The video version of this podcast can be found here:

https://youtu.be/Pi7cBcov2fI

This video makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode, I go through a thorough review of the NICE guideline [NG136] on Hypertension in adults, with a series of multiple-choice questions. Each question is paired with quotation, aiming to clarify key concepts and enhance understanding. This informative segment is created to support continuous learning always focusing on what is relevant in Primary Care only.

I am not giving medical advice; this video is intended for health care professionals; it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

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·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The resources consulted can be found here:

Hypertension in adults: diagnosis and management - NICE guideline [NG136]:

·      https://www.nice.org.uk/guidance/ng136

The NICE hypertension flowcharts can be found here:

·      Website: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517

The Clinic BP targets tables can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mFtrsXeUGOB58DKE?e=J7filE

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Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to do a revision of the NICE guidelines on hypertension, including the changes introduced in November 2023, always focusing on what is relevant in Primary Care only.

I have created a number of multiple-choice questions, many of them presented as clinical scenarios, which will help you revise, test your knowledge and also assist you in remembering the facts more effectively.

The range of questions varies from fairly easy and straightforward ones to others which are more complex and require more thinking. After each question and their four options, you will get the correct answer paired with a guiding quotation from the NICE guideline.

Please note that the correct answers only reflect the strict use of the guideline, not a flexible clinical judgement.

Finally, I am going to delegate the reading of this section to an automated voice. I hope that you find it useful.

Good luck with your self-test!

Sarah, a 50-year-old woman with type 2 diabetes and hypertension, is starting step 1 antihypertensive treatment. What should be offered to her?

 Calcium-channel blocker

 Thiazide-like diuretic

 ACE inhibitor or ARB

 Beta-blocker

The correct answer is: 

ACE inhibitor or ARB

NICE quote:

Offer an ACE inhibitor or an ARB to adults starting step 1 antihypertensive treatment who:

have type 2 diabetes and are of any age or family origin

What is recommended regarding lifestyle advice for people with suspected or diagnosed hypertension?

 Offer magnesium, and potassium supplements.

 Discourage excessive consumption of coffee and other caffeine-rich products.

 Avoid physical activity.

 Offer calcium supplements.

The correct answer is: 

Discourage excessive consumption of coffee and other caffeine-rich products.

NICE quote:

Discourage excessive consumption of coffee and other caffeine-rich products. 

Emma, a 54-year-old woman with hypertension, is taking an ACE inhibitor as step 1 treatment. Despite this, her blood pressure remains uncontrolled. What should be offered to her as step 2 treatment?

 Alpha-blocker

 Calcium-channel blocker

 ARB

 Beta-blocker

The correct answer is: 

Calcium-channel blocker

NICE quote:

If hypertension is not controlled in adults taking step 1 treatment of an ACE inhibitor or ARB, offer the choice of 1 of the following drugs in addition to step 1 treatment:

a Calcium-channel blocker or

a thiazide-like diuretic. 

James, a 40-year-old man, has severe hypertension of 188/123 with no symptoms indicating same-day referral. What should be considered for confirmation of diagnosis?

 Repeat clinic blood pressure measurement within 7 days

 Repeat clinic blood pressure measurement within 14 days

 Start antihypertensive drug treatment immediately

 HBPM after 7 days of lifestyle modifications

The correct answer is: 

Repeat clinic blood pressure measurement within 7 days.

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral:

If no target organ damage is identified, confirm diagnosis by:

repeating clinic blood pressure measurement within 7 days, or

considering monitoring using ABPM (or HBPM if ABPM is not suitable or not tolerated), … ensuring a clinical review within 7 days.

What action is recommended when there is a significant difference in blood pressure readings between both arms?

 Repeat the measurements with the same arm.

 Discard the measurements and measure blood pressure again after 24 hours.

 Repeat the measurements with the arm showing the higher reading.

 Ignore the difference and proceed with the diagnosis.

The correct answer is: 

Repeat the measurements with the arm showing the higher reading.

NICE quote:

If the difference in readings between arms remains more than 15 mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading.

Tom, a 65-year-old man with hypertension on step 1 treatment, develops oedema as a side effect of Calcium-channel blocker therapy. What alternative treatment should be offered to him?

 Thiazide-like diuretic

 ARB

 ACE inhibitor

 Beta-blocker

The correct answer is: 

Thiazide-like diuretic

NICE quote:

If a Calcium-channel blocker is not tolerated, for example because of oedema, offer a thiazide-like diuretic to treat hypertension.

If a person has severe hypertension with a clinic blood pressure of 180/120 mmHg or higher, but no symptoms indicating same-day referral, what action should be taken?

 Start antihypertensive drug treatment immediately

 Monitor using ABPM

 Repeat clinic blood pressure measurement within 30 days

 Carry out investigations for target organ damage

The correct answer is: 

Carry out investigations for target organ damage

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral …, carry out investigations for target organ damage … as soon as possible.

Emma, a 55-year-old woman with hypertension, is considering combining ACE inhibitor with ARB for better blood pressure control. What should she be advised regarding this combination?

 Combination therapy is recommended for better control.

 Combination therapy should be avoided.

 Combination therapy is suitable only for resistant hypertension.

 Combination therapy is recommended only for people with diabetes.

The correct answer is: 

Combination therapy should be avoided.

NICE quote:

Do not combine an ACE inhibitor with an ARB to treat hypertension. 

For which group of patients is seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment recommended?

 Adults aged over 80.

 Adults aged under 40.

 Adults aged between 40 and 60.

 Adults aged between 60 and 80.

The correct answer is: 

Adults aged under 40.

NICE quote:

For adults aged under 40 with hypertension, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of the long-term balance of treatment benefit and risks.

When would you suspect phaeochromocytoma?

 If they have a history of hypertension.

 If they experience labile blood pressure.

 If they have mild headaches.

 If they have leg pain.

The correct answer is: 

If they experience labile blood pressure.

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis). 

What is the definition of stage 1 hypertension?

 Clinic blood pressure of 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilloedema.

 Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg.

 Clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg.

 Clinic systolic blood pressure of 180 mmHg or higher.

The correct answer is: 

Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg.

NICE quote:

Stage 1 hypertension

Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent ABPM daytime average or HBPM average blood pressure ranging from 135/85 mmHg to 149/94 mmHg.

Tom, a 65-year-old man with hypertension, has recently started a new exercise regimen and dietary changes to manage his blood pressure. How should his response to lifestyle changes be monitored?

 Immediately arrange ABPM.

 Monitor blood pressure every 6 months.

 Immediately organise HBPM.

 Use clinic blood pressure measurements.

The correct answer is: 

Use clinic blood pressure measurements.

NICE quote:

Use clinic blood pressure measurements to monitor the response to lifestyle changes or drug treatment in people with hypertension. 

Emily, a 55-year-old asymptomatic woman, is found to have no target organ damage despite a blood pressure of 173/122 mmHg. What is an acceptable choice to confirm the diagnosis of hypertension?

 Repeat clinic blood pressure measurement within 7 days.

 Start antihypertensive drug treatment immediately.

 Monitor Emily's blood pressure using ABPM for two weeks.

 Check Emily's Blood pressure in the emergency Department.

The correct answer is: 

Repeat clinic blood pressure measurement within 7 days.

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral:

If no target organ damage is identified, confirm diagnosis by:

repeating clinic blood pressure measurement within 7 days, or

considering monitoring using ABPM (or HBPM if ABPM is not suitable or not tolerated), … ensuring a clinical review within 7 days.

John, a 60-year-old man with hypertension, experiences cough as a side effect of ACE inhibitor therapy. What alternative treatment should be offered to him?

 Thiazide diuretic

 Calcium-channel blocker

 Thiazide-like diuretic

 ARB

The correct answer is: 

ARB

NICE quote:

If an ACE inhibitor is not tolerated, for example because of cough, offer an ARB to treat hypertension. 

What action should be taken if a person with a blood pressure of 185/110 mmHg has signs of retinal haemorrhage or papilloedema?

 Monitor blood pressure using HBPM

 Start antihypertensive drug treatment immediately

 Refer to ophthalmology

 Refer for specialist assessment on the same day

The correct answer is: 

Refer for specialist assessment on the same day

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:

signs of retinal haemorrhage or papilloedema (accelerated hypertension) or

life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury. 

Which term refers to a discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements?

 Accelerated hypertension

 Masked hypertension

 White-coat effect

 Persistent hypertension

The correct answer is: 

White-coat effect.

NICE quote:

White-coat effect

A discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis.

Sarah, a 75-year-old woman on antihypertensive medication and type 2 diabetes, experiences dizziness when standing up. How should her blood pressure be managed considering her symptoms?

 No treatment is necessary.

 Review medication and treat to a blood pressure target based on sitting blood pressure.

 Review medication and treat to a blood pressure target based on standing blood pressure.

 Review medication and treat to a blood pressure target based on lying down blood pressure.

The correct answer is: 

Review medication and treat to a blood pressure target based on standing blood pressure.

NICE quote:

In people with a significant postural drop or symptoms of postural hypotension, treat to a blood pressure target based on standing blood pressure.

After checking the blood pressure twice, how should clinic blood pressure be recorded?

 Record the higher of the last 2 measurements.

 Record the average of all measurements taken during the consultation.

 Record the lower of the last 2 measurements.

 Record the first measurement only.

The correct answer is: 

Record the lower of the last 2 measurements.

NICE quote:

Record the lower of the last 2 measurements as the clinic blood pressure.

When should investigations for target organ damage be carried out in a person with severe hypertension (180/120 mmHg or higher)?

 Within 30 days

 As soon as possible

 After confirming the diagnosis with ABPM

 After starting antihypertensive drug treatment

The correct answer is: 

As soon as possible

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral …, carry out investigations for target organ damage … as soon as possible.

James, a 60-year-old man with hypertension and type 2 diabetes, is starting step 1 antihypertensive treatment. What drug should be offered to him?

 Thiazide-like diuretic

 Beta-blocker

 ACE inhibitor

 Calcium-channel blocker

The correct answer is: 

ACE inhibitor

NICE quote:

Offer an ACE inhibitor or an ARB to adults starting step 1 antihypertensive treatment who:

have type 2 diabetes and are of any age or family origin 

John, a 50-year-old man, presents with a clinic blood pressure of 185/125 mmHg. He has no symptoms indicating same-day referral. What should be done next?

 Start antihypertensive drug treatment immediately.

 Monitor John's blood pressure using HBPM.

 Repeat clinic blood pressure measurement within 7 days.

 Perform investigations for target organ damage.

The correct answer is: 

Perform investigations for target organ damage.

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral …, carry out investigations for target organ damage … as soon as possible

Emma, a 45-year-old woman with hypertension, is of Black African origin and does not have type 2 diabetes. What drug should be offered to her as step 1 antihypertensive treatment?

 ARB

 ACE inhibitor

 Thiazide-like diuretic

 Calcium-channel blocker

The correct answer is: 

Calcium-channel blocker

NICE quote:

Offer a calcium-channel blocker (Calcium-channel blocker) to adults starting step 1 antihypertensive treatment who:

…

are of Black African or African–Caribbean family origin and do not have type 2 diabetes (of any age). 

Lisa, a 70-year-old woman, is experiencing new onset confusion along with a clinic blood pressure of 185/125 mmHg. What is the appropriate step?

 Start antihypertensive drug treatment immediately.

 Repeat clinic blood pressure measurement within 7 days.

 Monitor Lisa's blood pressure using ABPM with a review within 7 days.

 Refer Lisa for specialist assessment on the same day.

The correct answer is: 

Refer Lisa for specialist assessment on the same day.

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:

signs of retinal haemorrhage or papilloedema (accelerated hypertension) or

life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury. 

In what range of clinic blood pressure should ambulatory blood pressure monitoring (ABPM) be offered to confirm the diagnosis of hypertension?

 130/80 mmHg to 150/100 mmHg

 120/80 mmHg to 160/100 mmHg

 140/90 mmHg to 180/120 mmHg

 150/90 mmHg to 190/130 mmHg

The correct answer is: 

140/90 mmHg to 180/120 mmHg.

NICE quote:

If clinic blood pressure is between 140/90 mmHg and 180/120 mmHg, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. 

Which term describes clinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher?

 Target organ damage

 Stage 3 or severe hypertension

 White-coat effect

 Persistent hypertension

The correct answer is: 

Stage 3 or severe hypertension.

NICE quote:

Stage 3 or severe hypertension

Clinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher.

How should blood pressure be measured if pulse irregularity is detected?

 Use automated devices

 Measure manually using direct auscultation over the brachial artery

 Ignore the irregularity and proceed with automated measurement

 Measure manually using direct auscultation over the radial artery

The correct answer is: 

Measure manually using direct auscultation over the brachial artery

NICE quote:

Because automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation), palpate the radial or brachial pulse before measuring blood pressure. If pulse irregularity is present, measure blood pressure manually using direct auscultation over the brachial artery. 

When should antihypertensive drug treatment be offered in addition to lifestyle advice to adults with persistent stage 2 hypertension (clinic BP 160/100 or higher)?

 Only in individuals aged under 60.

 Only in individuals aged over 80.

 Only in individuals aged between 60 and 80.

 To adults of any age.

The correct answer is: 

To adults of any age.

NICE quote:

Offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension. Use clinical judgement for people of any age with frailty or multimorbidity

Mark, a 65-year-old man, presents with a clinic blood pressure of 180/120 mmHg but no symptoms indicating same-day referral. What action should be taken next?

 Start antihypertensive drug treatment immediately.

 Monitor Mark's blood pressure using HBPM.

 Repeat clinic blood pressure measurement within 7 days.

 Perform investigations for target organ damage.

The correct answer is: 

Perform investigations for target organ damage.

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral …, carry out investigations for target organ damage … as soon as possible

James, a 65-year-old man of Black African origin with hypertension, is already taking a Calcium-channel blocker as step 1 treatment. Despite this, his blood pressure remains uncontrolled. What should be offered to him as step 2 treatment?

 ACE inhibitor

 ARB

 Alpha-blocker

 Beta-blocker

The correct answer is: 

ARB

NICE quote:

If hypertension is not controlled in adults taking step 1 treatment of a Calcium-channel blocker, offer the choice of 1 of the following drugs in addition to step 1 treatment:

an ACE inhibitor or

an ARB or

a thiazide-like diuretic.

If hypertension is not controlled in adults of Black African or African–Caribbean family origin who do not have type 2 diabetes taking step 1 treatment, consider an ARB, in preference to an ACE inhibitor, in addition to step 1 treatment.

What should be done while waiting for confirmation of a diagnosis of hypertension with ABMP?

 Immediate initiation of antihypertensive medication.

 Investigations for target organ damage followed by formal cardiovascular risk assessment.

 Minimise physical activity.

 Home blood pressure monitoring (HBPM) for at least 10 days.

The correct answer is: 

Investigations for target organ damage followed by formal cardiovascular risk assessment.

NICE quote:

While waiting for confirmation of a diagnosis of hypertension, carry out:

investigations for target organ damage …, followed by

formal assessment of cardiovascular risk using a cardiovascular risk assessment tool 

Emma, a 50-year-old woman with hypertension, has conflicting clinic and non-clinic blood pressure results. What additional method of blood pressure monitoring should be considered for her?

 Use only clinic blood pressure measurements by a doctor.

 Use only clinic blood pressure measurements by a nurse.

 Use only clinic blood pressure measurements in the community, e.g. pharmacy.

 Use ABPM or HBPM in addition to clinic blood pressure measurements.

The correct answer is: 

Use ABPM or HBPM in addition to clinic blood pressure measurements.

NICE quote:

Consider ABPM or HBPM, in addition to clinic blood pressure measurements, for people with hypertension identified as having a white-coat effect or masked hypertension (in which clinic and non-clinic blood pressure results are conflicting). Be aware that the corresponding measurements for ABPM and HBPM are 5 mmHg lower than for clinic measurements.

What is recommended when measuring the initial blood pressure in people with symptoms of postural hypotension?

 Measure blood pressure with the person standing

 Measure blood pressure after vigorous exercise

 Measure blood pressure in a crowded environment

 Measure blood pressure with the person lying on their back or consider a seated position if it's inconvenient to lie down

The correct answer is: 

Measure blood pressure with the person lying on their back or consider a seated position if it's inconvenient to lie down

NICE quote:

In people with symptoms of postural hypotension, including falls or postural dizziness:

measure blood pressure with the person lying on their back (or consider a seated position, if it is inconvenient to measure blood pressure with the person lying down)

Tom, a 65-year-old man without type 2 diabetes, is starting step 1 antihypertensive treatment. What drug should be offered to him?

 ACE inhibitor

 Thiazide-like diuretic

 ARB

 Calcium-channel blocker

The correct answer is: 

Calcium-channel blocker

NICE quote:

Offer a calcium-channel blocker to adults starting step 1 antihypertensive treatment who:

are aged 55 or over and do not have type 2 diabetes

What is the definition of masked hypertension?

 Clinic blood pressure of 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilloedema

 High blood pressure at repeated clinical encounters

 Clinic blood pressure measurements are normal, but blood pressure measurements are higher when taken outside the clinic

 Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg

The correct answer is: 

Clinic blood pressure measurements are normal, but blood pressure measurements are higher when taken outside the clinic.

NICE quote:

Masked hypertension

Clinic blood pressure measurements are normal (less than 140/90 mmHg), but blood pressure measurements are higher when taken outside the clinic using average daytime ambulatory blood pressure monitoring (ABPM) or average home blood pressure monitoring (HBPM) blood pressure measurements.

When should people with a clinic blood pressure of 180/120 mmHg and higher be referred for specialist assessment on the same day?

 If they experience hip pain

 If they have a cardiovascular risk >10%

 If they have signs of retinal haemorrhage or papilloedema

 If they have a history of hypertension

The correct answer is: 

If they have signs of retinal haemorrhage or papilloedema

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:

signs of retinal haemorrhage or papilloedema (accelerated hypertension) or

life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury.

Sarah, a 70-year-old woman with hypertension, is already on treatment with a Calcium-channel blocker as step 1 therapy. Despite this, her blood pressure remains uncontrolled. What should be offered to her as step 2 treatment?

 ACE inhibitor

 Spironolactone

 Beta-blocker

 Alpha-blocker

The correct answer is: 

ACE inhibitor

NICE quote:

If hypertension is not controlled in adults taking step 1 treatment of a Calcium-channel blocker, offer the choice of 1 of the following drugs in addition to step 1 treatment:

an ACE inhibitor or

an ARB or

a thiazide-like diuretic. 

David, a 60-year-old man, experiences labile blood pressure along with headaches and palpitations. What should be considered for David?

 Start antihypertensive drug treatment immediately.

 Repeat clinic blood pressure measurement within 7 days.

 Monitor David's blood pressure using HBPM.

 Refer David for specialist assessment on the same day.

The correct answer is: 

Refer David for specialist assessment on the same day (suspected phaeochromocytoma).

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis). 

When should subsequent blood pressures be measured in people with confirmed postural hypotension?

 After 5 minutes of standing

 Once, regardless of symptoms

 With the person lying down

 With the person standing for at least 1 minute

The correct answer is: 

With the person standing for at least 1 minute

NICE quote:

measure blood pressure again after the person has been standing for at least 1 minute.

If the person's systolic blood pressure falls by 20 mmHg or more, or their diastolic blood pressure falls by 10 mmHg or more, after the person has been standing for at least 1 minute:

measure subsequent blood pressures with the person standing

Jack, a 45-year-old Asian man without type 2 diabetes, is starting step 1 antihypertensive treatment. What drug should be offered to him?

 ACE inhibitor

 Thiazide-like diuretic

 Beta-blocker

 Calcium-channel blocker

The correct answer is: 

ACE inhibitor

NICE quote:

Offer an ACE inhibitor or an ARB to adults starting step 1 antihypertensive treatment who:

…

are aged under 55 but not of Black African or African–Caribbean family origin.

How often should blood pressure be measured in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease?

 At least monthly

 At least quarterly

 At least six monthly

 At least annually

The correct answer is: 

At least annually

NICE quote:

Measure blood pressure at least annually in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease. Offer and reinforce preventive lifestyle advice.

Sarah, a 60-year-old woman with hypertension is on amlodipine, ramipril and indapamide and she has been advised to reduce her dietary sodium intake. However, she asks if she can use salt substitutes containing potassium chloride instead. How should the healthcare provider respond to Sarah's inquiry?

 Encourage her to use salt substitutes containing potassium chloride.

 Discourage any changes in dietary sodium intake.

 Advise her to reduce sodium salt and avoid substitutes containing potassium chloride.

 Ignore her dietary sodium intake and manage with antihypertensive medication.

The correct answer is: 

Advise her to reduce sodium salt and avoid substitutes containing potassium chloride.

NICE quote:

Note that salt substitutes containing potassium chloride should not be used by older people, people with diabetes, pregnant women, people with kidney disease and people taking some antihypertensive drugs, such as ACE inhibitors and angiotensin II receptor blockers. Encourage salt reduction in these groups.

Tom is a 55-year-old man with hypertension, chronic kidney disease and type 2 diabetes. What guideline should be consulted for guidance on choice of hypertensive agent?

 NICE guideline on type 2 diabetes.

 NICE guideline on chronic kidney disease.

 NICE guideline on hypertension.

 NICE guideline on type 1 diabetes.

The correct answer is: 

NICE guideline on chronic kidney disease.

NICE quote:

For guidance on choice of hypertensive agent in people with chronic kidney disease, see NICE's guideline on chronic kidney disease.

How many consecutive measurements should be taken for each blood pressure recording when using HBPM to confirm a diagnosis of hypertension?

 One measurement per recording.

 Three consecutive measurements per recording at least one minute apart.

 Two consecutive measurements per recording at least one minute apart.

 Four consecutive measurements per recording at least one minute apart.

The correct answer is: 

Two consecutive measurements per recording at least one minute apart.

NICE quote:

When using HBPM to confirm a diagnosis of hypertension, ensure that:

for each blood pressure recording, 2 consecutive measurements are taken, at least 1 minute apart and with the person seated and

blood pressure is recorded twice daily, ideally in the morning and evening and

blood pressure recording continues for at least 4 days, ideally for 7 days.

Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension. 

What action should be taken if target organ damage is identified in an asymptomatic person with severe hypertension?

 Repeat clinic blood pressure measurement within 7 days

 Consider monitoring using ABPM

 Start antihypertensive drug treatment immediately

 Refer for specialist assessment

The correct answer is: 

Start antihypertensive drug treatment immediately.

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral …:

If target organ damage is identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.

James, a 60-year-old man without type 2 diabetes, is starting step 1 antihypertensive treatment. What drug should be offered to him based on the guideline?

 ARB

 Thiazide-like diuretic

 ACE inhibitor

 Calcium-channel blocker

The correct answer is: 

Calcium-channel blocker

NICE quote:

Offer a calcium-channel blocker (Calcium-channel blocker) to adults starting step 1 antihypertensive treatment who:

are aged 55 or over and do not have type 2 diabetes

What should be encouraged regarding dietary sodium intake?

 Keeping a diary of sodium intake.

 Substituting sodium salt with salt substitutes containing potassium chloride.

 Reducing or substituting sodium salt.

 Discouraging any changes in dietary sodium intake.

The correct answer is: 

Reducing or substituting sodium salt.

NICE quote:

Encourage people to keep their dietary sodium intake low, either by reducing or substituting sodium salt, as this can reduce blood pressure. 

What is the definition of accelerated hypertension?

 Clinic blood pressure of 160/100 mmHg or higher

 Clinic blood pressure of 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilloedema

 Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg

 Clinic systolic blood pressure of 180 mmHg or higher

The correct answer is: 

Clinic blood pressure of 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilloedema.

NICE quote:

Accelerated hypertension

A severe increase in blood pressure to 180/120 mmHg or higher (and often over 220/120 mmHg) with signs of retinal haemorrhage and/or papilloedema (swelling of the optic nerve). It is usually associated with new or progressive target organ damage and is also known as malignant hypertension.

John, a 60-year-old man with hypertension, is already on treatment with bendroflumethiazide and has stable, well-controlled blood pressure. What should be done regarding his treatment?

 Continue with current treatment

 Switch to an ACE inhibitor

 Switch to indapamide immediately

 Switch to Calcium-channel blocker

The correct answer is: 

Continue with current treatment.

NICE quote:

For adults with hypertension already having treatment with bendroflumethiazide or hydrochlorothiazide, who have stable, well-controlled blood pressure, continue with their current treatment.

What is a recommended choice if no target organ damage is identified in a person with severe hypertension?

 Repeat clinic blood pressure measurement within 30 days

 Start antihypertensive drug treatment immediately

 Monitor using HBPM for two weeks

 Confirm diagnosis by repeating clinic blood pressure measurement within 7 days

The correct answer is: 

Confirm diagnosis by repeating clinic blood pressure measurement within 7 days

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral:

If no target organ damage is identified, confirm diagnosis by:

repeating clinic blood pressure measurement within 7 days, or

considering monitoring using ABPM (or HBPM if ABPM is not suitable or not tolerated), … ensuring a clinical review within 7 days. 

When should specialist investigations be considered for possible secondary causes of hypertension?

 Only in severe cases of hypertension

 In all cases of hypertension

 When signs and symptoms suggest a secondary cause

 When there is a family history of hypertension

The correct answer is: 

When signs and symptoms suggest a secondary cause

NICE quote:

Consider the need for specialist investigations in people with signs and symptoms suggesting a secondary cause of hypertension. 

Tom, a 70-year-old man with resistant hypertension, has uncontrolled blood pressure despite optimal tolerated doses of four drugs. What should be considered next?

 Adding a fifth antihypertensive drug

 Seeking specialist advice

 Discontinuing treatment

 Continuing current treatment without changes

The correct answer is: 

Seeking specialist advice

NICE quote:

For people with confirmed resistant hypertension, consider adding a fourth antihypertensive drug as step 4 treatment or seeking specialist advice. 

Why is it advised to palpate the radial or brachial pulse before measuring blood pressure?

 To ensure the person is in a relaxed setting.

 To confirm the presence of atrial fibrillation.

 To check for pulse irregularity.

 To standardize the blood pressure measurement environment.

The correct answer is: 

To check for pulse irregularity.

NICE quote:

Because automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation), palpate the radial or brachial pulse before measuring blood pressure. 

Emma is a 50-year-old woman with isolated systolic hypertension. How should she be treated?

 She should have the same blood pressure target but be treated with a calcium channel blocker by default.

 If the diastolic blood pressure is below 80 mmHg, she should be treated with lifestyle changes only.

 She should have the same treatment as people with both raised systolic and diastolic blood pressure.

 No treatment is necessary for isolated systolic hypertension, just close monitoring.

The correct answer is: 

She should have the same treatment as people with both raised systolic and diastolic blood pressure.

NICE quote:

Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or more) the same treatment as people with both raised systolic and diastolic blood pressure.

What is the definition of persistent hypertension?

 High blood pressure at repeated clinical encounters

 Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg

 Clinic blood pressure of 160/100 mmHg or higher

 Clinic systolic blood pressure of 180 mmHg or higher

The correct answer is: 

High blood pressure at repeated clinical encounters.

NICE quote:

Persistent hypertension

High blood pressure at repeated clinical encounters.

James, a 75-year-old man with stage 1 hypertension, has a clinic blood pressure of 150/90 mmHg for several months. How should the healthcare provider manage James' hypertension?

 Monitor blood pressure for further 6 months.

 Ignore his hypertension.

 Start antihypertensive drug treatment straightaway.

 Consider treatment if has end organ damage, diabetes of a cardiovascular risk of 10% or higher.

The correct answer is: 

Consider treatment if has end organ damage, diabetes of a cardiovascular risk of 10% or higher.

NICE quote:

Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under 80 with persistent stage 1 hypertension who have 1 or more of the following:

target organ damage

established cardiovascular disease

renal disease

diabetes

an estimated 10‑year risk of cardiovascular disease of 10% or more.

Use clinical judgement for people with frailty or multimorbidity

James, a 75-year-old man with hypertension, is using ABPM to monitor his blood pressure response to treatment. What should be his target blood pressure based on HBPM?

 Below 130/80 mmHg

 Below 135/85 mmHg

 Below 140/90 mmHg

 Below 145/85 mmHg

The correct answer is: 

Below 135/85 mmHg

NICE quote:

When using ABPM or HBPM to monitor the response to treatment in adults with hypertension, use the average blood pressure level taken during the person's usual waking hours ... Reduce blood pressure and ensure that it is maintained:

below 135/85 mmHg for adults aged under 80

below 145/85 mmHg for adults aged 80 and over.

How often should clinic blood pressure be measured subsequently if hypertension is not diagnosed initially?

 Every 2 years.

 Every 3 years.

 Every 5 years.

 Every year.

The correct answer is: 

Every 5 years.

NICE quote:

If hypertension is not diagnosed, measure the person's clinic blood pressure at least every 5 years subsequently, and consider measuring it more frequently if the person's clinic blood pressure is close to 140/90 mmHg. 

James, a 50-year-old man with hypertension, is considering taking calcium, magnesium, or potassium supplements to help reduce his blood pressure. What should the healthcare provider tell James about the effectiveness of these supplements?

 Inform him that these supplements can decrease blood pressure but do not recommend them.

 Advise him to avoid these supplements as they have no effect on blood pressure.

 Encourage him to start taking these supplements.

 Suggest he consult with a specialist before starting these supplements.

The correct answer is: 

Advise him to avoid these supplements as they have no effect on blood pressure.

NICE quote:

Do not offer calcium, magnesium or potassium supplements as a method for reducing blood pressure. 

John, a 60-year-old man with hypertension, is interested in self-monitoring his blood pressure at home. Which method of blood pressure monitoring should he use?

 ABPM only.

 Clinic blood pressure measurements only.

 Blood pressure monitoring in local pharmacy.

 Use HBPM for self-monitoring.

The correct answer is: 

Use HBPM for self-monitoring.

NICE quote:

Advise people with hypertension who choose to self-monitor their blood pressure to use HBPM.

What is the definition of stage 2 hypertension?

 Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg

 Clinic blood pressure of 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilloedema

 Clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg

 Clinic blood pressure of 180/100 mmHg or higher

The correct answer is: 

Clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg.

NICE quote:

Stage 2 hypertension

Clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg and subsequent ABPM daytime average or HBPM average blood pressure of 150/95 mmHg or higher.

Sarah, a 45-year-old woman, visits the clinic with a clinic blood pressure of 190/130 mmHg. Upon examination, signs of retinal haemorrhage are noted. What is the appropriate action?

 Start antihypertensive drug treatment immediately.

 Repeat clinic blood pressure measurement within 7 days.

 Refer Sarah for specialist assessment on the same day.

 Refer Sarah to the Eye Clinic urgently.

The correct answer is: 

Refer Sarah for specialist assessment on the same day.

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:

signs of retinal haemorrhage or papilloedema (accelerated hypertension) or

life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury. 

Sarah, a 55-year-old woman with hypertension and no other medical history, is aiming to reduce her blood pressure. What should her clinic blood pressure target be?

 Below 130/80 mmHg

 Below 140/90 mmHg

 Below 150/90 mmHg

 Below 160/100 mmHg

The correct answer is: 

Below 140/90 mmHg

NICE quote:

For adults with hypertension aged under 80, reduce clinic blood pressure to below 140/90 mmHg and ensure that it is maintained below that level. 

Emma, a 60-year-old woman with a blood pressure persistently just over 160/100 mmHg, has been following lifestyle advice but her blood pressure remains elevated. What treatment option should now be offered to Emma?

 Continue lifestyle advice periodically.

 No treatment, just more regular monitoring.

 Antihypertensive drug treatment.

 Immediate statin therapy.

The correct answer is: 

Antihypertensive drug treatment.

NICE quote:

Offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension. Use clinical judgement for people of any age with frailty or multimorbidity

What action is recommended if hypertension is not diagnosed but there is evidence of target organ damage?

 Initiate antihypertensive medication immediately.

 Repeat clinic blood pressure measurements after 24 hours.

 Consider carrying out investigations for alternative causes of target organ damage.

 Discontinue further blood pressure monitoring.

The correct answer is: 

Consider carrying out investigations for alternative causes of target organ damage.

NICE quote:

If hypertension is not diagnosed but there is evidence of target organ damage, consider carrying out investigations for alternative causes of the target organ damage

Which term describes damage to organs such as the heart, brain, kidneys, and eyes?

 Masked hypertension

 White-coat effect

 Target organ damage

 Stage 3 or severe hypertension

The correct answer is: 

Target organ damage.

NICE quote:

Target organ damage

Damage to organs such as the heart, brain, kidneys and eyes. Examples are left ventricular hypertrophy, chronic kidney disease, hypertensive retinopathy or increased urine albumin:creatinine ratio.

Compared with the lying down blood pressure reading, when can postural hypotension be diagnosed?

 When the standing systolic blood pressure drops by 20mmHg and the standing diastolic blood pressure drops by 10 mmHg

 When both the standing systolic and diastolic blood pressure drops by 20mmHg

 When the standing systolic blood pressure drops by 10mmHg and the standing diastolic blood pressure drops by 20 mmHg

 When both the standing systolic and diastolic blood pressure drops by 10mmHg.

The correct answer is:

When the standing systolic blood pressure drops by 20mmHg and the standing diastolic blood pressure drops by 10 mmHg

NICE quote:

Postural hypotension: If the person's systolic blood pressure falls by 20 mmHg or more, or their diastolic blood pressure falls by 10 mmHg or more, after the person has been standing for at least 1 minute

Which symptoms warrant same-day specialist assessment for a person with severe hypertension?

 Mild headache

 Diarrhoea

 Limb pain

 Signs of heart failure

The correct answer is: 

Signs of heart failure

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:

signs of retinal haemorrhage or papilloedema (accelerated hypertension) or

life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury. 

What alternative is recommended if ambulatory blood pressure monitoring (ABPM) is unsuitable or the person cannot tolerate it?

 Repeat clinic blood pressure measurements.

 Offer home blood pressure monitoring (HBPM).

 Refer the person to specialist care.

 Disregard the diagnosis of hypertension.

The correct answer is: 

Offer home blood pressure monitoring (HBPM).

NICE quote:

If ABPM is unsuitable or the person is unable to tolerate it, offer home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension.

Emma, a 75-year-old woman with hypertension, experiences oedema as a side effect of Calcium-channel blocker therapy. What alternative treatment should be offered to her?

 ARB

 Beta-blocker

 ACE inhibitor

 Thiazide-like diuretic

The correct answer is: 

Thiazide-like diuretic

NICE quote:

If a Calcium-channel blocker is not tolerated, for example because of oedema, offer a thiazide-like diuretic to treat hypertension. 

How should cardiovascular risk be estimated in people with hypertension?

 Use ABPM measurements to calculate cardiovascular risk

 Estimate cardiovascular risk based on family history

 Use clinic blood pressure measurements to calculate cardiovascular risk

 Rely on symptoms reported by the patient to calculate cardiovascular risk

The correct answer is: 

Use clinic blood pressure measurements to calculate cardiovascular risk

NICE quote:

Use clinic blood pressure measurements to calculate cardiovascular risk. 

John, a 70-year-old man with stage 1 hypertension (clinic blood pressure between 140/90 and 160/100 mmHg), has established cardiovascular disease. He is unsure about starting antihypertensive drug treatment. How should the healthcare provider discuss treatment options with John?

 Discuss with him his individual cardiovascular disease risk and treatment preferences, then consider treatment.

 Start antihypertensive drug treatment without discussing options.

 Just offer lifestyle advice.

 Advise him to continue monitoring for now.

The correct answer is: 

Discuss with him his individual cardiovascular disease risk and treatment preferences, then consider treatment.

NICE quote:

Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under 80 with persistent stage 1 hypertension who have 1 or more of the following:

target organ damage

established cardiovascular disease

renal disease

diabetes

an estimated 10‑year risk of cardiovascular disease of 10% or more.

Use clinical judgement for people with frailty or multimorbidity

John, an active and fit 85-year-old man with a medical history of hypertension and hyperlipidaemia only, is experiencing difficulty maintaining his blood pressure below the recommended target. What should his clinic blood pressure target be?

 Below 130/80 mmHg

 Below 140/90 mmHg

 Below 150/90 mmHg

 Below 160/100 mmHg

The correct answer is: 

Below 150/90 mmHg

NICE quote:

For adults with hypertension aged 80 and over, reduce clinic blood pressure to below 150/90 mmHg and ensure that it is maintained below that level. Use clinical judgement for people with frailty or multimorbidity.

What action should be taken if the person's blood pressure falls by specific thresholds after standing for at least 1 minute?

 Review the person's current medication.

 Immediately refer the person to specialist care.

 Measure subsequent blood pressures with the person lying down.

 Disregard the symptoms and continue with regular monitoring.

The correct answer is: 

Review the person's current medication.

NICE quote:

If the person's systolic blood pressure falls by 20 mmHg or more, or their diastolic blood pressure falls by 10 mmHg or more, after the person has been standing for at least 1 minute:

consider likely causes, including reviewing their current medication

What is the term for a severe increase in blood pressure to 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilloedema?

 Masked hypertension

 Stage 2 hypertension

 Accelerated hypertension

 Persistent hypertension

The correct answer is: 

Accelerated hypertension.

NICE quote:

Accelerated hypertension

A severe increase in blood pressure to 180/120 mmHg or higher (and often over 220/120 mmHg) with signs of retinal haemorrhage and/or papilloedema (swelling of the optic nerve). It is usually associated with new or progressive target organ damage and is also known as malignant hypertension.

Sarah, a 55-year-old woman with stage 1 hypertension (clinic blood pressure between 140/90 and 160/100 mmHg) is considering starting antihypertensive drug treatment. How should the healthcare provider advise Sarah?

 Monitor blood pressure daily for six months

 Recommend against antihypertensive drug treatment at present.

 Consider antihypertensive drug treatment in addition to lifestyle advice regardless cardiovascular risk.

 Consider antihypertensive drug treatment in addition to lifestyle advice if cardiovascular risk is 10% or greater.

The correct answer is: 

Consider antihypertensive drug treatment in addition to lifestyle advice regardless cardiovascular risk.

NICE quote:

Consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 hypertension and an estimated 10‑year risk below 10%. Bear in mind that 10‑year cardiovascular risk may underestimate the lifetime probability of developing cardiovascular disease. 

What should be done if a person has suspected phaeochromocytoma?

 Start antihypertensive drug treatment immediately

 Refer for specialist assessment within 30 days

 Monitor using ABPM

 Refer for same-day specialist assessment

The correct answer is: 

Refer for same-day specialist assessment.

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis). 

Tom, a 40-year-old man of Black African origin with hypertension and type 2 diabetes, is considering starting antihypertensive drug treatment. What should be considered when choosing his medication?

 Prescribe an ACE inhibitor in preference.

 Prescribe an ARB in preference.

 Avoid ACE inhibitors and ARBs.

 Prescribe a calcium channel blocker in preference.

The correct answer is: 

Prescribe an ARB in preference.

NICE quote:

When choosing antihypertensive drug treatment for adults of Black African or African–Caribbean family origin, consider an angiotensin II receptor blocker (ARB), in preference to an angiotensin-converting enzyme (ACE) inhibitor. 

Emma, a 60-year-old woman with hypertension, is using ABPM to monitor her blood pressure response to treatment. What should be her target blood pressure based on ABPM?

 Below 130/80 mmHg

 Below 135/85 mmHg

 Below 140/90 mmHg

 Below 145/85 mmHg

The correct answer is: 

Below 135/85 mmHg

NICE quote:

When using ABPM or HBPM to monitor the response to treatment in adults with hypertension, use the average blood pressure level taken during the person's usual waking hours … Reduce blood pressure and ensure that it is maintained:

below 135/85 mmHg for adults aged under 80

below 145/85 mmHg for adults aged 80 and over.

When should hypertension be confirmed in people with a clinic blood pressure of 140/90 mmHg or higher?

 ABPM daytime average or HBPM average of 130/80 mmHg or higher.

 ABPM daytime average or HBPM average of 135/85 mmHg or higher.

 ABPM daytime average or HBPM average of 140/90 mmHg or higher.

 ABPM daytime average or HBPM average of 145/95 mmHg or higher.

The correct answer is: 

ABPM daytime average or HBPM average of 135/85 mmHg or higher.

NICE quote:

Confirm diagnosis of hypertension in people with a:

clinic blood pressure of 140/90 mmHg or higher and

ABPM daytime average or HBPM average of 135/85 mmHg or higher. 

If a person with severe hypertension has no symptoms indicating same-day referral, what is an acceptable option for confirmation of diagnosis?

 ABPM with review within 7 days

 Repeat clinic blood pressure measurement within 30 days

 Start antihypertensive drug treatment immediately

 Lifestyle modifications

The correct answer is: 

ABPM with review within 7 days

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral:

If no target organ damage is identified, confirm diagnosis by:

repeating clinic blood pressure measurement within 7 days, or

considering monitoring using ABPM (or HBPM if ABPM is not suitable or not tolerated), … ensuring a clinical review within 7 days. 

Sarah, a 65-year-old woman with hypertension, type 2 diabetes and chronic heart failure, is prescribed antihypertensive drug treatment. What guideline should be followed for her medication choice?

 NICE guideline on hypertension.

 NICE guideline on type 2 diabetes.

 NICE guideline on acute heart failure.

 NICE guideline on chronic heart failure.

The correct answer is: 

NICE guideline on chronic heart failure.

NICE quote:

For people with cardiovascular disease:

Follow the recommendations for disease-specific indications in the NICE guideline on their condition ... Relevant recommendations include:

… acute coronary syndromes

… acute heart failure

… chronic heart failure

… stable angina

… type 1 diabetes ...

What is an essential initial test for end organ damage that should be offered to all people with hypertension?

 Dipstick for leucocytes in the urine

 Blood test for calcium and vitamin D

 An echocardiogram

 A 12-lead ECG

The correct answer is: 

A 12-lead ECG

NICE quote:

For all people with hypertension offer to:

… a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip

… measure …HbA1C, electrolytes, creatinine, estimated glomerular filtration rate, total cholesterol and HDL cholesterol

examine the fundi for the presence of hypertensive retinopathy

arrange for a 12‑lead electrocardiograph to be performed. 

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.