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Stem A (outpatient — diagnosis and first-line therapy)
A 52-year-old Indian man attends clinic with clinic BP readings of 158/98 and 156/96 mmHg on two separate visits (correct technique, both arms). He is asymptomatic. BMI 31 kg/m², non-smoker, no diabetes. Creatinine 82 µmol/L, K⁺ 4.1 mmol/L, fasting glucose 5.4 mmol/L, HbA1c 5.6%, urine ACR 12 mg/g. ECG: left ventricular hypertrophy by voltage. Home BP averages 148/92 mmHg.
Stem B (emergency — for part d)
Separately, a 64-year-old woman presents with severe headache, BP 220/130 mmHg, confusion, and bilateral papilloedema. CT head excludes haemorrhage. Creatinine has risen from baseline 90 to 180 µmol/L.
Questions
a) Stem A — define the diagnosis using guideline thresholds and state the ESC/ESH grade. (3 marks)
Essential (primary) hypertension, confirmed by repeated office BP ≥140/90 mmHg plus home BP ≥135/85 mmHg (rules out white-coat).
ESC/ESH grade 2 hypertension (systolic 160–179 and/or diastolic 100–109).
ACC/AHA would label this stage 2 (≥140/90). Target-organ damage is already present (LVH).
b) Outline non-pharmacological measures with concrete targets, then first-line drug choice with exact agent, dose and rationale for this patient. (4 marks)
Lifestyle (prescribe, not just advise):
- Salt <5 g/day (DASH-style diet); weight loss toward BMI <25
- Aerobic exercise ≥150 min/week moderate intensity
- Alcohol ≤14 units/week men (less better); stop any NSAIDs/decongestants
- Sleep apnoea screen if snoring/daytime somnolence
Drug: start dual therapy early for grade 2 — e.g. amlodipine 5 mg OD + ramipril 5 mg OD (or single-pill combination).
Rationale: ACEI + dihydropyridine CCB is evidence-based (ACCOMPLISH preferred amlodipine over thiazide with ACEI in high-risk patients); ACEI preferred over ARB first-line if cost/access allow; thiazide-like (chlortalidone 12.5–25 mg OD or indapamide 1.5 mg SR OD) is an acceptable alternative third pillar.
Avoid ACEI+ARB combination (ONTARGET harm). Recheck electrolytes/creatinine 1–2 weeks after ACEI start.
c) State BP treatment targets and name one landmark intensive-control trial with its systolic target. (3 marks)
- Most adults / diabetes / CKD / high CV risk: <130/80 mmHg if tolerated (ESC/ESH 2018/2023; ACC/AHA).
- Older frail patients: individualise; often <140/90 first.
SPRINT: intensive SBP target <120 mmHg (automated office) vs <140 reduced composite CV events and death in high-risk non-diabetic adults — at cost of more hypotension, syncope, electrolyte issues.
d) Stem B — is this urgency or emergency? Immediate management with IV agents, doses, and MAP reduction targets. (5 marks)
Hypertensive emergency — severe BP elevation with acute target-organ damage (hypertensive encephalopathy + papilloedema + AKI). Urgency = severe BP without acute TOD.
Management: HDU/ICU; arterial line if available; do not drop BP precipitously.
- Aim ≈10–20% reduction in MAP in first hour, then further ≈5–15% over next 23 h toward ~160/100 if stable.
- Labetalol 20 mg IV over 2 min, repeat 20–80 mg every 10 min (max ≈300 mg) or infusion 1–2 mg/min.
- Alternatives: nicardipine 5 mg/h IV, titrate by 2.5 mg/h every 5–15 min (usual 5–15 mg/h); GTN 5–200 µg/min if ACS/pulmonary oedema; sodium nitroprusside 0.25–10 µg/kg/min (short-term; cyanide risk).
- Treat seizures/raised ICP pathway if needed; investigate secondary causes once stabilised.
Additional teaching points (mark-scoring phrases)
Resistant hypertension: office BP above target on ≥3 agents at optimal doses including a diuretic, with confirmed adherence and out-of-office readings → add spironolactone 25–50 mg OD (PATHWAY-2 first among bisoprolol/doxazosin). Screen primary aldosteronism (ARR) especially if hypokalaemia.
Secondary work-up red flags: abrupt onset, age <30 or >55 with severe HTN, resistant HTN, hypokalaemia, abdominal bruit (renovascular), radio-femoral delay (coarctation), paroxysms (phaeochromocytoma), Cushingoid habitus, OSA.
Pregnancy: labetalol / nifedipine / methyldopa preferred; ACEI/ARB/spironolactone contraindicated. Severe pre-eclampsia: MgSO₄ 4 g IV load then 1 g/h, deliver fetus, controlled BP reduction.