Hypertension — resistant hypertension assessment and management OSCE station (NEET-PG/INICET)

Candidate instructions

You are the doctor in the medical outpatient department. A 58-year-old man has been referred for persistently elevated blood pressure despite three antihypertensive drugs. You have 8 minutes to assess him and outline a management plan, and 2 minutes for examiner questions.

Provided data: BP 158/96 mmHg (right arm, seated, average of two readings); medications — ramipril 10 mg OD, amlodipine 10 mg OD, indapamide 2.5 mg OD; serum potassium 3.3 mmol/L; creatinine 88 micromol/L (eGFR normal). He confirms he takes every dose.

Candidate tasks

1. Confirm the diagnosis of resistant hypertension and exclude white-coat/pseudo-resistance (adherence, correct technique, out-of-office confirmation).
2. Take a focused history for secondary-cause clues and contributing factors (drug history including NSAIDs/herbal remedies, sleep apnoea, alcohol, salt intake, snoring).
3. Perform (or describe) a focused examination for target-organ damage and secondary-cause signs (fundoscopy, cardiovascular, renal bruit, radio-femoral delay).
4. Outline the investigations you would arrange, including screening for primary aldosteronism.
5. Present a stepwise management plan, including the 4th-line agent and lifestyle measures.

Examiner checklist (mark each as done / partial / not done)

• Confirms resistant hypertension correctly (BP above target despite ≥ 3 antihypertensives at optimal doses including a diuretic, on a CCB and an ACEi/ARB).^[2]
• Excludes pseudo-resistance: confirms adherence, requests out-of-office (ambulatory/home) BP confirmation, and checks measurement technique and cuff size.^[1]
• Identifies the hypokalaemia as a clue to primary aldosteronism and arranges an aldosterone-to-renin ratio (noting interfering drugs should be addressed).^[2]
• Screens the drug history for contributors (NSAIDs, sympathomimetics, liquorice, herbal remedies, alcohol) and asks about obstructive sleep apnoea (snoring, daytime sleepiness).^[2]
• Performs (or describes) examination for target-organ damage and secondary causes: fundoscopy, cardiovascular (LV heave, S4), abdominal bruit (renal artery stenosis), radio-femoral delay (coarctation).^[1]
• Arranges appropriate baseline investigations (urinalysis, U&E/creatinine/eGFR, ECG for LVH, lipids/HbA1c; renal ultrasound ± Doppler and CTA where renovascular disease is suspected).^[1]
• States the correct 4th-line agent: spironolactone 25–50 mg once daily (or eplerenone), supported by PATHWAY-2.^[3]
• Reinforces lifestyle measures (salt < 5 g NaCl/day, DASH diet, weight loss, exercise, alcohol moderation, smoking cessation).^[1]
• Communicates the plan clearly and structures the assessment logically (confirm → screen → examine → investigate → treat).

Model answer / expected standard

This man has resistant hypertension — BP above target despite three antihypertensives at optimal doses including a diuretic (ramipril 10 mg + amlodipine 10 mg + indapamide 2.5 mg), confirmed adherent. The hypokalaemia (3.3 mmol/L) is a red flag for primary aldosteronism, the commonest endocrine secondary cause, and must be evaluated with a plasma aldosterone-to-renin ratio (ideally after correcting the potassium and addressing interfering drugs). First, exclude pseudo-resistance: confirm the reading with 24-h ambulatory BP monitoring, check technique/cuff size, and screen the drug history for contributors (NSAIDs, liquorice, herbal remedies, alcohol) and symptoms of obstructive sleep apnoea. Examine for target-organ damage (fundoscopy, LV heave, S4) and secondary causes (abdominal bruit, radio-femoral delay). Management: (1) reinforce lifestyle (salt restriction, DASH diet, weight loss, exercise); (2) add a mineralocorticoid receptor antagonist — spironolactone 25–50 mg once daily — which PATHWAY-2 showed to be the optimal 4th-line agent, monitoring potassium and renal function; (3) complete the secondary-cause workup and treat any cause found; (4) arrange close follow-up with home BP monitoring and, if still uncontrolled, consider tertiary referral and (selectively) renal denervation.^[1][2][3]

Common errors

• Diagnosing "resistant hypertension" without confirming adherence and out-of-office BP (pseudo-resistance is common).
• Ignoring the hypokalaemia as a clue to primary aldosteronism, or attributing it to the diuretic without measuring the aldosterone-to-renin ratio.
• Failing to screen the drug history for NSAIDs, liquorice, herbal remedies and alcohol.
• Adding a beta-blocker or alpha-blocker as the 4th-line agent instead of spironolactone (PATHWAY-2).
• Not reinforcing lifestyle measures (especially salt restriction), which is mandatory for all patients.
• Not examining for secondary-cause signs (abdominal bruit, radio-femoral delay) or target-organ damage.

References

The station is built on the 2023 ESH hypertension guideline, the AHA scientific statement on resistant hypertension, and the PATHWAY-2 trial of spironolactone for drug-resistant hypertension.^[1][2][3]

References3ShowHide

1. [1]Mancia G, Kreutz R, Brunström M, et al. 2023 ESH Guidelines for the management of arterial hypertension. Journal of Hypertension, 2023.PMID 37345492
2. [2]Carey RM, Calhoun DA, Bakris GL, et al. Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association. Hypertension, 2018.PMID 30354828
3. [3]Williams B, MacDonald TM, Morant S, et al. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2). Lancet, 2015.PMID 26414968