Hypertension: Diagnosis, Management, and Complications for PLAB 1
Hypertension, or high blood pressure, is a critical topic for the PLAB 1 exam. Understanding its diagnosis, management strategies, and potential complications is essential for safe and effective patient care in the UK healthcare system.
Defining Hypertension
Hypertension is defined as a sustained elevation of blood pressure. In the UK, the NICE guidelines are paramount. Generally, a diagnosis is made when clinic blood pressure readings are consistently 140/90 mmHg or higher in adults.
Diagnosis of Hypertension
Accurate diagnosis is key. It typically involves multiple readings over time and may include ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) to confirm sustained hypertension and rule out 'white coat hypertension'.
| Method | Description | When to Use |
|---|---|---|
| Clinic BP | Readings taken in a clinical setting. | Initial screening and diagnosis confirmation. |
| HBPM | Patient records BP at home. | Confirming diagnosis, monitoring treatment effectiveness, identifying white coat hypertension. |
| ABPM | 24-hour monitoring with a portable device. | Confirming diagnosis, assessing nocturnal dipping, investigating resistant hypertension. |
140/90 mmHg or higher on multiple occasions.
Management of Hypertension
Management is multi-faceted, involving lifestyle modifications and pharmacological interventions. The choice of medication depends on patient factors, comorbidities, and response to treatment.
Lifestyle Modifications
These are the first line of management and include dietary changes (reducing salt intake, DASH diet), regular physical activity, weight management, limiting alcohol consumption, and smoking cessation.
Pharmacological Management
NICE guidelines recommend a stepped approach. For most individuals under 55, the initial drug of choice is an ACE inhibitor or an ARB. For those over 55 or of Black African/Caribbean origin, a calcium channel blocker is often preferred. Further steps involve adding other drug classes like thiazide-like diuretics or beta-blockers if targets are not met.
The pharmacological management of hypertension follows a stepped approach. Step 1 typically involves an ACE inhibitor (e.g., ramipril) or an ARB (e.g., losartan). Step 2 adds a calcium channel blocker (e.g., amlodipine) or a thiazide-like diuretic (e.g., indapamide). Step 3 may involve adding a beta-blocker (e.g., bisoprolol) or another diuretic if blood pressure remains uncontrolled. This systematic approach aims to achieve target blood pressure levels while minimizing side effects.
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Remember the ABCDs of hypertension management: ACE inhibitors/ARBs, Beta-blockers, Calcium channel blockers, and Diuretics. The order and combination depend on patient characteristics and comorbidities.
Complications of Hypertension
Uncontrolled hypertension can lead to serious long-term damage to various organ systems. Early detection and effective management are crucial to prevent these complications.
Cardiovascular Complications
These include left ventricular hypertrophy, heart failure, myocardial infarction (heart attack), and aortic dissection. Hypertension is a major risk factor for cardiovascular disease.
Cerebrovascular Complications
Hypertension significantly increases the risk of stroke (both ischaemic and haemorrhagic) and transient ischaemic attacks (TIAs).
Renal Complications
Hypertensive nephropathy can lead to chronic kidney disease and eventually renal failure. Regular monitoring of renal function (e.g., eGFR and ACR) is important in hypertensive patients.
Ocular Complications
Hypertensive retinopathy can cause visual disturbances, blurred vision, and even vision loss if left untreated. Fundoscopic examination can reveal characteristic changes.
Cardiovascular system, brain (cerebrovascular), and kidneys (renal).
Key Takeaways for PLAB 1
Focus on the NICE guidelines for diagnosis and management thresholds. Understand the stepped approach to pharmacological treatment and the rationale behind choosing specific drug classes. Be aware of the common and serious complications of hypertension and the importance of regular monitoring.
Learning Resources
The definitive UK guideline for the diagnosis and management of hypertension, essential for PLAB preparation.
A comprehensive overview of hypertension, including diagnosis, management, and complications, from a trusted medical resource.
Provides accessible information on the symptoms, causes, and general overview of hypertension from the UK's National Health Service.
Explains blood pressure readings and their significance in a clear and understandable manner.
A visual explanation of the stepped approach to hypertension management, useful for understanding treatment algorithms.
Details on ambulatory blood pressure monitoring, a key diagnostic tool for hypertension.
A detailed medical review of the various complications associated with uncontrolled hypertension.
Information on the DASH diet, a dietary approach proven to help manage hypertension.
A practical guide from the Royal College of General Practitioners, relevant for primary care settings in the UK.
Explains the concept of 'white coat hypertension' and its implications for diagnosis.