# Hypertension for NEET PG Medicine: ICMR 2026 Grades and Targets, Drugs, Secondary Causes, Retinopathy, Urgency vs Emergency Source: https://tracknation.in/story/hypertension-for-neet-pg-medicine-icmr-2026-grades-and-targets-drugs-secondary-causes-retinopathy-urgency-vs-emergency (TrackNation — free UPSC notes with PYQs) > NEET PG Medicine: the ICMR 2026 hypertension workflow (categories, diagnosis on two visits, targets, two-drug single-pill start, never two RAAS blockers), drug contraindications and side effects, secondary causes, white-coat hypertension, Keith-Wagener retinopathy grades, and urgency vs emergency, with a diagram, hooks, vignette MCQs and cards. ## Start Here 🎯 **Exam priority: High.** *Expect: classify a BP reading, when one reading is enough, targets for diabetics and the elderly, which drug to avoid in pregnancy, gout or asthma, why not ACEi + ARB, the commonest secondary cause, retinopathy grade 4, and the urgency-vs-emergency step.* CBME mapping: **GM 8.1–8.19**. Phaeochromocytoma and Conn syndrome pathology are in Pathology article 26; NP-NCD screening in Community Medicine. *ICMR grades, targets, drugs, urgency vs emergency, causes and retinopathy. Drawn by TrackNation.* ## Diagnose and Classify (ICMR 2026) - "A silent killer": most patients are asymptomatic, so **every adult ≥ 18 should have BP measured at every clinic visit**. - **Diagnosis**: ≥ 140/90 mm Hg on two different visits; a single visit is enough if ≥ 160/100. Use the higher category if only one value is high. Check orthostatic BP in adults ≥ 65. - **Targets**: all adults < 140/90; diabetes, CKD or established CVD < 130/80 (if tolerated); age ≥ 80 < 150/90. - **White-coat hypertension**: high in the clinic, normal out of the clinic. | **ICMR category** | **Systolic (mm Hg)** | **Diastolic (mm Hg)** | **Action** | | Normal | < 120 | < 80 | Reassure | | Elevated BP | 120–139 | 80–89 | Lifestyle | | Grade 1 | 140–159 | 90–99 | Drugs + lifestyle | | Grade 2 | 160–179 | 100–109 | Drugs + lifestyle | | Grade 3 | ≥ 180 | ≥ 110 | Drugs + lifestyle | ## Causes and Target Organs - **Primary** hypertension is about 85%. **Secondary** is usually due to **primary aldosteronism**; others: obstructive sleep apnoea, chronic kidney disease, renal artery stenosis, coarctation (legs lower than arms), phaeochromocytoma, Cushing syndrome, thyroid and parathyroid disease, drugs (steroids, stimulants, cocaine); liquorice worsens control. - **Renovascular**: about 80% atherosclerotic, 20% fibromuscular dysplasia; a renal bruit in fewer than half. - **Retinopathy (Keith-Wagener-Barker)**: 1 arteriolar narrowing; 2 narrowing + sclerosis; 3 haemorrhages and exudates; **4 papilloedema**. ## Treatment - **Lifestyle** (ICMR): no tobacco or alcohol, salt < 5 g/day, more fruit and vegetables, 30 minutes of activity daily, BMI < 23 kg/m², waist < 90 cm (men) and < 80 cm (women). - **Start with two classes**, preferably as a single-pill combination; monotherapy only for low-risk grade 1, age ≥ 80 or the frail. Use a **CCB or thiazide-like diuretic with an ACE inhibitor or ARB**; add the third class if needed; then spironolactone. **Never combine two RAAS blockers** (AKI risk). ICMR stepwise protocols start with amlodipine 5 mg and step up every 4 weeks. - Beta-blockers are not first-line, but suit angina, post-MI and heart failure. ACE inhibitors/ARBs are preferred in diabetes; ACE inhibitors are contraindicated in pregnancy; dry cough is their commonest and angioedema their most serious adverse effect. Methyldopa can cause Coombs-positive haemolytic anaemia. | **Class (ICMR examples)** | **Avoid in** | **Watch for** | | CCB — amlodipine | Heart failure | Pedal oedema, constipation | | ACE inhibitor — enalapril, ramipril | Pregnancy or planning it, prior angioedema, hyperkalaemia, bilateral renal artery stenosis | Dry cough, angioedema, high K, creatinine rise | | ARB — losartan, telmisartan, olmesartan | Pregnancy, bilateral renal artery stenosis | High K, hypotension, AKI | | Thiazide-like — chlorthalidone, HCTZ | Gout (and pregnancy per ICMR table) | Low Na, low K, high Ca, glucose intolerance | | Beta-blocker — metoprolol, carvedilol, labetalol | Asthma, severe bradycardia, 2nd/3rd-degree AV block | Fatigue, depression, sexual dysfunction | | MRA — spironolactone | Hyperkalaemia | Gynaecomastia, mastalgia | ## Urgency vs Emergency - **Urgency**: ≥ 180/120 without acute target-organ damage — start oral drugs, lower BP gradually over 24–48 hours, **no IV medicines**, review within a week. Anxiety is the commonest cause. - **Emergency**: the same levels plus target-organ damage — encephalopathy, retinopathy, pre-eclampsia/eclampsia, acute LV failure with pulmonary oedema, myocardial ischaemia, **aortic dissection**, renal failure. Short-acting IV drugs (labetalol, clevidipine, esmolol) then ICU titration; aim for a **20–25% fall in MAP over 1–2 hours**. ## Traps the Examiner Sets - One reading ≥ 160/100 is enough to diagnose (ICMR). - Severe BP without organ damage = urgency → oral, slow. - ACEi + ARB together: never. - Thiazide in gout, beta-blocker in asthma, ACEi in pregnancy — all avoid. - Commonest secondary cause: primary aldosteronism. ## Memory Hooks & Shortcuts *Shortcuts to lock in this article's numbers and lists. Each one only re-packages facts proven above.* - 🧠 **120 – 140 – 160 – 180: Normal, Grade 1, Grade 2, Grade 3 steps of 20** — BP grades - 🧠 **'A + C or D': ACEi/ARB with CCB or Diuretic** — drug pairing - 🧠 **Never double the RAAS — 'two rams butt heads (AKI)'** — no ACEi + ARB - 🧠 **Urgency = Unhurried oral; Emergency = IV in the ER** — urgency vs emergency - 🧠 **Retinopathy 4 = Four-letter 'disc' swells (papilloedema)** — KWB grade 4 - 🧠 **Aldo is the Usual secondary suspect** — secondary hypertension ## Rapid-Revision Cards - < 120/80. - 120–139 / 80–89: lifestyle. - 140–159/90–99; 160–179/100–109; ≥ 180/≥ 110. - ≥ 140/90 on 2 visits; ≥ 160/100 once. - < 140/90; DM/CKD/CVD < 130/80; ≥ 80 y < 150/90. - Two classes, single pill. - CCB or thiazide + ACEi/ARB. - ACEi + ARB. - Spironolactone (MRA). - Contraindicated. - Cough (commonest), angioedema (most serious). - Gout. - Asthma, severe bradycardia, AV block. - Pedal oedema, constipation. - Salt < 5 g; BMI < 23; waist < 90/80 cm; 30 min. - Primary aldosteronism. - Legs BP lower than arms. - 80% atherosclerosis, 20% FMD. - Papilloedema. - ≥ 180/120, no organ damage: oral, 24–48 h. - + organ damage: IV, MAP ↓ 20–25% in 1–2 h. ## Sources *Facts in this article were checked against these documents.* - Standard Treatment Workflow: Hypertension in Adults — ICMR / Department of Health Research, MoHFW, May 2026 (link) - MSD Manual Professional: Hypertension; Medications for Hypertension; Hypertensive Emergencies; Renovascular Hypertension — Merck & Co. (MSD Manuals), reviewed 2025–26 (link) - Competency Based Undergraduate Curriculum, General Medicine (GM 8) — National Medical Commission, 2024 ## Test Yourself: Practice Questions Thirty questions in NEET PG style, most of them clinical vignettes. ## Practice Questions (NEET PG pattern) *Original questions written in the style of the exam: +4 for a correct answer, −1 for a wrong one. Every answer was checked against the sources listed above. NEET PG papers are not published by NBEMS, so these are not past-paper questions.* **Q1.** A 45-year-old has BP 152/94 mm Hg on two separate clinic visits. By the ICMR 2026 workflow this is - (a) grade 2 hypertension - (b) grade 1 hypertension - (c) elevated BP - (d) normal **Answer: (b)** — Grade 1: 140–159 and/or 90–99. **Q2.** A reading of 166/104 mm Hg at one visit. Per ICMR, the diagnosis of hypertension - (a) needs ambulatory monitoring always - (b) needs three more visits - (c) cannot be made - (d) can be made at this single visit **Answer: (d)** — One visit suffices at ≥ 160/100. **Q3.** BP 132/86 mm Hg is classified by ICMR as - (a) grade 2 - (b) grade 1 hypertension - (c) normal - (d) elevated BP — lifestyle modification **Answer: (d)** — 120–139 and/or 80–89. **Q4.** The ICMR BP target for a hypertensive patient with diabetes is - (a) < 130/80 mm Hg if tolerated - (b) < 160/100 - (c) < 150/90 - (d) < 120/70 always **Answer: (a)** — General adults < 140/90; age ≥ 80 < 150/90. **Q5.** The ICMR target for an 84-year-old with hypertension is - (a) no target - (b) < 130/80 - (c) < 120/80 - (d) < 150/90 mm Hg **Answer: (d)** — Check orthostatic BP in those ≥ 65. **Q6.** The ICMR default initial drug treatment for most adults with hypertension is - (a) lifestyle only for 1 year - (b) a beta-blocker alone - (c) two drugs from different classes, preferably a single pill - (d) a diuretic alone **Answer: (c)** — Monotherapy only for low-risk grade 1, ≥ 80 years or frail. **Q7.** Which combination does the ICMR workflow forbid? - (a) chlorthalidone with an ACE inhibitor - (b) an ACE inhibitor with an ARB - (c) amlodipine with chlorthalidone - (d) amlodipine with telmisartan **Answer: (b)** — Two RAAS blockers raise AKI risk. **Q8.** If BP stays uncontrolled on a CCB, ACE inhibitor/ARB and thiazide-like diuretic, the ICMR workflow suggests adding - (a) a loop diuretic in all - (b) a second ACE inhibitor - (c) digoxin - (d) a mineralocorticoid receptor antagonist such as spironolactone **Answer: (d)** — Resistant hypertension step. **Q9.** A pregnant woman with chronic hypertension should NOT receive - (a) lifestyle advice - (b) labetalol - (c) BP monitoring - (d) an ACE inhibitor **Answer: (d)** — ACE inhibitors (and ARBs) are contraindicated in pregnancy; labetalol is used in pregnancy. **Q10.** A patient on enalapril develops a persistent dry cough. This is - (a) caused by hyperkalaemia - (b) a sign of heart failure always - (c) the commonest adverse effect of ACE inhibitors - (d) an allergy to all antihypertensives **Answer: (c)** — Angioedema is the most serious. **Q11.** A hypertensive man with recurrent gout should avoid - (a) telmisartan - (b) thiazide-like diuretics - (c) losartan - (d) amlodipine **Answer: (b)** — Thiazides raise urate. **Q12.** Ankle swelling after starting amlodipine is - (a) a sign of renal failure - (b) a recognised side effect of CCBs - (c) heart failure in all cases - (d) drug allergy **Answer: (b)** — Constipation is another. **Q13.** A hypertensive asthmatic should not be given - (a) chlorthalidone - (b) amlodipine - (c) telmisartan - (d) a beta-blocker **Answer: (d)** — Also avoid with severe bradycardia or 2nd/3rd-degree block. **Q14.** Beta-blockers as antihypertensives are best reserved for patients who also have - (a) pregnancy-planning only - (b) asthma - (c) angina, previous MI or heart failure - (d) gout **Answer: (c)** — They are not first-line otherwise. **Q15.** The ICMR salt limit for hypertensive patients is - (a) no limit - (b) < 2 g/day of sodium chloride only for kidney disease - (c) < 10 g/day - (d) < 5 g/day **Answer: (d)** — With activity 30 min/day and BMI < 23. **Q16.** The ICMR waist circumference targets are - (a) < 102 cm men, < 88 cm women - (b) < 90 cm for men and < 80 cm for women - (c) < 80 cm men, < 70 cm women - (d) none **Answer: (b)** — BMI target < 23 kg/m². **Q17.** The commonest identifiable cause of secondary hypertension is - (a) primary aldosteronism - (b) Cushing syndrome - (c) coarctation of the aorta - (d) phaeochromocytoma **Answer: (a)** — Sleep apnoea, CKD and renal artery stenosis follow. **Q18.** A young man has arm hypertension with much lower BP in the legs and delayed femoral pulses. The likely cause is - (a) coarctation of the aorta - (b) white-coat hypertension - (c) renal artery stenosis - (d) primary aldosteronism **Answer: (a)** — A vascular cause of secondary hypertension. **Q19.** A young woman's renovascular hypertension is due to fibromuscular dysplasia. Of all renovascular hypertension, this cause accounts for about - (a) 20% - (b) 50% - (c) 5% - (d) 80% **Answer: (a)** — Atherosclerosis causes about 80%. **Q20.** Fundoscopy in a severely hypertensive patient shows papilloedema. The Keith-Wagener-Barker grade is - (a) 1 - (b) 2 - (c) 4 - (d) 3 **Answer: (c)** — Grade 3 = haemorrhages and exudates. **Q21.** Haemorrhages and exudates with arteriolar changes but no papilloedema correspond to hypertensive retinopathy grade - (a) 4 - (b) 3 - (c) 1 - (d) 2 **Answer: (b)** — Grade 4 adds papilloedema. **Q22.** A patient's BP is 186/122 mm Hg; he is asymptomatic with no target-organ damage. Per ICMR, management is - (a) sublingual nifedipine to normal within 1 hour - (b) oral antihypertensives with gradual lowering over 24–48 hours - (c) IV labetalol infusion in ICU - (d) IV nitroprusside **Answer: (b)** — Hypertensive urgency; no IV medicines. **Q23.** A hypertensive emergency differs from urgency by the presence of - (a) headache alone - (b) age over 60 - (c) acute target-organ damage - (d) a higher systolic number only **Answer: (c)** — Brain, heart, kidneys, aorta, retina, pregnancy. **Q24.** In a hypertensive emergency (excluding special cases), the initial goal is to lower mean arterial pressure by - (a) 10% over 24 hours - (b) to normal within 30 minutes - (c) 50% within 10 minutes - (d) 20–25% over 1–2 hours **Answer: (d)** — Short-acting IV drugs, then ICU titration. **Q25.** Which is a target-organ complication defining a hypertensive emergency? - (a) palpitations alone - (b) white-coat effect - (c) isolated headache with anxiety - (d) acute aortic dissection **Answer: (d)** — Also encephalopathy, pulmonary oedema, MI, eclampsia, renal failure. **Q26.** The commonest cause of hypertensive urgency is - (a) phaeochromocytoma - (b) aortic dissection - (c) renal artery stenosis - (d) anxiety **Answer: (d)** — Treat the anxiety; acute complications are unlikely. **Q27.** A patient's BP is high in clinic but normal on home and ambulatory readings. This is - (a) grade 2 hypertension - (b) resistant hypertension - (c) masked hypertension - (d) white-coat hypertension **Answer: (d)** — Out-of-office readings settle the diagnosis. **Q28.** In patients with diabetes and hypertension, the antihypertensive class of choice is - (a) ACE inhibitor or ARB - (b) alpha-blocker - (c) beta-blocker - (d) loop diuretic **Answer: (a)** — Unless pregnant. **Q29.** Primary (essential) hypertension accounts for about - (a) 99% - (b) 50% - (c) 15% - (d) 85% of cases **Answer: (d)** — Secondary: 5–15%. **Q30.** An antihypertensive that can cause Coombs-positive haemolytic anaemia is - (a) chlorthalidone - (b) telmisartan - (c) methyldopa - (d) amlodipine **Answer: (c)** — A centrally acting drug. ### Active Recall From memory: give the ICMR BP categories, diagnostic rule and targets; describe the ICMR drug strategy and forbidden combination; list contraindications and side effects of each class; name secondary causes and retinopathy grades; and contrast urgency with emergency management.