Hypertension — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 45-year-old man has a screening office BP of 152/96 mmHg at a GP visit. He has no symptoms and no known cardiovascular disease, and on examination there is no sign of target organ damage.^[1]

1. Using the 2024 ESC guideline, state his provisional BP category, and give the ESC 2024 recommendation on how the diagnosis should be confirmed at his screening BP level, with its class. (3)^[1]
2. Describe the ESC 2024 home BP monitoring protocol and the home threshold for hypertension. (3)^[1]
3. List the ESC 2024 routine tests for the initial work-up and what each assesses. (2)^[1]
4. How would the 2025 AHA/ACC guideline classify a confirmed average of 152/96 mm Hg, at what average SBP or DBP does it recommend starting BP-lowering medication in all adults with hypertension, and with how many first-line agents should he start? (2)^[2]

Model answers — SAQ 1

1. His screening office BP is in the ESC 2024 hypertension range (office systolic 140 mmHg or more or diastolic 90 mmHg or more), but hypertension is a confirmed diagnosis.^[1] Also creditable for the category: ESC 2024 recommends that BP be categorised as non-elevated BP, elevated BP and hypertension to aid treatment decisions (Class I, Level B).^[1] Where screening office BP is 140–159/90–99 mmHg, ESC 2024 recommends basing the diagnosis on out-of-office measurement with ABPM and/or HBPM; if these are not logistically or economically feasible, the diagnosis can be made on repeated office measurements on more than one visit (Class I, Level B).^[1] Also creditable: ESC 2024 recommends out-of-office BP measurement for diagnostic purposes, particularly because it can detect both white-coat and masked hypertension; where out-of-office measurement is not logistically and/or economically feasible, it recommends that the diagnosis be confirmed with a repeat office measurement using the correct standardised technique (Class I, Level B).^[1]
2. Patients follow the same preparation as in the clinic; two measurements are taken 1–2 min apart at each session, twice a day (morning and evening) at the same time, for a minimum of 3 days and up to 7 days.^[1] All readings are averaged, and if the 3-day average is close to the treatment threshold, measurement continues for the full 7 days.^[1] Morning readings are taken before breakfast and medication, but not immediately after waking.^[1] Patients keep a record of their home readings and ask for the device accuracy to be checked intermittently; devices older than 4 years may be inaccurate and, if inaccurate, should be replaced.^[1] An average home BP of 135/85 mmHg or more (equivalent to office BP of 140/90 mmHg or more) diagnoses hypertension.^[1]
3. ESC 2024 Table 8 routine tests: fasting blood glucose (and HbA1c if fasting glucose is elevated) for CVD risk and comorbidities; serum lipids for CVD risk; blood sodium and potassium, haemoglobin and/or haematocrit, calcium and TSH to screen for secondary hypertension (primary aldosteronism, Cushing’s disease, polycythaemia, hyperparathyroidism, hyperthyroidism); blood creatinine and eGFR with urinalysis and urinary albumin-to-creatinine ratio for CVD risk, HMOD, treatment choice and renoparenchymal or renovascular screening; and a 12-lead ECG for HMOD (left atrial enlargement, LVH) and for irregular pulse and other comorbidities (AF, previous acute MI).^[1]
4. AHA/ACC 2025 would classify a confirmed average of 152/96 mm Hg as stage 2 hypertension (SBP of 140 mm Hg or more or DBP of 90 mm Hg or more), its categories being based on an average of 2 or more careful readings on 2 or more occasions.^[2] Also creditable for the category: AHA/ACC 2025 recommends that BP in adults be categorised as normal, elevated, or stage 1 or 2 hypertension to prevent and treat high BP (COR 1, LOE B-NR).^[2] Starting threshold: in all adults with hypertension, it recommends initiating BP-lowering medication when average SBP is 140 mm Hg or more (Section 5.2.2 row 1), or when average DBP is 90 mm Hg or more (row 2), to reduce the risk of cardiovascular events and total mortality (each COR 1, LOE A).^[2] Number of agents: in adults with stage 2 hypertension (SBP 140 mm Hg or more and DBP 90 mm Hg or more, as here), it recommends initiating antihypertensive drug therapy with 2 first-line agents of different classes, ideally in a single-pill combination, to improve BP control and adherence (Section 5.2.4 row 1, COR 1, LOE B-R).^[2]

SAQ 2 (10 marks)

Practice scenario. A 34-year-old woman, not obese, has office BP of 150/96 mmHg on two visits; 24-h ABPM shows a 24-h mean of 138/86 mmHg and a daytime mean of 142/90 mmHg. She takes a combined oestrogen-progesterone oral contraceptive. She has no known CVD, diabetes, CKD or familial hypercholesterolaemia.^[1]

1. Is hypertension confirmed under ESC 2024? Give the relevant ambulatory thresholds. (2)^[1]
2. What does ESC 2024 recommend about secondary-hypertension screening in her, and with what class? Name the two causes of secondary hypertension that the ESC 2024 young-adult section singles out in young women. (3)^[1]
3. Give the ESC 2024 Table 13 screening test for any four causes of secondary hypertension. (3)^[1]
4. For her, what does ESC 2024 recommend about starting treatment once hypertension is confirmed: when, at what BP, and with what initial therapy? (2)^[1]

Model answers — SAQ 2

1. Yes. ESC 2024 thresholds for hypertension are 135/85 mmHg or more for daytime ABPM and 130/80 mmHg or more for 24-h ABPM; both her daytime and 24-h means exceed them.^[1] Also creditable: the ESC 2024 night-time ABPM threshold for hypertension is 120/70 mmHg or more (no night-time mean is given for her).^[1] Also creditable: at a screening office BP of 140–159/90–99 mmHg, as hers, ESC 2024 recommends basing the diagnosis on out-of-office measurement with ABPM and/or HBPM, and if these are not logistically or economically feasible the diagnosis can be made on repeated office measurements on more than one visit (Class I, Level B). It also recommends out-of-office BP measurement for diagnostic purposes, particularly because it can detect both white-coat and masked hypertension, with the diagnosis confirmed by a repeat standardised office measurement where out-of-office measurement is not feasible (Class I, Level B). She has had ABPM.^[1]
2. ESC 2024 recommends comprehensive screening for the main causes of secondary hypertension in adults diagnosed with hypertension before the age of 40 years, except obese young adults, in whom it recommends starting with an obstructive sleep apnoea evaluation (Class I, Level B).^[1] Also creditable: ESC 2024 states that screening for primary aldosteronism by renin and aldosterone measurements should be considered in all adults with confirmed hypertension (BP of 140/90 mmHg or more) (Class IIa, Level B); her hypertension is confirmed.^[1] Also creditable: ESC 2024 recommends that patients with hypertension presenting with suggestive signs, symptoms or medical history of secondary hypertension are appropriately screened for secondary hypertension (Class I, Level B); in young adults, ESC 2024 names drug-induced hypertension (e.g. oestrogen-progesterone oral contraceptives) among the major causes.^[1] Combined oestrogen-progesterone contraceptives are among the most common causes of drug-induced hypertension in young women and should not be used in hypertensive women unless no other method is available or acceptable; progestin-only contraceptives are generally considered safe in women with hypertension.^[1] Fibromuscular dysplasia should be considered as a cause of secondary hypertension in young women.^[1]
3. ESC 2024 Table 13 (optional tests that should be used to screen for secondary hypertension in the presence of suggestive signs, symptoms or medical history) has nine cause–test pairs; any four earn the marks.^[1] Primary aldosteronism: aldosterone-to-renin ratio (reviewing prior potassium levels can also provide helpful information, as hypokalaemia increases the likelihood of coexistent primary hyperaldosteronism). Renovascular hypertension: renal Doppler ultrasound; abdominal CT angiogram or MRI. Phaeochromocytoma/paraganglioma: 24-h urinary and/or plasma metanephrine and normetanephrine.^[1] Obstructive sleep apnoea syndrome: overnight ambulatory polysomnography. Renal parenchymal disease: plasma creatinine, sodium and potassium; eGFR; urine dipstick for blood and protein; urinary albumin-to-creatinine ratio; renal ultrasound. Cushing’s syndrome: 24-h urinary free cortisol; low-dose dexamethasone suppression test.^[1] Thyroid disease (hyper- or hypothyroidism): TSH. Hyperparathyroidism: parathyroid hormone; calcium and phosphate. Coarctation of the aorta: echocardiogram; aortic CT angiogram.^[1]
4. ESC 2024 recommends that, in hypertensive patients with confirmed BP of 140/90 mmHg or more, irrespective of CVD risk, lifestyle measures and pharmacological BP-lowering treatment are initiated promptly to reduce CVD risk (Class I, Level A).^[1] Given trial evidence for more effective BP control than monotherapy, ESC 2024 recommends combination BP-lowering treatment as initial therapy for most patients with confirmed hypertension (BP of 140/90 mmHg or more); preferred combinations are a RAS blocker (an ACE inhibitor or an ARB) with a dihydropyridine CCB or a diuretic, and exceptions to consider include patients aged 85 years or older, those with symptomatic orthostatic hypotension, moderate-to-severe frailty, or elevated BP (systolic 120–139 mmHg or diastolic 70–89 mmHg) with a concomitant indication for treatment (Class I, Level B).^[1] Also creditable from the same table: ACE inhibitors, ARBs, dihydropyridine CCBs and diuretics (thiazides and thiazide-like drugs such as chlorthalidone and indapamide) are recommended as first-line treatments to lower BP, having shown the most effective reduction of BP and CVD events (Class I, Level A); and in patients receiving combination BP-lowering treatment, fixed-dose single-pill combination treatment is recommended (Class I, Level B).^[1] The ESC text adds that, in the absence of established CVD, diabetes, familial hypercholesterolaemia and moderate or severe CKD, an office treatment-initiation threshold of 140/90 mmHg is appropriate in most young adults, and that a discussion about family planning should be held with young women of childbearing potential at each visit.^[1]