Hypertension

Question 1

Stage 1 HTN?

Answer 1

> 140/90

Question 2

Stage 2 HTN?

Answer 2

> 160/90

Question 3

Severe HTN?

Answer 3

> 180/110

Question 4

Malignant HTN?

Answer 4

> 180/110 + organ damage

Question 5

what tests do you do for the following:

• confirm diagnosis?
• look for end organ damage?

Answer 5

To confirm diagnosis:
- ABPM or home BP monitoring.

To look for end organ damage:
- ECG or ECHO (any LVH?, past MI?)

Question 6

IF you have a BP over >140/90 what do you do?

if you have a BP over >180/110 what do you do?

Answer 6

offer ABPM

start antiHTN therapy immediately. consider referral

Question 7

once you have done a ABPM and your BP is found to be th following - what do you do?

<135/85?

> 135/85?

> 150/95?

Answer 7

<135/85?

no Rx - but consider if high risk

> 135/85?

Stage 1 HTN - Rx if CV risk is >20%/10yrs

> 150/95?

Stage 2 HTN - Rx

Question 8

HTN - Mx

1st line/ if Stage 1 HTN?

2nd line/if Stage 2 HTN?

3rd line?

resistant HTN?

Answer 8

1st line/ if Stage 1 HTN

• if <55 : ACEi or ARB
• if >55/black : Ca2+ channel blocker (nifedipine)

2nd line/if Stage 2 HTN

• ACE i + nifedipine OR thiazide-like diuretic (indapamide)

3rd line:

ACE i + nifedipine + thiazide-like diuretic

resistant HTN?

• all three + spironolactone

Question 9

what study + why are beta blockers no longer used first line for HTN?

Answer 9

ALLHAT Study

Beta-blockers aren’t first line for hypertension as they increase risk of new onset diabetes.

Question 10

A nurse informs you of a 28-year-old woman who is 24 weeks pregnant. He says that she has a blood pressure reading of 155/90 mmHg. Her previous blood pressure 2 days ago was 152/85 mmHg. She was previously healthy prior to becoming pregnant.

What is the first line management in this situation?

hydralazine 
urgent delivery of fetus 
lifestyle 
Oral labetalol 
IM steroid injections

Answer 10

Oral labetalol

This woman has moderate gestational hypertension. According to the current guidelines, the first line treatment is Oral labetalol.

Question 11

A 42-year-old man of Afro-Caribbean origin is diagnosed as having hypertension. Secondary causes of hypertension have been excluded. What is the most appropriate initial drug therapy?

losartan
bisoprolol
doxazosin
amlodipine

Answer 11

amlodipine

ACE inhibitors have reduced efficacy in black patients and are therefore not used first-line

Question 12

You review a 51-year-old hypertensive patient who you started on 2.5mg of ramipril one month ago. He is complaining of a tickly cough since starting the medication which is keeping him awake at night. However, is blood pressure is now within normal limits.

What should you advise him?

stop ramipril and prescribe amlodipine

stop ramipril and prescribe candesartan

Answer 12

stop ramipril and prescribe candesartan

For a patient under 55 who is intolerant to an ACE-i the next step would be to offer an angiotensin 2 receptor blocker (ARB)

Question 13

A 50-year-old Caucasian man is found to have blood pressure measurements of 150/100mmHg, 148/95mmHg and 160/95mmHg on three consecutive visits to his GP surgery. He declines ambulatory blood pressure monitoring as it will interfere with his work as a window cleaner. Home blood pressure readings are consistently above 150/95mmHg.

What is the best initial management?

amlodipine
indapamide
lifestyle
ramipril

Answer 13

ramipril

Question 14

A 62-year-old man is reviewed. His blood pressure is poorly controlled at 152/90 mmHg despite treatment with ramipril 10mg od, bendroflumethiazide 2.5mg od and amlodipine 10mg od. In addition to the antihypertensives he also takes aspirin and simvastatin.

What is the most appropriate change to his medication?

add furosemide
add spironolactone
add candesartan
add atenolol

Answer 14

add spironolactone

Question 15

A 72-year-old man is started on amlodipine 5mg od for hypertension. He has no other past medical history of note and routine bloods (including fasting glucose) and ECG were normal. What should his target blood pressure (based on clinic readings) be once on treatment?

130/80
140/80
140/85
140/90

Answer 15

Blood pressure target (based on clinic readings) for patients < 80 years - 140/90 mmHg

Question 16

You are reviewing a 75-year-old male patient with hypertension. He takes 10mg once a day of ramipril and 10mg once a day of amlodipine. His blood pressure remains uncontrolled and you want to start a third agent. His K+is 4.3 mmol/l.

According to the NICE guidelines, what would be the most appropriate third-line agent for this man?

bendroflumethiazide
candesartan
spironolactone
indapamide

Answer 16

indapamide

In a hypertensive patient on an ACE-i and calcium channel blocker who requires a third agent, thiazide-type diuretics are next line

Question 17

You see a 62-year-old man in your GP practice who is normally fit and well. He came to see you two weeks ago as his blood pressure reading was high (150/92 mmHg) when he checked it at the chemist. He has since had blood tests including plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol and HDL cholesterol. He had normal renal function and his glucose was within normal limits. A urine dip for protein was normal and an ECG was also normal. You check the back of his eyes and the fundi are normal. Ambulatory blood pressure monitoring (ABPM) was performed and the average blood pressure was 140/90 mmHg. You calculate his QRisk score as 16%.

What treatment plan is the most appropriate for this patient?

no treatment needed

offer lifestyle advice

offer statin therapy + lifestyle advice

Answer 17

offer statin therapy + lifestyle advice

An adult under 80 years old with type one hypertension, no end organ damage and a QRisk of >10% but < 20% should be treated with atorvastatin and lifestyle advice initially