Hypertension — structured viva

Structured oral on hypertension: defending out-of-office confirmation and the white-coat/masked phenotypes, class choice from ALLHAT and network meta-analysis, intensive targets and their limits, resistant hypertension and PATHWAY-2, urgency versus emergency, and hypertension in pregnancy.

Prompt

The examiner opens: 'A colleague says every raised reading in the surgery needs treatment — why do you keep ordering home monitors before you prescribe?' The viva branches through measurement science, drug-class evidence, target-setting trials, resistant hypertension, acute presentations and pregnancy.

Stem

You are the GP. A colleague argues that clinic readings are enough and home monitors just delay treatment. ^[2]

References35Show

[1]Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines Hypertension, 2018.PMID 29133356
[2]Krist AH, Davidson KW, Mangione CM, et al. Screening for Hypertension in Adults: US Preventive Services Task Force Reaffirmation Recommendation Statement JAMA, 2021.PMID 33904861
[3]Muntner P, Shimbo D, Carey RM, et al. Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association Hypertension, 2019.PMID 30827125
[4]Tientcheu D, Ayers C, Das SR, et al. Target Organ Complications and Cardiovascular Events Associated With Masked Hypertension and White-Coat Hypertension: Analysis From the Dallas Heart Study J Am Coll Cardiol, 2015.PMID 26564592
[5]Huang Y, Huang W, Mai W, et al. White-coat hypertension is a risk factor for cardiovascular diseases and total mortality J Hypertens, 2017.PMID 28253216
[6]Monticone S, Burrello J, Tizzani D, et al. Prevalence and Clinical Manifestations of Primary Aldosteronism Encountered in Primary Care Practice J Am Coll Cardiol, 2017.PMID 28385310
[7]Mulatero P, Monticone S, Deinum J, et al. Genetics, prevalence, screening and confirmation of primary aldosteronism: a position statement and consensus of the Working Group on Endocrine Hypertension of The European Society of Hypertension J Hypertens, 2020.PMID 32890264
[8]Burrello J, Monticone S, Losano I, et al. Prevalence of Hypokalemia and Primary Aldosteronism in 5100 Patients Referred to a Tertiary Hypertension Unit Hypertension, 2020.PMID 32114853
[9]Goupil R, Desbiens LC, Merabtine A, et al. Subclinical Primary Aldosteronism and Major Adverse Cardiovascular Events: A Longitudinal Population-Based Cohort Study Circulation, 2025.PMID 40631720
[10]Funder JW, Carey RM, Mantero F, et al. The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline J Clin Endocrinol Metab, 2016.PMID 26934393
[11]Carey RM Special Article - The management of resistant hypertension: A 2020 update Prog Cardiovasc Dis, 2020.PMID 32795462
[12]Williams B, MacDonald TM, Morant S, et al. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial Lancet, 2015.PMID 26414968
[13]Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group N Engl J Med, 1997.PMID 9099655
[14]Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group N Engl J Med, 2001.PMID 11136953
[15]He FJ, Li J, Macgregor GA Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials BMJ, 2013.PMID 23558162
[16]Neter JE, Stam BE, Kok FJ, et al. Influence of weight reduction on blood pressure: a meta-analysis of randomized controlled trials Hypertension, 2003.PMID 12975389
[17]Cornelissen VA, Smart NA Exercise training for blood pressure: a systematic review and meta-analysis J Am Heart Assoc, 2013.PMID 23525435
[18]Roerecke M, Kaczorowski J, Tobe SW, et al. The effect of a reduction in alcohol consumption on blood pressure: a systematic review and meta-analysis Lancet Public Health, 2017.PMID 29253389
[19]ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) JAMA, 2002.PMID 12479763
[20]Ettehad D, Emdin CA, Kiran A, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis Lancet, 2016.PMID 26724178
[21]Wiysonge CS, Bradley HA, Volmink J, et al. Beta-blockers for hypertension Cochrane Database Syst Rev, 2017.PMID 28107561
[22]Wright JT Jr, Williamson JD, Whelton PK, et al. A Randomized Trial of Intensive versus Standard Blood-Pressure Control N Engl J Med, 2015.PMID 26551272
[23]Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years: A Randomized Clinical Trial JAMA, 2016.PMID 27195814
[24]Cushman WC, Evans GW, Byington RP, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus N Engl J Med, 2010.PMID 20228401
[25]Patel A, MacMahon S, Chalmers J, et al. Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial Lancet, 2007.PMID 17765963
[26]UK Prospective Diabetes Study Group Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group BMJ, 1998.PMID 9732337
[27]PROGRESS Collaborative Group Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack Lancet, 2001.PMID 11589932
[28]Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older N Engl J Med, 2008.PMID 18378519
[29]Tita AT, Szychowski JM, Boggess K, et al. Treatment for Mild Chronic Hypertension during Pregnancy N Engl J Med, 2022.PMID 35363951
[30]Magee LA, von Dadelszen P, Rey E, et al. Less-tight versus tight control of hypertension in pregnancy N Engl J Med, 2015.PMID 25629739
[31]Brown MA, Magee LA, Kenny LC, et al. Hypertensive Disorders of Pregnancy: ISSHP Classification, Diagnosis, and Management Recommendations for International Practice Hypertension, 2018.PMID 29899139
[32]Cooper WO, Hernandez-Diaz S, Arbogast PG, et al. Major congenital malformations after first-trimester exposure to ACE inhibitors N Engl J Med, 2006.PMID 16760444
[33]Peixoto AJ Acute Severe Hypertension N Engl J Med, 2019.PMID 31693807
[34]Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease Kidney Int, 2021.PMID 33637192
[35]Astarita A, Covella M, Vallelonga F, et al. Hypertensive emergencies and urgencies in emergency departments: a systematic review and meta-analysis J Hypertens, 2020.PMID 32510905

Hypertension — structured viva

Stem

You are the GP. A colleague argues that clinic readings are enough and home monitors just delay treatment. ^[2]

References35Show

[1]Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines Hypertension, 2018.PMID 29133356
[2]Krist AH, Davidson KW, Mangione CM, et al. Screening for Hypertension in Adults: US Preventive Services Task Force Reaffirmation Recommendation Statement JAMA, 2021.PMID 33904861
[3]Muntner P, Shimbo D, Carey RM, et al. Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association Hypertension, 2019.PMID 30827125
[4]Tientcheu D, Ayers C, Das SR, et al. Target Organ Complications and Cardiovascular Events Associated With Masked Hypertension and White-Coat Hypertension: Analysis From the Dallas Heart Study J Am Coll Cardiol, 2015.PMID 26564592
[5]Huang Y, Huang W, Mai W, et al. White-coat hypertension is a risk factor for cardiovascular diseases and total mortality J Hypertens, 2017.PMID 28253216
[6]Monticone S, Burrello J, Tizzani D, et al. Prevalence and Clinical Manifestations of Primary Aldosteronism Encountered in Primary Care Practice J Am Coll Cardiol, 2017.PMID 28385310
[7]Mulatero P, Monticone S, Deinum J, et al. Genetics, prevalence, screening and confirmation of primary aldosteronism: a position statement and consensus of the Working Group on Endocrine Hypertension of The European Society of Hypertension J Hypertens, 2020.PMID 32890264
[8]Burrello J, Monticone S, Losano I, et al. Prevalence of Hypokalemia and Primary Aldosteronism in 5100 Patients Referred to a Tertiary Hypertension Unit Hypertension, 2020.PMID 32114853
[9]Goupil R, Desbiens LC, Merabtine A, et al. Subclinical Primary Aldosteronism and Major Adverse Cardiovascular Events: A Longitudinal Population-Based Cohort Study Circulation, 2025.PMID 40631720
[10]Funder JW, Carey RM, Mantero F, et al. The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline J Clin Endocrinol Metab, 2016.PMID 26934393
[11]Carey RM Special Article - The management of resistant hypertension: A 2020 update Prog Cardiovasc Dis, 2020.PMID 32795462
[12]Williams B, MacDonald TM, Morant S, et al. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial Lancet, 2015.PMID 26414968
[13]Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group N Engl J Med, 1997.PMID 9099655
[14]Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group N Engl J Med, 2001.PMID 11136953
[15]He FJ, Li J, Macgregor GA Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials BMJ, 2013.PMID 23558162
[16]Neter JE, Stam BE, Kok FJ, et al. Influence of weight reduction on blood pressure: a meta-analysis of randomized controlled trials Hypertension, 2003.PMID 12975389
[17]Cornelissen VA, Smart NA Exercise training for blood pressure: a systematic review and meta-analysis J Am Heart Assoc, 2013.PMID 23525435
[18]Roerecke M, Kaczorowski J, Tobe SW, et al. The effect of a reduction in alcohol consumption on blood pressure: a systematic review and meta-analysis Lancet Public Health, 2017.PMID 29253389
[19]ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) JAMA, 2002.PMID 12479763
[20]Ettehad D, Emdin CA, Kiran A, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis Lancet, 2016.PMID 26724178
[21]Wiysonge CS, Bradley HA, Volmink J, et al. Beta-blockers for hypertension Cochrane Database Syst Rev, 2017.PMID 28107561
[22]Wright JT Jr, Williamson JD, Whelton PK, et al. A Randomized Trial of Intensive versus Standard Blood-Pressure Control N Engl J Med, 2015.PMID 26551272
[23]Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years: A Randomized Clinical Trial JAMA, 2016.PMID 27195814
[24]Cushman WC, Evans GW, Byington RP, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus N Engl J Med, 2010.PMID 20228401
[25]Patel A, MacMahon S, Chalmers J, et al. Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial Lancet, 2007.PMID 17765963
[26]UK Prospective Diabetes Study Group Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group BMJ, 1998.PMID 9732337
[27]PROGRESS Collaborative Group Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack Lancet, 2001.PMID 11589932
[28]Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older N Engl J Med, 2008.PMID 18378519
[29]Tita AT, Szychowski JM, Boggess K, et al. Treatment for Mild Chronic Hypertension during Pregnancy N Engl J Med, 2022.PMID 35363951
[30]Magee LA, von Dadelszen P, Rey E, et al. Less-tight versus tight control of hypertension in pregnancy N Engl J Med, 2015.PMID 25629739
[31]Brown MA, Magee LA, Kenny LC, et al. Hypertensive Disorders of Pregnancy: ISSHP Classification, Diagnosis, and Management Recommendations for International Practice Hypertension, 2018.PMID 29899139
[32]Cooper WO, Hernandez-Diaz S, Arbogast PG, et al. Major congenital malformations after first-trimester exposure to ACE inhibitors N Engl J Med, 2006.PMID 16760444
[33]Peixoto AJ Acute Severe Hypertension N Engl J Med, 2019.PMID 31693807
[34]Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease Kidney Int, 2021.PMID 33637192
[35]Astarita A, Covella M, Vallelonga F, et al. Hypertensive emergencies and urgencies in emergency departments: a systematic review and meta-analysis J Hypertens, 2020.PMID 32510905