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Q1: Definition and measurement (2 min)
- Office HTN (ESC/ESH): ≥140/90 mmHg on repeated measurements; home ≥135/85; ABPM daytime ≥135/85
- Correct technique: seated 5 min, back supported, cuff at heart level, correct cuff size, both arms first visit, average of ≥2 readings
- White-coat vs masked hypertension — need out-of-office confirmation
Q2: Classification and targets (2 min)
- ESC grades 1 (140–159/90–99), 2 (160–179/100–109), 3 (≥180/≥110)
- ACC/AHA stage 1 starts at 130/80 — know the regional delta
- Targets: most <130/80 if tolerated; intensive evidence from SPRINT (SBP <120) in selected high-risk non-diabetics
Q3: First-line drugs with doses (3 min)
- ACEI e.g. ramipril 2.5–10 mg OD or ARB e.g. losartan 50–100 mg OD
- CCB amlodipine 5–10 mg OD
- Thiazide-like chlortalidone 12.5–25 mg or indapamide 1.5 mg SR
- Combination early for grade ≥2; never combine ACEI+ARB (ONTARGET)
- Ethnicity/age nuances: CCB/thiazide often preferred first in Black adults (NICE)
Q4: Resistant hypertension (3 min)
- Definition: above target on 3 drugs including diuretic, confirmed adherence + out-of-office BP
- 4th line: spironolactone 25 mg OD (PATHWAY-2) unless hyperkalaemia/advanced CKD
- Screen secondary: primary aldosteronism (ARR off interfering drugs if possible), OSA, renovascular, phaeo, Cushing, coarctation, drugs (NSAID, OCP, steroids, liquorice)
Q5: Hypertensive emergency vs urgency (3 min)
- Emergency = severe BP with acute TOD (encephalopathy, ICH/ischaemic stroke protocols differ, ACS, flash pulmonary oedema, aortic dissection, eclampsia, microangiopathic haemolysis, AKI)
- Urgency = severe BP, no acute TOD — oral agents, controlled outpatient/observation pathway
- IV options: labetalol 20 mg bolus ± infusion; nicardipine; GTN; nitroprusside
- MAP fall 10–20% first hour then gradual; exception: aortic dissection needs rapid SBP often to <120 with beta-blockade first
Q6: Special populations (2 min)
- Pregnancy: labetalol, nifedipine, methyldopa; no ACEI/ARB; MgSO₄ for eclampsia prophylaxis in severe PET
- CKD: ACEI/ARB cornerstone if albuminuria; watch creatinine rise <30% acceptable; SGLT2i if diabetic/CKD criteria
- Diabetes: target usually <130/80; ACEI/ARB if albuminuria
- Elderly/frail: start low, go slow; avoid overtreatment orthostatic hypotension
Q7: Landmark trials (2 min)
- SPRINT — intensive SBP control benefit
- PATHWAY-2 — spironolactone best 4th agent in resistant HTN
- ACCOMPLISH — ACEI+amlodipine better than ACEI+HCTZ in high-risk
- ONTARGET — telmisartan non-inferior to ramipril; combination worse