Hypertension — structured viva

Stem

Practice viva. You are the cardiology registrar. The examiner works through BP categories, measurement technique, out-of-office confirmation, white-coat and masked phenotypes, CVD risk assessment in elevated BP, secondary-hypertension triggers, and treatment thresholds and targets. Answer for a non-pregnant adult unless stated.

Branch A — Categories

Examiner: How do the 2024 ESC and 2025 AHA/ACC guidelines categorise blood pressure?

Strong answer:

• ESC 2024 recommends categorising BP as non-elevated BP, elevated BP and hypertension to aid treatment decisions (Class I, Level B).^[1]
• Non-elevated BP is a systolic BP below 120 mmHg and a diastolic BP below 70 mmHg; elevated BP is an office systolic BP of 120–139 mmHg or diastolic BP of 70–89 mmHg; hypertension is a confirmed office systolic BP of 140 mmHg or more or diastolic BP of 90 mmHg or more.^[1]
• AHA/ACC 2025 recommends categorising BP as normal, elevated, or stage 1 or 2 hypertension to prevent and treat high BP (COR 1, LOE B-NR): normal SBP below 120 and DBP below 80 mm Hg; elevated SBP 120 to 129 and DBP below 80; stage 1 SBP 130 to 139 or DBP 80 to 89; stage 2 SBP 140 or more or DBP 90 or more.^[2]
• AHA/ACC 2025 bases its categories on an average of 2 or more careful readings obtained on 2 or more occasions.^[2]

Follow-up: Why does ESC 2024 avoid the term normal BP for its lowest category?^[1]

• It uses the term non-elevated BP because its categories are treatment categories, not prognostic ones; it avoids terms such as normal BP, optimal BP or normotension in defining this category because relative CVD risk starts to increase below this threshold (even as low as 90 mmHg systolic, particularly among women).^[1]

Branch B — Measuring office BP

Examiner: Walk me through an ESC-standard office BP measurement.

Strong answer:

• ESC 2024 recommends measuring BP with a validated and calibrated device, enforcing the correct measurement technique, and applying a consistent approach for each patient (Class I, Level B).^[1]
• Seat the patient comfortably after 5 min of rest, with no exercise, caffeine or tobacco for at least 30 min; legs unfolded, back and arm supported, and clothing removed at the cuff site.^[1]
• Use an appropriately sized cuff (bladder length 75%–100% and width 35%–50% of arm circumference) on the upper arm at heart level.^[1]
• By manual auscultation, take three readings 1–2 min apart, adding readings only if they differ by more than 10 mmHg, and record the average of the last two.^[1]
• ESC 2024 recommends measuring office BP in both arms at least at the first visit, because a between-arm systolic difference of more than 10 mmHg is associated with increased CVD risk and may indicate arterial stenosis, and, if such a difference is recorded, using the arm with the higher reading for all subsequent readings (both Class I, Level B).^[1]
• ESC 2024 recommends pulse palpation at rest in all patients undergoing BP measurement, to determine heart rate and arrhythmias such as AF (Class I, Level C).^[1]
• Assessment for orthostatic hypotension (a drop of 20 mmHg or more systolic and/or 10 mmHg or more diastolic at 1 and/or 3 min after standing, after 5 min lying or sitting) should be considered at least at the initial diagnosis of elevated BP or hypertension and thereafter if suggestive symptoms arise (ESC 2024, Class IIa, Level C).^[1]

Follow-up: And if the patient is in atrial fibrillation?^[1]

• ESC 2024 Recommendation Table 1: most automated oscillometric monitors have not been validated for BP measurement in AF; BP measurement should be considered using a manual auscultatory method in these circumstances where possible (Class IIa, Level C).^[1]
• AHA/ACC 2025 notes that evidence from validation studies of oscillometric devices in AF is limited.^[2]

Branch C — Confirming the diagnosis

Examiner: A 50-year-old has a screening office BP of 150/95 mmHg. How do you confirm hypertension?

Strong answer:

• ESC 2024 recommends out-of-office BP measurement for diagnosis, particularly because it can detect white-coat and masked hypertension; if out-of-office measurement is not logistically and/or economically feasible, it recommends that the diagnosis be confirmed with a repeat standardised office measurement (Class I, Level B).^[1]
• At a screening office BP of 140–159/90–99 mmHg, ESC 2024 recommends basing the diagnosis on 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]
• ESC 2024 out-of-office hypertension thresholds are 135/85 mmHg for home and daytime ABPM, 130/80 mmHg for 24-h ABPM and 120/70 mmHg at night.^[1]
• AHA/ACC 2025 recommends ABPM or HBPM to confirm suspected hypertension (COR 1, LOE A).^[2]
• In untreated adults with office SBP of 130 mm Hg or more or DBP of 80 mm Hg or more, and without office SBP of 160 mm Hg or more or DBP of 100 mm Hg or more, AHA/ACC 2025 states it is reasonable to exclude white-coat hypertension with out-of-office monitoring before a diagnosis of hypertension is made (COR 2a, LOE B-NR).^[2]

Follow-up: What changes at 165/102 mmHg, and at 185/115 mmHg?^[1]

• Where screening office BP is 160/100 mmHg or more, ESC 2024 recommends that BP of 160–179/100–109 mmHg be confirmed as soon as possible (e.g. within 1 month), preferably by home or ambulatory measurement, and that at 180/110 mmHg or more hypertensive emergency be excluded (Class I, Level C).^[1]
• At a screening BP above 180/110 mmHg without a hypertensive emergency, the ESC 2024 text (not a table row) adds that prompt confirmation (preferably within a week) can be considered before starting treatment.^[1]

Branch D — White-coat and masked phenotypes

Examiner: Define white-coat and masked hypertension using ESC 2024, and tell me what AHA/ACC 2025 says about their cardiovascular risk and their course over time.

Strong answer:

• ESC 2024: white-coat hypertension is BP above the diagnostic threshold in the office but below it in home or ambulatory settings, e.g. 140/90 mmHg or more in the office but below 135/85 mmHg at home or on daytime ambulatory BP (or 24-h BP below 130/80 mmHg).^[1]
• Masked hypertension is the reverse, e.g. below 140/90 mmHg in clinic but 135/85 mmHg or more at home or on daytime ambulatory BP (or 24-h BP of 130/80 mmHg or more).^[1]
• AHA/ACC 2025, citing systematic reviews and meta-analyses of observational studies: compared with sustained normotension, white-coat hypertension is associated with no risk to a moderately increased risk of CVD (a risk that may only be increased among older adults with high baseline CVD risk), whereas masked hypertension is associated with an increased risk of CVD events in a range similar to sustained hypertension.^[2]
• AHA/ACC 2025 notes that a higher proportion of people with white-coat or masked hypertension than with sustained normotension have sustained hypertension at follow-up.^[2]
• Its formal row: in adults with white-coat hypertension or masked hypertension, out-of-office BP monitoring is reasonable to exclude transition to a diagnosis of sustained hypertension (COR 2a, LOE B-NR).^[2]

Follow-up: And in a patient already on treatment: which phenotypes does AHA/ACC 2025 name, what cardiovascular risk do they carry, and when does it consider out-of-office monitoring reasonable to exclude them?^[2]

• For people taking antihypertensive medication, AHA/ACC 2025 Table 9 names controlled hypertension (not high in the office or outside), uncontrolled hypertension (high in both), masked uncontrolled hypertension (not high in the office, high outside) and white-coat effect (high in the office, not high outside).^[2]
• Studies have consistently shown that white-coat effect is not associated with an increased risk of CVD events and mortality compared with controlled hypertension, whereas systematic reviews and meta-analyses show that masked uncontrolled hypertension is associated with increased CVD events and mortality.^[2]
• In apparent treatment-resistant hypertension on office BP, it is reasonable to exclude white-coat effect, a form of pseudo-resistance, with out-of-office monitoring (COR 2a, LOE C-LD).^[2]
• In adults taking antihypertensive medication with office SBP of 130 mm Hg or more or DBP of 80 mm Hg or more, but without resistant hypertension or office SBP of 160 mm Hg or more or DBP of 100 mm Hg or more, it is reasonable to exclude white-coat effect with out-of-office monitoring (COR 2a, LOE B-NR).^[2]
• In adults taking antihypertensive medication with office SBP below 130 mm Hg and DBP below 80 mm Hg, it may be reasonable to exclude masked uncontrolled hypertension with out-of-office monitoring (COR 2b, LOE B-NR).^[2]
• ESC 2024 reports that masked uncontrolled hypertension occurs in 30% of patients treated for hypertension and is more often due to poorly controlled nocturnal than daytime BP on ABPM.^[1]

Branch E — Risk assessment in elevated BP

Examiner: A 60-year-old with no known clinical cardiovascular disease, no diabetes, no frailty or orthostatic hypotension and a good life expectancy has confirmed elevated BP under ESC 2024. How do you decide about drugs?

Strong answer:

• ESC 2024 recommends a risk-based approach: people with moderate or severe CKD, established CVD, HMOD, diabetes mellitus or familial hypercholesterolaemia are considered at increased risk (Class I, Level B).^[1]
• If none of these is present, SCORE2 is recommended at 40–69 years to assess 10-year risk of fatal and non-fatal CVD (Class I, Level B), and it is recommended that, irrespective of age, people with elevated BP and a SCORE2 or SCORE2-OP risk of 10% or more be considered at increased risk for CVD for the purposes of risk-based management of their elevated BP (Class I, Level B).^[1]
• In elevated BP with borderline risk (5% to below 10%), ESC 2024 states that a history of pregnancy complications (gestational diabetes, gestational hypertension, pre-term delivery, pre-eclampsia, one or more stillbirths, recurrent miscarriage) and the shared modifiers (high-risk ethnicity such as South Asian, family history of premature atherosclerotic CVD, socio-economic deprivation, auto-immune inflammatory disorders, HIV and severe mental illness) should be considered to up-classify risk (both Class IIa, Level B).^[1]
• In elevated BP with sufficiently high risk (10-year risk of 10% or more; or 5% to ≤10% plus risk modifiers or abnormal risk tool tests; or high-risk conditions such as established CVD, diabetes, moderate or severe CKD, familial hypercholesterolaemia or HMOD), after 3 months of lifestyle intervention, drug treatment is recommended for confirmed BP of 130/80 mmHg or more to reduce CVD risk (Class I, Level A).^[1]
• In elevated BP with low/medium risk (below 10% over 10 years), BP lowering with lifestyle measures is recommended and can reduce the risk of CVD (Class I, Level B).^[1]
• If a risk-based treatment decision remains uncertain for a person with elevated BP after risk scoring and modifiers, CAC score, carotid or femoral plaque on ultrasound, high-sensitivity cardiac troponin or BNP, or PWV may be considered to improve risk stratification in borderline risk (5% to below 10%), after shared decision-making and considering costs (Class IIb, Level B).^[1]
• ESC 2024 also says that, in elevated BP, BP-lowering treatment should always be started on the basis of individual clinical judgement and shared decision-making.^[1]
• While a person with elevated BP does not currently meet risk thresholds for BP-lowering treatment, a repeat BP measurement and risk assessment within 1 year should be considered (ESC 2024, Class IIa, Level C).^[1]

Follow-up: At what average BP thresholds would AHA/ACC 2025 start drugs for the same patient?^[2]

• AHA/ACC 2025 uses PREVENT and defines increased short-term or 10-year risk as a 10-year predicted CVD risk of 7.5% or more.^[2]
• AHA/ACC 2025 categories, based on an average of 2 or more careful readings on 2 or more occasions: SBP 130–139 or DBP 80–89 mm Hg is stage 1 hypertension, SBP 120–129 with DBP below 80 mm Hg is elevated, and SBP below 120 with DBP below 80 mm Hg is normal.^[2]
• Its drug-initiation rows are written for adults with hypertension. If the patient’s average BP is in the stage 1 range, with no clinical CVD but with diabetes, CKD or a PREVENT risk of 7.5% or more, it recommends drugs at average SBP of 130 mm Hg or more (COR 1, LOE A) or DBP of 80 mm Hg or more (COR 1, LOE C-LD), to reduce the risk of CVD events and total mortality.^[2]
• If the patient’s average BP is in the stage 1 range, with no clinical CVD and a PREVENT risk below 7.5%, drugs are recommended if average SBP remains 130 mm Hg or more, or DBP is 80 mm Hg or more, after a 3- to 6-month trial of lifestyle intervention, to prevent target organ damage and mitigate further rise in BP (COR 1, LOE B-R).^[2]

Branch F — Secondary hypertension triggers

Examiner: When do you screen for secondary hypertension, and for primary aldosteronism in particular?

Strong answer:

• ESC 2024 recommends screening patients with hypertension who present with suggestive signs, symptoms or medical history of secondary hypertension (Class I, Level B), and comprehensive screening for the main causes in adults diagnosed before 40 years, except obese young adults, in whom it recommends starting with an obstructive sleep apnoea evaluation (Class I, Level B).^[1]
• AHA/ACC 2025 recommends, in adults with hypertension, screening for specific forms of secondary hypertension when clinical suspicion is present, to increase rates of detection, diagnosis and specific targeted therapy (COR 1, LOE C-EO).^[2]
• ESC 2024 states that screening for primary aldosteronism by renin and aldosterone measurement should be considered in all adults with confirmed hypertension (BP of 140/90 mmHg or more) (Class IIa, Level B).^[1]
• AHA/ACC 2025 recommends primary aldosteronism screening in adults with hypertension and any of the following: resistant hypertension (regardless of hypokalaemia), hypokalaemia (spontaneous or diuretic induced), OSA, incidentally discovered adrenal mass, family history of early-onset hypertension, or stroke at a young age (under 40 years) (COR 1, LOE C-EO); it says screening may be considered in adults with stage 2 hypertension (COR 2b, LOE C-EO), in both cases to increase rates of detection, diagnosis and specific targeted therapy.^[2]
• In adults with an indication for screening, AHA/ACC 2025 recommends plasma aldosterone, renin activity and the aldosterone-to-renin activity ratio for initial screening, to assess for biochemical evidence of primary aldosteronism (COR 1, LOE C-LD), and continuing most antihypertensive medications other than mineralocorticoid receptor antagonists before initial screening, to minimise barriers to or delays in screening (COR 1, LOE C-EO).^[2]

Follow-up: Why not wait for hypokalaemia?^[2]

• Spontaneous hypokalaemia is present in only 20% to 50% of patients with primary aldosteronism (AHA/ACC 2025), and ESC 2024 notes that a history of hypokalaemia is not present in most patients diagnosed with the condition.^[2][1]

Branch G — Targets, and the Australian view

Examiner: What on-treatment target do you aim for, and what does Australian guidance add?

Strong answer:

• To reduce CVD risk, ESC 2024 recommends targeting treated systolic BP to 120–129 mmHg in most adults, provided treatment is well tolerated (Class I, Level A), and a systolic BP as low as reasonably achievable if treatment is poorly tolerated and 120–129 mmHg is not possible (Class I, Level A).^[1]
• ESC 2024 exceptions, because the CVD benefit of a 120–129 mmHg target may not generalise to these settings: more lenient, personalised targets (e.g. below 140 mmHg) should be considered with pre-treatment symptomatic orthostatic hypotension and/or age 85 years or older (Class IIa, Level C), and (e.g. below 140/90 mmHg) may be considered with clinically significant moderate-to-severe frailty at any age and/or limited predicted lifespan under 3 years (Class IIb, Level C).^[1]
• If on-treatment systolic BP is at or below 120–129 mmHg but diastolic BP is 80 mmHg or more, intensifying treatment to a diastolic BP of 70–79 mmHg may be considered to reduce CVD risk (ESC 2024, Class IIb, Level C).^[1]
• AHA/ACC 2025 recommends, in confirmed hypertension at increased risk (PREVENT 7.5% or more), an SBP goal of at least below 130 mm Hg with encouragement to achieve below 120 mm Hg (COR 1, LOE A) and a DBP target below 80 mm Hg (COR 1, LOE B-R), to reduce the risk of cardiovascular events and total mortality.^[2]
• In confirmed hypertension not at increased risk, an SBP goal below 130 mm Hg with encouragement to achieve below 120 mm Hg may be reasonable to reduce risk of further BP elevation (COR 2b, LOE B-NR), and a DBP target below 80 mm Hg may be reasonable to reduce the risk of cardiovascular events (COR 2b, LOE B-NR).^[2]
• The 2016 National Heart Foundation of Australia guideline treats uncomplicated hypertension to a target below 140/90 mmHg, or lower if tolerated, and offers ambulatory and/or home monitoring if clinic BP is 140/90 mmHg or more.^[3]
• It adds that, in selected high cardiovascular risk populations, aiming for a systolic target below 120 mmHg can improve cardiovascular outcomes; if that target is pursued, close follow-up is recommended to identify treatment-related adverse effects including hypotension, syncope, electrolyte abnormalities and acute kidney injury.^[3]
• A Hypertension Australia and National Hypertension Taskforce of Australia position statement makes automated office BP (AOBP) the recommended measurement standard for the diagnosis and management of hypertension, with an AOBP hypertension threshold of 135/85 mmHg.^[4]