You have been referred a 65-year-old man whom the GP has been struggling to manage. For the last year his clinic blood pressure recordings have been persistently around 150/90 mmHg, but he claims to suffer from the ‘white coat’ phenomenon, with home recordings of around 135/90 mmHg which you are satisfied have been undertaken appropriately. He is otherwise healthy, having implemented dietary changes and increased his exercise over the last year, but smokes and intends to continue.
What do you recommend?
A 65-year-old non-diabetic male smoker will have a 10-year CVD risk of >20%. Home recordings are usually accurate and lower (10/5 mmHg) than clinic measurements where the white coat phenomenon does not apply. Treatment should be commenced if repeated home (or ambulatory average) measurements are >135/85 mmHg (Stage 1 hypertension) and, as the patient has already been trying lifestyle measures for over 3 months, pharmacological treatment should be recommended.
A 55-year-old female inpatient has recently been diagnosed with a transient ischaemic attack (TIA), which was confirmed by cerebral MRI. Echocardiography and carotid ultrasound are essentially normal. Her blood pressure during admission is 130/80 mmHg.
What management do you suggest?
Cryptogenic strokes or TIAs are 40% of cerebrovascular events. Patients are treated as for any cerebrovascular event, with aspirin 300 mg once daily for 2 weeks and then 75 mg once daily, lifestyle changes, and antihypertensive medication. Antihypertensive medication is recommended for normotensive and hypertensive individuals who have suffered a cardiovascular or cerebrovascular event or have established renal disease. PFOs are present in 30% of normal individuals, so should only be considered if there are no other obvious risk factors for a cardiovascular event.
You requested a 24-hour ambulatory blood pressure monitor to assess an individual’s response to treatment. It has revealed an average daytime recording of 143/95 mmHg and a night-time average of 134/80 mmHg. He is aged 57, is non-diabetic, and has appropriately adjusted his lifestyle. Medication was commenced a year ago, and he has been on 5 mg of ramipril for 3 months with a recent tolerated mild cough, which may be unrelated.
What is the best treatment option?
Optimal treated BP is <140/85 mmHg. SBP and DBP are equally important but SBP is more difficult to reduce. Whilst reassessing lifestyle changes is appropriate, most individuals in studies did not attain their target BP and required dual medication for the most effective treatment. Given the possibility of a side effect, increasing the ACE inhibitor is inappropriate and continuing monitoring would seem sensible. In a non-diabetic over 55 the British Hypertension Society would recommend either a calcium-channel blocker or a thiazide-like diuretic.
According to the Joint British Society (JBS) Guidelines CVD risk model, every increase of 20/10 mmHg in blood pressure increases your 10-year CVD risk by a factor of:
Blood pressure is one of the most preventable risk factors for cardiovascular disease. It is estimated that an increase of 20/10 mmHg in blood pressure doubles your CVD risk. The JBS CVD chart estimates the likelihood of a CVD event within 10 years. It is based on the Framingham risk, but uses CVD rather than coronary heart disease (CHD) as an endpoint. Framingham risk is based on a northern European male population aged 40–59, and thus is not accurate for all individuals.
Routine initial investigations in a 58-year-old patient with recently diagnosed Grade 3 hypertension should include all of the following, except:
Urinary albumin-to-creatinine ratio is a routine investigation for protein and blood to assess for target organ damage (TOD). Serum creatinine and electrolytes may help identify TOD and a possible cause of secondary hypertension (renal disease or Conn’s syndrome). Fasting glucose and lipids help to stratify risk and will influence treatment. Fundoscopy is a simple examination that provides evidence of end-organ damage and can identify malignant hypertension. Echocardiogram is a useful measure of TOD (left ventricular hypertrophy) but is not a necessary initial examination.
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