-skin" thickening of arteriolar walls, often with fibrinoid necrosis
Lesion
Hypertensive heart disease
Seen In
Long-standing hypertension
Features
Concentric left ventricular hypertrophy
Clinical Features
Symptoms:
- Most patients have no symptoms
- Headache, often occipital and in the morning, in some patients
- Dizziness, palpitations and fatigue
- Symptoms of target organ damage, such as breathlessness, chest pain or neurological deficit
- Symptoms of a secondary cause
Target Organ Damage
| Organ | Effect |
|---|---|
| Heart | Left ventricular hypertrophy, coronary artery disease, heart failure, atrial fibrillation |
| Brain | Stroke (ischaemic and haemorrhagic), hypertensive encephalopathy, vascular dementia |
| Kidney | Nephrosclerosis, chronic kidney disease, proteinuria |
| Eye | Hypertensive retinopathy |
| Vessels | Aortic aneurysm, aortic dissection, peripheral arterial disease |
Organ
Heart
Effect
Left ventricular hypertrophy, coronary artery disease, heart failure, atrial fibrillation
Organ
Brain
Effect
Stroke (ischaemic and haemorrhagic), hypertensive encephalopathy, vascular dementia
Organ
Kidney
Effect
Nephrosclerosis, chronic kidney disease, proteinuria
Organ
Eye
Effect
Hypertensive retinopathy
Organ
Vessels
Effect
Aortic aneurysm, aortic dissection, peripheral arterial disease
Hypertensive Retinopathy (Keith-Wagener-Barker Grading)
| Grade | Findings |
|---|---|
| I | Mild generalised arteriolar narrowing |
| II | Arteriovenous nipping and more marked narrowing |
| III | Flame-shaped haemorrhages, cotton wool spots, hard exudates |
| IV | Grade III changes with papilloedema |
Grade
I
Findings
Mild generalised arteriolar narrowing
Grade
II
Findings
Arteriovenous nipping and more marked narrowing
Grade
III
Findings
Flame-shaped haemorrhages, cotton wool spots, hard exudates
Grade
IV
Findings
Grade III changes with papilloedema
Diagnosis
Correct Blood Pressure Measurement
- Seat the patient quietly for at least 5 minutes with back supported
- Keep the arm supported at heart level
- Use a cuff of the correct size
- Avoid caffeine, smoking and exercise for 30 minutes before measurement
- Take at least two readings and average them
- Measure in both arms at the first visit
- Confirm with repeat visits, home monitoring or ambulatory monitoring
Investigations
| Investigation | Purpose |
|---|---|
| Urine examination (protein, blood) | Renal damage |
| Serum creatinine and eGFR | Renal function |
| Serum electrolytes | Hypokalaemia may suggest hyperaldosteronism or diuretic effect |
| Fasting glucose or HbA1c | Diabetes |
| Lipid profile | Cardiovascular risk |
| ECG | Left ventricular hypertrophy, ischaemia, arrhythmia |
| Fundoscopy | Hypertensive retinopathy |
| Echocardiography | Left ventricular hypertrophy and function |
| Specific tests | For suspected secondary causes, for example renal imaging or hormonal studies |
Investigation
Urine examination (protein, blood)
Purpose
Renal damage
Investigation
Serum creatinine and eGFR
Purpose
Renal function
Investigation
Serum electrolytes
Purpose
Hypokalaemia may suggest hyperaldosteronism or diuretic effect
Investigation
Fasting glucose or HbA1c
Purpose
Diabetes
Investigation
Lipid profile
Purpose
Cardiovascular risk
Investigation
ECG
Purpose
Left ventricular hypertrophy, ischaemia, arrhythmia
Investigation
Fundoscopy
Purpose
Hypertensive retinopathy
Investigation
Echocardiography
Purpose
Left ventricular hypertrophy and function
Investigation
Specific tests
Purpose
For suspected secondary causes, for example renal imaging or hormonal studies
Management
Lifestyle Modification (All Patients)
| Measure | Advice |
|---|---|
| Salt reduction | WHO recommends less than 5 g of salt per day for adults |
| Diet | Diet rich in fruits, vegetables and low-fat dairy (DASH-type diet) |
| Weight control | Reduce weight if overweight |
| Physical activity | Regular aerobic exercise |
| Alcohol | Limit intake |
| Smoking | Stop completely |
Measure
Salt reduction
Advice
WHO recommends less than 5 g of salt per day for adults
Measure
Diet
Advice
Diet rich in fruits, vegetables and low-fat dairy (DASH-type diet)
Measure
Weight control
Advice
Reduce weight if overweight
Measure
Physical activity
Advice
Regular aerobic exercise
Measure
Alcohol
Advice
Limit intake
Measure
Smoking
Advice
Stop completely
First-Line Drug Classes
| Drug Class | Examples | Key Adverse Effects |
|---|---|---|
| ACE inhibitors | Enalapril, ramipril | Dry cough, angioedema, hyperkalaemia; contraindicated in pregnancy |
| Angiotensin receptor blockers (ARBs) | Losartan, telmisartan | Hyperkalaemia; contraindicated in pregnancy |
| Calcium channel blockers | Amlodipine | Ankle oedema, flushing, headache |
| Thiazide and thiazide-like diuretics | Hydrochlorothiazide, chlorthalidone, indapamide | Hypokalaemia, hyperuricaemia, hyperglycaemia |
Drug Class
ACE inhibitors
Examples
Enalapril, ramipril
Key Adverse Effects
Dry cough, angioedema, hyperkalaemia; contraindicated in pregnancy
Drug Class
Angiotensin receptor blockers (ARBs)
Examples
Losartan, telmisartan
Key Adverse Effects
Hyperkalaemia; contraindicated in pregnancy
Drug Class
Calcium channel blockers
Examples
Amlodipine
Key Adverse Effects
Ankle oedema, flushing, headache
Drug Class
Thiazide and thiazide-like diuretics
Examples
Hydrochlorothiazide, chlorthalidone, indapamide
Key Adverse Effects
Hypokalaemia, hyperuricaemia, hyperglycaemia
Other drugs: Beta-blockers (for compelling indications), mineralocorticoid receptor antagonists such as spironolactone (useful in resistant hypertension), alpha-blockers and centrally acting drugs.
Choosing Drugs for Compelling Indications
| Situation | Preferred Drugs |
|---|---|
| Diabetes or chronic kidney disease with proteinuria | ACE inhibitor or ARB |
| After myocardial infarction | Beta-blocker and ACE inhibitor |
| Heart failure with reduced ejection fraction | ACE inhibitor or ARB, beta-blocker, mineralocorticoid antagonist, diuretic |
| Pregnancy | Labetalol, nifedipine, methyldopa |
| Isolated systolic hypertension in elderly people | Calcium channel blocker or thiazide |
Situation
Diabetes or chronic kidney disease with proteinuria
Preferred Drugs
ACE inhibitor or ARB
Situation
After myocardial infarction
Preferred Drugs
Beta-blocker and ACE inhibitor
Situation
Heart failure with reduced ejection fraction
Preferred Drugs
ACE inhibitor or ARB, beta-blocker, mineralocorticoid antagonist, diuretic
Situation
Pregnancy
Preferred Drugs
Labetalol, nifedipine, methyldopa
Situation
Isolated systolic hypertension in elderly people
Preferred Drugs
Calcium channel blocker or thiazide
For a revision-ready version, see the antihypertensive drugs classification chart.
Hypertensive Emergency (MBBS Level)
- Admit and monitor closely
- Lower blood pressure in a controlled, gradual way with intravenous drugs, because a rapid fall can cause ischaemia of the brain, heart and kidneys
- Treat the specific organ damage, such as encephalopathy, pulmonary oedema or aortic dissection
Complications
- Stroke
- Coronary artery disease and myocardial infarction
- Heart failure
- Chronic kidney disease
- Hypertensive retinopathy and vision loss
- Aortic dissection and aneurysm
- Hypertensive encephalopathy
- Vascular dementia
Prevention and Control (Community Medicine Angle)
| Level | Measures |
|---|---|
| Primordial | Healthy diet, low salt intake and physical activity from childhood |
| Primary | Weight control, salt reduction, alcohol limitation and stopping smoking in people at risk |
| Secondary | Screening and early treatment; in India, population-based screening for common non-communicable diseases covers people aged 30 years and above |
| Tertiary | Managing complications and rehabilitation |
Level
Primordial
Measures
Healthy diet, low salt intake and physical activity from childhood
Level
Primary
Measures
Weight control, salt reduction, alcohol limitation and stopping smoking in people at risk
Level
Secondary
Measures
Screening and early treatment; in India, population-based screening for common non-communicable diseases covers people aged 30 years and above
Level
Tertiary
Measures
Managing complications and rehabilitation
India: The India Hypertension Control Initiative (IHCI) supports standardised treatment protocols and follow-up of patients with hypertension within the public health system.
Prognosis
Well-controlled hypertension markedly reduces the risk of stroke, heart attack, heart failure and kidney disease. Uncontrolled hypertension leads to progressive target organ damage and is a leading contributor to cardiovascular death.
Quick Viva Questions
Q: Why do ACE inhibitors cause dry cough? A: They block the breakdown of bradykinin, which accumulates and irritates the airways.
Q: Why are ACE inhibitors and ARBs avoided in pregnancy? A: They are fetotoxic and can damage the developing fetal kidneys.
Q: Radio-femoral delay suggests which cause of hypertension? A: Coarctation of the aorta.
Q: Which electrolyte clue suggests primary hyperaldosteronism? A: Hypokalaemia in a patient with hypertension.
Q: What kidney lesion is typical of malignant hypertension? A: Hyperplastic (onion-skin) arteriolosclerosis with fibrinoid necrosis.
How Hypertension Appears in MBBS University Exams
Typical question styles (not attributed to specific papers or years):
- "Classify hypertension. Discuss the aetiology, clinical features, complications and management of essential hypertension." (Long essay, General Medicine)
- "Classify antihypertensive drugs. Write the mechanism of action and adverse effects of ACE inhibitors." (Long essay, Pharmacology)
- "Write a short note on causes of secondary hypertension." (Short note, Medicine)
- "Write a short note on hypertensive retinopathy." (Short note, Ophthalmology)
- "Describe the pathology of hypertensive vascular disease." (Short note, Pathology)
- "Describe the epidemiology and prevention of hypertension." (Community Medicine)
Frequently Asked Questions
What is the cut-off for hypertension?
Most guidelines used in India define hypertension as 140/90 mmHg or above on repeated measurement. The 2017 ACC/AHA guideline uses a lower threshold of 130/80 mmHg.
Which antihypertensive drugs are safe in pregnancy?
Labetalol, nifedipine and methyldopa are commonly used. ACE inhibitors and ARBs are contraindicated in pregnancy.
Can I download the hypertension PPT for my presentation?
Yes. Use the Download PPT button at the top of this page. The GeckoMed app also gives offline access to the slides and notes.
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