Cardiovascular · Flagship case
Hypertension
Hypertension · Clinical Reasoning Framework v2
GP & SCA · NICE NG136 / CKS 2026
≥140/90Clinic → investigate
≥135/85ABPM/HBPM = HTN
≥180/120Urgent assessment
<140/90Target <80 yrs
<130/80DM / CKD target
K⁺ 4.5Spiro pivot
QRISK ≥10%Statin + treat Stage 1
1–2–1Monitoring rule
📋 Clinical Stem — First Presentation of Elevated Blood Pressure
A patient presents with an incidental or newly identified high blood pressure reading
"The patient has been referred / attended following a blood pressure reading of 160/100 mmHg recorded [in A&E / at a pharmacy / at a well-person check / by their employer / at a new patient registration]. They have no significant past medical history on record and are not currently on any regular medication."
This stem is intentionally broad to cover the full range of first-presentation scenarios. The same clinical reasoning pathway applies regardless of where the BP was first detected. Adapt your opening based on the specific setting given.
Scenario A — A&E incidentalFound during attendance for minor injury (e.g. wrist laceration). Patient had no prior BP concerns and is surprised by the finding.
Scenario B — Self-referralPharmacy or home BP machine. Patient has been checking repeatedly and is anxious about results they have read online.
Scenario C — Asymptomatic screenRoutine new-patient registration or annual health review. Patient was entirely unaware. No symptoms at all.
Scenario D — OccupationalPre-operative assessment or occupational health screen (e.g. HGV driver). Patient has specific concerns about implications for work or surgery.
Scenario E — Family history drivenFH of stroke or heart attack prompts self-referral. Patient is anxious and requests medication proactively.
Key variables to adapt forAge · Ethnicity · Comorbidities (DM, CKD, HF) · Pregnancy status · Current medications · Social context and psychosocial stressors
Steps:
1
Step 1
History Taking — Open Question First · Targeted Questions · ICE · Psychosocial Context
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Why each question matters: Every question should change something — urgency, DDx, investigation, or management. Always start with an open question to let the patient set the agenda before moving to targeted questions. Psychosocial context is not optional — it shapes both the cause and the feasibility of every management decision.
🎓 Consultation opener — use existing information first
"I've got the note here from A&E showing your blood pressure was 160/100 when you came in with your wrist. I'd like to understand what's been on your mind since then — can you tell me how you're feeling about all of this?"
Asking for information already in the referral letter = Domain 1 deduction. Use what you have. Then open the floor to the patient.
1A — Start with an open question: let the patient lead, then move to targeted questions
1B — Red flags: must not miss · must ask · must act
🚨
Red Flags — act before continuing history
| Red flag | Why dangerous | Action |
|---|---|---|
| BP ≥180/120 + headache / confusion / visual change / chest pain / focal neurology | Hypertensive emergency — target organ damage: encephalopathy, AKI, haemorrhage, ACS, or stroke | 999 immediately |
| Sudden "worst ever" thunderclap headache | Subarachnoid haemorrhage — 50% 30-day mortality if missed. CT within 6h, LP if CT negative. | 999 immediately |
| Tearing interscapular pain + BP arm difference >20 mmHg | Aortic dissection. Type A = immediate surgery. Do NOT give thrombolytics or aspirin. | 999 — no aspirin |
| Papilloedema / retinal haemorrhage on fundoscopy | Accelerated HTN — grades 3–4 retinopathy. Do NOT lower BP rapidly in community. | Same-day hospital |
| FAST positive (facial/arm/leg weakness, speech) | Stroke or TIA — thrombolysis window 4.5 hours. 90-day stroke risk post-TIA 10–15%. | 999 — FAST protocol |
| Phaeochromocytoma crisis (paroxysmal triad + BP >180/120) | Catecholamine storm. Starting BB alone → paradoxical HTN via unopposed alpha stimulation. | 999 / same-day endocrinology |
🛡️
Safeguarding Considerations — Consider in Every Consultation
Hypertension can be a marker of harm. Unexplained or resistant HTN — especially in women, older adults, or those with social vulnerabilities — may have a safeguarding component. Always consider the wider context.
🏠 Domestic Abuse / Intimate Partner Violence
- Chronic fear and stress → sustained sympathetic activation → elevated BP
- Partner attending and speaking over patient = controlling behaviour signal; consider seeing patient alone
- Vague explanations for injuries; inconsistency in history; reluctance to speak freely
- Ask sensitively: "How are things at home? Do you feel safe?"
- Use DASH tool if concerned. Refer to IDVA / MARAC if high risk.
👴 Older Adults / Carer-related Concern
- Carer withholding or improperly administering medication
- Financial abuse → inability to afford food, medication, or heating
- Unexplained deterioration in self-care or missed appointments
- Signs of neglect: weight loss, poor hygiene, untreated medical conditions
- Refer to Adult Safeguarding if concern identified; document clearly
🧒 Children in the Household
- Parent with uncontrolled severe HTN or mental health crisis may be unable to provide safe care
- If 999 is needed for a patient who is sole carer: who is looking after the children right now?
- Chronic parental stress or substance misuse may overlap with child safeguarding concerns
- Document; consider referral to children's services if child is at risk
💊 Self-Harm / Medication Misuse Risk
- Antihypertensive overdose is possible in deliberate self-harm (especially beta-blockers, calcium channel blockers)
- If prescribing to a patient at risk: consider pack size limit; alert co-prescribers; safety-net explicitly
- Screen for depression and anxiety — both strongly associated with poor BP control and non-adherence
- PHQ-9 / GAD-7 if any concern; refer to NHS Talking Therapies or mental health services as appropriate
If a safeguarding concern is identified: You do not need certainty — a concern is sufficient to act. Document clearly in records. Discuss with your safeguarding lead. Refer to the appropriate agency (IDVA, Adult Safeguarding, Children's Services). Follow your organisation's policy. Do not let the BP management agenda override immediate safety.
1C — PMH · FH · Drug history · Social history: management impact
1D — ICE: Ideas · Concerns · Expectations — in every consultation, not just SCA
💭 Ideas
"What do you think is going on with your blood pressure? What does a reading of 160/100 mean to you?"
Uncovers the patient's internal model. They may believe high BP = imminent stroke, or that it is caused entirely by work stress, or that it will go away on its own. Each belief requires a different response.
😟 Concerns
"You mentioned your grandmother had a stroke — that must have been very frightening. What are you most worried could happen to you specifically?"
Names the hidden agenda. Addresses the fear directly, not just the number. In clinic this builds trust and adherence. In SCA it prevents the patient dismissing your management plan.
🎯 Expectations
"I completely understand why you felt starting tablets today was the right step. Can I explain what I think will actually give you the best protection — and then we decide together?"
Validates the request without complying reflexively. Positions NICE guidance as shared reasoning, not as GP refusal. Maintains the relationship while explaining clinical rationale.
1E — Psychosocial context: the person behind the pressure
🏢 Work & Occupation
Shift work disrupts circadian BP patterns. High-stress occupations (emergency services, healthcare, teaching) sustain sympathetic activation. Job insecurity → chronic anxiety → elevated BP.
"How is work at the moment? Is there a lot of pressure on you right now?"Occupational triggers may be partially reversible — knowing them changes the urgency and nature of medication decisions.
💑 Relationships & Family
Bereavement, relationship breakdown, caring responsibilities, and family conflict all raise baseline sympathetic activity. Social support is the strongest predictor of long-term medication adherence.
"How are things at home? Do you have good support around you?"Isolated patients need simpler regimens and more proactive follow-up to compensate for lack of support.
💰 Financial & Practical Barriers
Prescription costs, ability to attend follow-up, access to healthy food, and safe spaces to exercise all determine whether a plan is achievable. Deprivation and HTN are closely linked.
"Are there any practical things — financial or otherwise — that might make it harder to follow through with treatment?"Offer: prepayment certificates, social prescribing, community exercise schemes, food bank signposting.
😰 Anxiety & Mental Health
Anxiety amplifies white coat effect. Depression predicts poor adherence. Untreated anxiety may drive a cycle of repeated BP checks and escalating fear that perpetuates the problem.
"How has this been affecting your mood or sleep? Have you been feeling anxious or low since you found out?"Screen with PHQ-9/GAD-7 if concerned. Treat co-morbid mental health actively alongside BP management.
🧠 Health Beliefs & Culture
Beliefs about medication ("chemicals are harmful"), fatalism, cultural models of illness, and previous negative healthcare experiences shape engagement fundamentally. Ethnicity affects pharmacology AND trust.
"How do you feel generally about taking medication long-term? Are there any concerns about tablets specifically?"Shared decision-making only works if the patient's explanatory framework is understood and respected first.
🌐 Social Isolation & Housing
Loneliness and social exclusion are independent cardiovascular risk factors. Poor housing (noise, overcrowding, food insecurity) directly raises stress hormones and prevents sustainable lifestyle change.
"Is there anyone at home with you? Do you feel connected to people around you?"Social prescribing referral may be as clinically important as medication — especially in isolated patients.
🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills
Key phrases that score
"I can see from the A&E note that your BP was 160/100..."
"Tell me, in your own words, what's been going on and how you've been feeling..."
"...especially after what happened to your grandmother — what are you most worried about?"
"How has this been affecting your day-to-day life — work, sleep, relationships?"
Deductions (examiner flags)
- Asking info already in the A&E letter (Domain 1 deduction)
- Opening with closed SOCRATES-style Qs before open question
- Tick-box ICE without naming and exploring grandmother's stroke
- Missing NSAIDs from A&E discharge or drug history
- No psychosocial context gathered at all
- Not considering safeguarding in the wider context
🔴 Red — failing
Ignores letter; starts with closed Qs; no ICE; no psychosocial; repeats info already provided; grandmother's stroke not acknowledged
🟠 Amber — borderline
Opens reasonably but ICE formulaic; grandmother acknowledged once but not explored; some psychosocial gathered but incomplete; finishes history after 8+ min
🟢 Green — passing
Uses letter; open Q first; ICE completed with grandmother's stroke named and explored; psychosocial including work/relationships/mental health; data gathering complete by 6–7 min
2
Step 2
Triage Engine — Emergency · Urgent · Routine
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The most important decision in every consultation. Before examination, investigations, or management — triage determines whether the patient leaves safely. Getting this wrong = patient harm.
🔴 Emergency
999 or Same-Day Hospital
Call 999 / A&E now- BP ≥180/120 + any symptomHeadache, confusion, visual change, chest pain, SOB, focal neurology
- Accelerated / malignant HTNPapilloedema or retinal haemorrhage — do NOT lower BP rapidly in community
- Hypertensive encephalopathyAltered GCS or seizure
- STEMI / ACSAspirin 300mg → 999 → GTN if SBP >90
- Aortic dissectionTearing back pain + BP arm difference — no aspirin, no thrombolysis
- FAST positive stroke / TIAThrombolysis window closes at 4.5 hours
🟠 Urgent
Same-Day GP / Urgent Referral
Days to 2 weeks- BP ≥180/120 but asymptomaticUrgent same-week face-to-face; ABPM within days
- Suspected phaeochromocytoma (stable)24h urine metadrenalines; urgent endocrinology — no BB alone
- Suspected Conn's syndromeUnprovoked K⁺ <3.5 + HTN → aldosterone:renin ratio
- Target organ damage foundAKI, LVH, retinopathy grade 3–4 → secondary care
- Resistant HTN ≥3 drugsAfter excluding pseudo-resistance → hypertension specialist
- Age <40 with confirmed HTNSecondary cause evaluation
🟢 Routine
Manage in Primary Care
GP practice- Stage 1 (ABPM 135–149/85–94)Lifestyle ± drug based on QRISK3 + comorbidities
- Stage 2 (ABPM ≥150/95), no emergencyStart drug treatment + lifestyle
- White-coat confirmed (<135/85 on ABPM)No treatment; annual review
- Masked HTN (clinic normal, ABPM elevated)Treat as confirmed HTN
- Established HTN, stable treatmentAnnual structured review
🎓 SCA Checkpoint — Step 2TasksGlobal Skills
Say this before management
"Before I explain my thinking, I want to make sure there's nothing that needs urgent attention right now — let me ask a few specific questions about symptoms..."
"I need to rule out anything serious first — can I ask specifically about headache / vision / chest pain / weakness?"
Deductions
- Jumping to management without an explicit triage screen
- Missing BP ≥180/120 as urgent even if asymptomatic
- Not considering secondary causes when triggers are present
- Failing to verbalise the safety screen — examiners score what they hear
🔴 Red
Goes straight to management plan; no safety screen; misses BP ≥180/120 urgency
🟠 Amber
Some red flag questions asked but not all verbalised; reasoning not made explicit to examiner
🟢 Green
All red flags screened and named aloud; correctly triages emergency / urgent / routine; rules in/out serious disease explicitly before management
3
Step 3
Do I Need This Examination?
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"Will this examination change management?" is the key question before any clinical assessment. Every finding below has a direct management consequence.
🎓 SCA Checkpoint — Step 3Tasks
How to propose examination
"I'd like to check a few things — your blood pressure in both arms, your pulse, and I'd like to look at the back of your eyes. Each of these tells me something important about whether there's any damage from the high blood pressure."
Deductions
- Proposing examination without explaining rationale — loses management mark
- Only taking one-arm BP at a first consultation
- Not considering fundoscopy in first presentation of HTN
🔴 Red
No examination proposed or rationale given; misses both-arm BP requirement; no fundoscopy considered
🟠 Amber
Examination proposed but rationale not explained; one arm only; fundoscopy not mentioned
🟢 Green
Appropriate examination selected with rationale; both arms; fundoscopy; interpretation links to management change
4
Step 4
Do I Need This Investigation?
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Every investigation should answer a specific clinical question. Before requesting any test: what result will change my management?
🎓 SCA Checkpoint — Step 4TasksRelating to Others
How to explain investigations to the patient
"I'd like to fit a blood pressure monitor that records your BP every 30 minutes over 24 hours. This gives a much more accurate picture than a single reading, and helps us decide whether treatment is actually needed."
"I'd also like some blood tests — checking your kidneys, blood sugar, and cholesterol — to understand your overall risk and make sure any tablet we choose is safe for you."
"By the way, would you prefer to wear the monitor, or would home readings suit you better? Either is fine — I want to pick what works for you."
Deductions
- Starting medication before ABPM result — clear NICE NG136 violation
- Ordering tests without explaining why to the patient
- Missing QRISK3 as driver of Stage 1 treatment decision
- Not offering ABPM vs HBPM as patient choice
🔴 Red
Prescribes without ABPM; orders tests without explanation; QRISK3 not mentioned; no patient choice offered
🟠 Amber
ABPM requested but not explained; partial blood panel; QRISK3 not discussed with patient as a number
🟢 Green
ABPM vs HBPM offered as shared choice; full baseline bloods explained with rationale; QRISK3 number discussed; each test linked to a management question
5
Step 5
Reaching a Diagnosis & DDx — Explained in Plain Language
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Two types of diagnosis in primary care: conditions you can confidently diagnose and manage in GP, and conditions you suspect but must refer. Know which is which — then explain the diagnosis clearly in language the patient can understand, and address their own ideas about what is happening.
🗣️ Explaining the Diagnosis in Plain Language — say something like this
"Your blood pressure is the force with which your heart pushes blood around your body. Think of it like water pressure in a pipe — if the pressure stays too high for too long, it can quietly damage the pipes over time. In your body, that means a higher risk of stroke, heart attack, or damage to your kidneys and eyes. The critical thing is: most people with high blood pressure feel completely well — so the only way to know is to measure it properly. The good news is that once we know about it, it's very manageable, and most people live completely normal lives."
💬 Addressing the patient's own explanation — why it may not be the full picture
"It's just stress — once things calm down at work, it'll sort itself out."
"Stress definitely plays a role, and I want to understand what's happening in your life. But what we find in most people is that once blood pressure rises, it tends not to return to normal by itself — even when the stressor passes. Over time the blood vessels adapt to the higher pressure and start treating it as normal. That's exactly why we need to measure it properly rather than wait and see — so we can prevent any long-term damage."
"Surely if it were serious I'd feel it?"
"That's exactly what makes high blood pressure so important to catch — most people feel completely well. It's sometimes called the 'silent problem' because the damage builds slowly and invisibly in your blood vessels over years. Catching it now, while you feel fine, is exactly the right time — because it means we can prevent problems rather than treat them after they happen."
A — Diagnosable in Primary Care
GP can diagnose
Essential (Primary) HTN (90%)
ABPM ≥135/85 with no secondary cause features. No investigations pointing to renal, endocrine, or vascular aetiology.
White-Coat HTN
Clinic ≥140/90 but ABPM <135/85. No treatment — monitor annually.
Masked HTN
Normal clinic BP but ABPM ≥135/85. Treat as confirmed HTN — worse prognosis than white-coat.
B — Suspected — Refer
Refer for confirmation
Secondary HTN (10%)
Age <40 · resistant to ≥3 drugs · K⁺ <3.5 unprovoked · paroxysmal symptoms · renal bruit. Refer to relevant specialist.
Pseudo-Resistance
Most common cause: non-adherence. Confirm with ABPM + tablet count before escalating.
OSA-Driven HTN
Absent nocturnal dip + heavy snoring + morning headaches. Sleep study referral.
C — Emergency — Act Now
Diagnose & act
Hypertensive Emergency
BP ≥180/120 + target organ damage. Do NOT lower BP rapidly in community — controlled reduction in ICU only.
Accelerated HTN
Papilloedema / retinal haemorrhage (grade 3–4). Same-day hospital — irreversible damage if delayed.
🎓 SCA Checkpoint — Step 5TasksRelating to Others
Verbalising diagnosis in plain language
"Think of it like pressure in a pipe — if it stays too high for too long, it quietly damages the vessels supplying your heart, kidneys, eyes, and brain. You can't feel it happening, which is exactly why measuring it properly matters."
"I know you're worried this could mean a stroke like your grandmother — and I want to address that directly. What we're doing right now is exactly how we prevent that. Catching this before there are any symptoms puts us in the best possible position."
Deductions
- Medical jargon without lay explanation (systolic, hypertension, etc.)
- Not addressing the patient's own explanation or fear about the diagnosis
- Diagnosing and prescribing before ABPM result is back
- Failing to verbalise the working diagnosis aloud
🔴 Red
Jargon throughout; patient's specific fear (stroke/grandmother) not addressed; prescribes before confirmed diagnosis; no lay explanation
🟠 Amber
Some lay language used but patient's own ideas not specifically challenged or addressed; diagnosis verbalised but not shared as a conversation
🟢 Green
Pipe/pressure analogy or equivalent; grandmother's stroke fear directly and specifically addressed; working diagnosis shared clearly; patient's own explanation acknowledged then gently corrected with reasoning
6
Step 6
If Referral Is Needed — What the GP Does Before & During
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Most platforms say "refer" and stop there. The gap between deciding to refer and the patient arriving in secondary care is where GP care has the biggest impact — and the biggest medico-legal risk.
🎓 SCA Checkpoint — Step 6TasksGlobal Skills
How to explain referral to the patient
"I want to refer you to a specialist because there may be an underlying cause for your blood pressure that we need to look into properly. In the meantime, I'm going to continue your blood pressure treatment so there's no gap in protection."
Deductions
- Stopping treatment while waiting for specialist appointment
- Not explaining what the referral is for or what to expect
- Prescribing beta-blocker alone before phaeochromocytoma excluded
🔴 Red
Refers without safety-netting; stops treatment while waiting; misses critical "do not" actions
🟠 Amber
Correct urgency for referral but patient not informed of reason or what to expect; interim management incomplete
🟢 Green
Correct urgency; reason explained to patient in plain language; interim management continues; "do not" actions clearly identified
7
Step 7
Management — Expectation · Goals · Lifestyle · Drug Selector · Drug Cards · Psychosocial · Follow-Up · Safety-Netting
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7A — Address the patient's expectation first: validate → explain → negotiate
🤝
Never dismiss the expectation — acknowledge it, share your reasoning, then agree a shared plan
1
Validate — name their expectation
Acknowledge what they came wanting. Don't make them feel wrong or naive for asking. This earns trust before you diverge.
"I completely understand why starting tablets today feels like the right thing — especially given what happened to your grandmother. That makes complete sense to me."2
Explain — share your clinical reasoning
Offer the reason behind your plan without lecturing. Frame it as 'best protection' not 'no, not yet.'
"What I want is to get this right for you — and that means confirming the diagnosis properly first. One reading can be affected by nerves, pain, or a hundred other things. Starting lifelong tablets based on one reading could mean treating someone who doesn't need it, or picking the wrong tablet for your specific situation."3
Negotiate — offer something today
Never leave with nothing agreed. The patient should feel this appointment was productive and that you are on their side.
"What I can do today is fit the 24-hour monitor, arrange your blood tests, and — most importantly — start you on some lifestyle changes that make a real difference even before tablets. And I will personally call you within 48 hours of the monitor with the results and our plan."
Key principle: The patient's expectation is not the enemy of good medicine — it is the starting point of the consultation. A plan arrived at through negotiation will always be better followed than one imposed without discussion.
7B — Why treatment matters: goals tailored to this patient
Treatment goals
↓ Stroke risk by up to 40%↓ MI risk by up to 20%
Prevent heart failureSlow CKD progression
Prevent vascular dementiaHalt retinopathy
Achieve BP targetReduce QRISK3 score
Motivational language — tailored to the patient
"Your 10-year risk of heart attack or stroke is around X%. With treatment and lifestyle changes, we can reduce that by a third or more — real events that won't happen to you."
"The goal isn't just a number on a machine. It's protecting the things that matter to you — being there for your family, keeping working, staying independent."
7C — Non-medication management: mechanism + evidence + tailored advice
Never give generic lifestyle advice. Each intervention below has a specific mechanism, a quantified BP effect, and a measurable outcome. Present it as a real treatment — and tailor it to what this patient's life actually looks like. One change agreed today beats five changes ignored.
Salt Reduction
Target: <6g/dayMechanism
↓ Plasma volume → ↓ cardiac output and vascular tone. Renin-independent pathway — works in all patients.
Practical
Don't add salt cooking. Most salt is hidden in processed food. Salt substitutes (K⁺) — caution in CKD/ACEi use.
DASH Diet
5+ portions fruit/veg dailyMechanism
↑ K⁺, Mg²⁺, Ca²⁺ → vasodilation and natriuresis. ↓ Saturated fat → improved endothelial function.
Practical
↑ Fruit, veg, whole grains, low-fat dairy. ↓ Red meat, sweets, sugary drinks.
Exercise
150 min/week moderateMechanism
↓ Peripheral vascular resistance via endothelial NO. ↓ Sympathetic activity. ↓ Resting HR.
Practical
Brisk walking, cycling, swimming. Even 10-min daily walks have measurable benefit — start where the patient is.
Weight Loss
~1 mmHg per kg lostMechanism
↓ Insulin resistance → ↓ renin-angiotensin activation. ↓ Adipokine-driven inflammation. ↓ Cardiac output.
Practical
Frame it: "Losing 5 kg is like taking a blood pressure tablet."
Alcohol Reduction
≤14 units/weekMechanism
Chronic alcohol → ↑ cortisol → ↑ RAAS → Na⁺ retention. Binge → catecholamine surges and acute BP spikes.
Practical
≤14u spread across ≥3 days. AUDIT-C brief intervention. DrinkCoach app referral.
Smoking Cessation
Complete cessationMechanism
Nicotine → acute sympathomimetic surge per cigarette. Long-term: endothelial damage, ↑ vascular stiffness, accelerated atherosclerosis.
Practical
QUIT service + NRT + varenicline. CO breath test at every visit motivates change.
7D — Prescribing guide: what to start, in what order, and why
NICE NG136 A+C+D step therapy is the backbone of hypertension prescribing. Every patient starts at Step 1 and escalates if BP remains above target after 4–8 weeks. Always check and optimise adherence before adding a new drug. Do not add Step 2 if Step 1 is not being taken correctly.
Step 1 — Monotherapy: A or C
Start one drug. Choice depends on age and ethnicity.
- Under 55, non-Afro-Caribbean → A (ACEi or ARB). Ramipril 1.25–2.5mg OD titrated to 10mg OD. Lisinopril as alternative. ARB (losartan, candesartan) if ACEi-intolerant (cough).
- 55 or over, or Afro-Caribbean any age → C (CCB). Amlodipine 5mg OD titrated to 10mg OD. Ankle oedema → switch to felodipine or add A.
- CKD or proteinuria (any age) → A (ACEi/ARB) — renoprotective regardless of ethnicity.
Review in 4–8 weeks. If BP still above target → check adherence first, then escalate to Step 2
Step 2 — Dual therapy: A + C
Add the drug not yet used from A or C. If started on A → add C. If started on C → add A.
- Combination lowers BP more than doubling the dose of either drug alone.
- ACEi + CCB combination has the strongest evidence base (ACCOMPLISH trial: ↓20% CVD events vs ACEi + thiazide).
- Fixed-dose combination tablets improve adherence — consider where available (e.g. perindopril + amlodipine).
Review in 4–8 weeks. If BP still above target → check adherence, then add D
Step 3 — Triple therapy: A + C + D
Add D (thiazide-like diuretic). Indapamide 1.5mg MR OD preferred over bendroflumethiazide (better CV outcomes evidence).
- Check U&Es and eGFR before starting and 4–6 weeks after — thiazides worsen K⁺ and can precipitate gout.
- If already on a thiazide for another reason, this counts as D — do not add a second diuretic.
- Consider once-daily combination tablet to simplify if tolerated.
Review in 4–8 weeks. If still above target on A+C+D → Step 4 (resistant HTN)
Step 4 — Resistant hypertension: A + C + D + consider 4th agent
BP above target on optimal doses of A + C + D. First, confirm true resistance — check adherence (urine drug screen if needed), exclude white-coat effect (ABPM), exclude secondary HTN.
- Serum K⁺ <4.5 mmol/L → spironolactone 25mg OD (most effective 4th agent, PATHWAY-2 trial). Monitor K⁺ + eGFR carefully — especially if on ACEi/ARB.
- Serum K⁺ ≥4.5 mmol/L → alpha-blocker (doxazosin) or beta-blocker (bisoprolol). Beta-blockers are no longer first-line in HTN but have a role in resistant HTN or if indicated for another reason (AF, IHD, HF).
- Refer to specialist hypertension clinic if still uncontrolled on 4 drugs.
⚠️ ACEi/ARB + K⁺-sparing diuretic = monitor K⁺ closely. Hyperkalaemia risk is real and can be life-threatening.
When NOT to prescribe / special cases
- ACEi/ARB contraindicated: pregnancy (teratogenic — stop immediately if pregnancy confirmed), bilateral renal artery stenosis, hyperkalaemia K⁺ >5.5. ACEi + ARB together — do not combine (↑ AKI + hyperkalaemia, no extra BP benefit).
- CCB caution: severe aortic stenosis (avoid peripheral vasodilation), decompensated HF (verapamil/diltiazem — avoid; amlodipine safe in HF).
- Thiazide caution: gout history (precipitates attack), hyponatraemia risk in elderly, worsens glucose in DM — benefit still outweighs in most.
- 3-month lifestyle trial before drug: NICE permits deferring medication in Stage 1 HTN (clinic 140–159/90–99, ABPM 135–149/85–94) with QRISK3 <10% and no organ damage, if patient willing to engage with lifestyle changes.
⚙ Interactive Medication Chooser — tick the patient profile, options re-tier live against NICE / BNF
A live, topic-scoped version of the standalone Medication Chooser. The static selector and reference cards below are unchanged.
7E — Medication selection tool — choose patient characteristics for tailored drug recommendations
Select patient characteristics — Step 1 drug recommendation appears below
Step 1 recommendation
Select patient characteristics above
7F — Drug reference cards: antihypertensive classes, doses & contraindications
ACE Inhibitor
Ramipril · Lisinopril
✓ Recommended
Step 11.25→10mg OD
✓ Prefer when
Type 2 diabetes (any age, any ethnicity)
CKD with proteinuria / ACR >3 — renoprotective
Age <55 · non-Afro-Caribbean
Post-MI / LV dysfunction / HFrEF · established CVD
✗ Avoid if
Pregnancy — oligohydramnios, renal agenesis
Angioedema history to ACEi
Bilateral RAS — precipitates AKI
K⁺ >5.5 — STOP. eGFR <30 — specialist.
Never combine with ARB
⚠ Side effects
Dry cough (10–15%) — switch to ARB, not stop the class
First-dose hypotension · Hyperkalaemia · AKI
Angioedema (0.1–0.5%) — may appear years later; 999
🔬 Monitor
U&Es + K⁺ within 1 week of starting or dose change
Interactions: NSAIDs (AKI), spiro (hyperK), lithium (toxicity)
💬 Counselling
"You may get a dry tickly cough — don't stop it; call us and we'll switch to a similar tablet. If your lips or throat ever swell, call 999 immediately."
Cough → switch to ARB, not off-class. Pre-warning about cough = Relating to Others mark.
ARB
Candesartan · Losartan
✓ Recommended
Step 18→32mg OD
✓ Prefer when
ACEi intolerance — cough or angioedema
DM / CKD — equal renoprotection to ACEi
Afro-Caribbean with DM (Step 2: ARB over ACEi)
HFrEF intolerant of ACEi
✗ Avoid if
Pregnancy — same CI as ACEi
Bilateral RAS
Concurrent ACEi — NEVER combine
K⁺ >5.5 — same risk as ACEi
⚠ Side effects
Significantly less dry cough — key advantage
Hyperkalaemia · AKI (same risk as ACEi)
Rare angioedema (lower than ACEi)
🔬 Monitor
U&Es + K⁺ within 1 week — same as ACEi
💬 Counselling
"Works the same way as the previous tablet but without the cough. We'll check kidneys in one week — this is routine, not a concern."
Angioedema to ACEi ≠ automatic ARB contraindication — cautious ARB use after specialist advice.
Calcium Channel Blocker
Amlodipine · Felodipine
✓ Recommended
Step 15→10mg OD
✓ Prefer when
Age ≥55 (no DM) — more effective than ACEi
Afro-Caribbean (no DM) — superior efficacy
Isolated systolic HTN · Raynaud's · Stable angina
✗ Avoid if
HFrEF — amlodipine worsens outcomes
Unstable angina · Severe aortic stenosis
Verapamil/diltiazem + beta-blocker → heart block
⚠ Side effects
Ankle oedema (10–15%) — vasodilatory, NOT fluid overload; diuretics don't help
Flushing, headache, palpitations, gingival hyperplasia
Grapefruit juice — markedly ↑ amlodipine levels
🔬 Monitor
No routine bloods required. Review oedema clinically.
Interactions: grapefruit; simvastatin (myopathy → use atorvastatin)
💬 Counselling
"You may notice ankle swelling — this is the tablet relaxing blood vessels and is not dangerous. Avoid grapefruit juice."
Ankle oedema ≠ fluid overload — don't add a diuretic. Adding ACEi at Step 2 actually reduces CCB oedema.
Thiazide-like Diuretic
Indapamide SR 1.5mg
✓ Recommended
Step 31.5mg SR OD (fixed)
✓ Prefer when
Step 3 add-on to ACEi/ARB + CCB
Elderly with isolated systolic HTN
Afro-Caribbean patients (more effective than ACEi alone)
✗ Avoid if
Active gout · Pregnancy · eGFR <30
Pre-existing hyponatraemia · Hypokalaemia <3.5 (correct first)
Diabetes — can worsen glycaemic control
⚠ Side effects
Hypokalaemia — amplifies digoxin toxicity
Hyponatraemia (especially elderly, first 2 weeks)
Hyperuricaemia → gout · Hyperglycaemia · Photosensitivity
🔬 Monitor
U&Es + Na⁺ + K⁺ within 2 weeks
Interactions: digoxin (hyperK toxicity); lithium; NSAIDs
💬 Counselling
"This is a gentle tablet — it won't make you rush to the toilet. We'll check your salts in 2 weeks as routine."
Indapamide SR 1.5mg (not IR 2.5mg) for HTN. IR is for diuresis in HF. Knowing this = Tasks domain mark.
Spironolactone
Aldosterone antagonist — Step 4
✓ Recommended
Step 425mg OD
✓ Prefer when
Step 4 resistant HTN + K⁺ ≤4.5 mmol/L
Confirmed Conn's syndrome (with endocrinology)
HFrEF — cardioprotective (eplerenone preferred post-MI)
✗ Avoid if
K⁺ >4.5 at Step 4 — use alpha or beta-blocker instead
eGFR <30 · Pregnancy · Addison's disease
eGFR 30–45 — specialist advice before starting
⚠ Side effects
Hyperkalaemia — K⁺ >5.5 = STOP immediately
Gynaecomastia in men (up to 10%) → switch to eplerenone
Menstrual irregularity · ↓ libido · GI upset
🔬 Monitor
U&Es + K⁺ within 1 month; then 3-monthly × 1yr
K⁺ >5.5 = STOP + recheck in 1 week
💬 Counselling
"Men sometimes notice breast tenderness — if so, we'll switch to a similar tablet. Don't stop without calling us first."
The K⁺ 4.5 pivot: ≤4.5 = spiro. >4.5 = alpha or beta-blocker. Know this without hesitation.
Alpha / Beta-blocker
Doxazosin · Bisoprolol
✓ Recommended
Step 41→16 / 2.5→20mg
✓ Prefer when
Step 4 + K⁺ >4.5 (spiro contraindicated)
Doxazosin: BPH (dual benefit) · phaeochromocytoma prep (alpha first)
Bisoprolol: AF rate control · post-MI · HFrEF · thyrotoxicosis
✗ Avoid if
Bisoprolol: Asthma · Severe COPD · 2°/3° heart block
Bisoprolol: Untreated phaeochromocytoma — alpha-blocker must come first
Bisoprolol: DM (masks hypo); PVD/Raynaud's
Doxazosin + sildenafil = profound hypotension — always ask
⚠ Side effects
Doxazosin: first-dose hypotension — TAKE AT BEDTIME
Doxazosin: dizziness, postural hypotension, urinary incontinence (women)
Bisoprolol: bradycardia, fatigue, nightmares, erectile dysfunction
Bisoprolol: NEVER stop abruptly — rebound HTN/angina crisis
🔬 Monitor
Doxazosin: standing BP. Always ask about PDE5 inhibitors before prescribing.
Bisoprolol: resting HR + BP. Verapamil/diltiazem = heart block risk.
💬 Counselling
"Take the first doxazosin at bedtime — it can cause dizziness when you stand up. Are you on any tablets for erectile dysfunction? Mixing them can be dangerous."
Doxazosin + sildenafil = dangerous hypotension. Always ask about PDE5 inhibitors. High-yield exam interaction.
7G — Psychosocial impact of the diagnosis: driving, work, relationships & daily life
🫂
High blood pressure affects more than physiology — address the real-life impact proactively
A new diagnosis of hypertension — and its treatment — has real implications for driving, employment, relationships, insurance, and mental wellbeing. Addressing these proactively builds trust, prevents future non-adherence, and is part of a truly patient-centred consultation. Raise these topics before the patient goes home wondering.
Driving
Hypertension alone does not require DVLA notification in most cases. However, BP >180/100 symptomatic, or any TIA/stroke, requires DVLA notification and may suspend driving.
For HGV/PCV licence holders: BP must be <180/100; inform employer and occupational health. This is commonly anxiety-provoking and must be raised explicitly.
If starting doxazosin or other drugs causing postural hypotension: advise caution for the first week.
"Your blood pressure alone doesn't affect your licence. But if you drive a large vehicle, there are thresholds we need to be aware of — let me explain what this means for you."Work & Occupation
Certain occupations (HGV/PCV drivers, pilots, armed forces, emergency services, healthcare) have strict BP thresholds for fitness to work. Employers or occupational health may need informing.
Shift work and high-stress roles should prompt a discussion about workplace adjustments or occupational health referral — these are modifiable contributing factors.
Patients may fear losing their job if hypertension is disclosed — address this sensitively and factually.
"Does your work involve driving a large vehicle, or do you have occupational health requirements? This might be relevant to how and when we manage things."Relationships & Sexual Health
Some antihypertensives — particularly beta-blockers — can cause or worsen erectile dysfunction. This is a leading cause of unannounced medication discontinuation.
Doxazosin combined with sildenafil causes dangerous hypotension — must be asked about before prescribing.
Encouraging a partner to attend future appointments can improve adherence and reduce household stress, particularly in patients with anxiety about the diagnosis.
"Some blood pressure tablets can affect sexual function — I want to mention this so you know to tell me if you notice any changes. Are you currently taking anything like Viagra or similar?"Exercise & Leisure
Exercise is one of the best treatments for hypertension (↓ SBP 4–9 mmHg). Unless BP is severely uncontrolled (SBP >180 symptomatic), patients should be reassured they can continue normal exercise including gym and sport.
Very high-intensity exercise (e.g. competitive weightlifting) with SBP >180 should be temporarily modified until BP is controlled — discuss specifically if relevant.
"Exercise is one of the best things you can do for your blood pressure. Unless your reading was very high, there's no reason to stop your normal activities — in fact, I'd encourage you to keep going."Insurance & Financial
A diagnosis of hypertension must be declared when applying for life insurance, income protection, or critical illness cover — this can affect premiums. Patients have a legal duty to disclose.
Unexpected financial anxiety about insurance is common. Acknowledge it, but advise they contact their insurer or broker directly for accurate information.
Prescription prepayment certificates reduce costs significantly for patients on multiple long-term medications.
"Worth knowing — a blood pressure diagnosis may need to be declared for certain insurance products. I'd suggest checking with your insurer directly. I can also point you towards prepayment certificates to reduce prescription costs."Mental Health & Adjustment
A new long-term condition diagnosis commonly triggers anxiety, denial, or low mood — particularly if associated with a feared family outcome (e.g. parent/grandparent who died of stroke).
Screen for depression and anxiety (PHQ-9/GAD-7). Refer to NHS Talking Therapies, social prescribing, or a wellbeing service if appropriate. Untreated anxiety perpetuates elevated BP.
Normalise the emotional response — receiving a diagnosis like this is significant, even when the condition is highly manageable.
"It's completely normal to feel worried — getting any new diagnosis can bring up a lot of feelings. How are you doing emotionally with all of this? Is there anything else weighing on you?"7H — Follow-up schedule
1
Within 5 days — face-to-face
Fit ABPM; all baseline bloods (U&E, HbA1c, lipids, ACR); ECG; fundoscopy or optician referral; examination; QRISK3.
2
Within 48h of ABPM result — named GP callback
Results + decision: white-coat / Stage 1 lifestyle ± drug / Stage 2 start drug. Named GP, named date — not "someone will call you".
3
2–4 weeks after any medication change
BP response + side effects. U&Es at 1 week if ACEi/ARB started. Titrate if target not met.
4
3 months — lifestyle-only Stage 1 patients
Repeat BP, lifestyle review, QRISK3 reassessment. Target not met → start drug.
5
Annual structured review — all confirmed HTN
BP + pulse · QRISK3 · U&E + ACR + eGFR · HbA1c · Lifestyle + adherence · Medication review · Complications screen · Psychosocial check-in
7I — Monitoring: the 1-2-1 rule + BP targets
Memory rule
ACEi / ARB / Spiro → U&Es within 1 week | Thiazide-like → U&Es within 2 weeks | Spiro Step 4 → U&Es within 1 month | All → structured review 1× per year
7J — Safety-netting: exact phrases + medico-legal rationale
⚠ Three scenario-specific phrases — use these verbatim
🔴 Emergency — all patients with elevated BP
"If you develop a sudden severe headache unlike any you've had before, sudden weakness or numbness on one side, sudden vision changes, chest pain, or confusion — call 999 immediately. Do not drive yourself. Do not wait to ring us first."
Names FAST symptoms explicitly → patient-activated emergency response. "Call 999" is medico-legally protective. "Seek help" is not.
💊 Medication — patients starting antihypertensives
"These tablets may make you feel dizzy when you stand up, especially in the first week. Move slowly from sitting to standing. If you feel faint, call us — but don't stop the tablets without speaking to us first."
Postural hypotension is the most common cause of early discontinuation. Pre-warning significantly improves adherence.
🟠 Drug-specific — ACEi patients
"You may develop a dry, tickly cough — not dangerous. Don't stop the tablet; call us and we'll switch to a very similar one. If you notice swelling of your lips, tongue, or throat, that is different — call 999 immediately."
Pre-warning about cough prevents unnecessary off-class switching. Angioedema counselling = potentially life-saving.
Why safety-netting matters beyond clinical care
Medico-legal protection: documented advice = defence if patient deteriorates
Patient empowerment: partner in safety, not passive recipient of instructions
Earlier escalation: specific symptom recognition → faster 999 activation
GMC Good Medical Practice: patients must understand when to seek urgent help
Adherence: explaining importance prevents dangerous abrupt stopping
Reduces anxiety: proactive safety-netting reduces the patient's fear of the unknown
Within 5 daysFace-to-face: ABPM, bloods, ECG, fundoscopy
Within 48h of ABPMNamed GP callback with result + plan
If Rx startedBP + U&Es in 2–4 weeks
📋 SCA Consultation Scorecard — self-assess your hypertension consultation
Hypertension — SCA Consultation Scorecard
Based on the official SCA Consultation Tool · RAG self-assessment · Use after every practice consultation
0/ 33 pts
Global Skills
Structure, language, responsiveness
0/7
Tasks
Data gathering, diagnosis, clinical management
0/15
Relating to Others
Communication, rapport, shared decision making
0/11
RAG Self-Assessment Guide — use this to score each item above
🔴 Red — not achieved
Item clearly missed — wrong drug for phenotype, treated on clinic BP without ABPM, red flags not screened, ICE not explored, generic lifestyle advice. Assessor marks absent.
🟠 Amber — partially achieved
Item attempted but incomplete — ABPM mentioned but not explained; correct drug but comorbidity not considered; QRISK done but not shared as a number; family fear noted but not explored in depth. Partial marks.
🟢 Green — fully achieved
Item clearly demonstrated — ABPM explained as "truer reading"; QRISK shared as "your personal X% risk"; correct drug explained in plain language for this patient; family fear named and addressed in the plan. Assessor marks present.
Complete the checklist above to see your score interpretation and feedback
🎓 SCA Checkpoint — Step 7 (Final)TasksRelating to OthersGlobal Skills
Closing the consultation
"Let me summarise what we've agreed today so it's completely clear..."
"I'll personally call you within 48 hours of the monitor finishing — with the results and our plan."
"If before then you develop [name symptoms explicitly], call 999 — not the surgery."
"We've talked about the driving and work side of things — please do come back if anything changes or causes a problem."
"Is there anything I've said that's unclear, or anything else on your mind?"
Deductions — closing
- Going to management before addressing patient's expectation
- "Come back if you feel unwell" — too vague, fails safety-netting mark
- No specific follow-up date or named GP callback
- Not summarising the agreed plan back to the patient
- Prescribing without ABPM/HBPM result
- Not closing with "anything else?"
- No psychosocial impact discussion (driving, work, relationships)
Tasks domain — full criteria
- Follows NICE NG136 throughout
- Investigations targeted and rationale given
- Follow-up: named GP, specific date, purpose stated
- Safety-netting: 999 named, specific symptoms listed
- Psychosocial impact addressed (driving, work, relationships)
Relating to Others — full criteria
- Patient expectation validated BEFORE management plan
- ICE used throughout — not just at start
- Grandmother's stroke named and revisited in management
- Shared decision: ABPM vs HBPM offered as patient choice
- One lifestyle change specifically agreed with patient
- Drug counselling phrase used for chosen medication
🔴 Red — failing
Management before expectation; vague safety-net; no follow-up date; no psychosocial; prescribes without ABPM; consultation feels like a lecture not a shared plan
🟠 Amber — borderline
Expectation acknowledged briefly; management plan reasonable; safety-net present but vague; some psychosocial missed; callback mentioned but not specific
🟢 Green — passing
Expectation validated then negotiated; shared plan arrived at together; safety-net with 999 named and symptoms specific; named GP callback within 48h; psychosocial (driving, work, relationships, mental health) addressed; closes with "anything else?"
"Doctor, I'd like to be started on blood pressure tablets please."
Who you are
52yo male, HGV driver. No PMH. No regular medications. A&E wrist laceration — BP 160/100 recorded. Worried ever since. Concerned about his HGV licence and telling his employer.
Hidden agenda
Grandmother died of stroke at 58. You believe high BP = imminent stroke = need tablets now. The HGV concern is secondary but surfaces if driving is mentioned. Fear drives the consultation.
Symptoms if asked directly
- No headache, no visual change
- No chest pain, no breathlessness
- No ankle swelling, no haematuria
- Paracetamol only for the wrist — not ibuprofen
Lifestyle + bonus details
- HGV driving; irregular meals; high-salt diet (fast food)
- Non-smoker; rarely drinks
- Works long hours; very stressed
- Snores "quite badly" — only reveals if directly asked
- Worried about telling his employer about his BP
"Why can't I just have the tablets now? I don't want what happened to my grandmother to happen to me. And will I lose my licence?"
Resolution: Accept management plan only when: (1) stroke fear acknowledged specifically by name, AND (2) HGV licence concern addressed factually, AND (3) specific follow-up date named. Snoring detail rewards observant candidates who ask about OSA.
Clinic Quick Reference
Hypertension — Clinical Decision Framework
NICE NG136 · CKS 2026 · First Presentation
expand
🚦 1 — Triage System
BP ≥140/90 recorded — confirm with ABPM, then stage urgency
↓
🔴 999 — Hypertensive Emergency
- BP ≥180/120 + encephalopathy / seizures / papilloedema
- BP ≥180/120 + ACS (chest pain, ECG changes)
- BP ≥180/120 + aortic dissection (tearing back/chest pain)
- BP ≥180/120 + eclampsia (pregnancy + seizures)
- BP ≥180/120 + haemorrhagic stroke / acute pulmonary oedema
999 · Reduce MAP by ≤25% over first hour · Do NOT lower BP too fast
🟠 Urgent — same-day
- BP ≥180/120 without organ damage — call 111/GP same-day
- Malignant HTN (BP ≥180/120 + grade 3–4 retinopathy)
- Suspected phaeochromocytoma (episodic HTN + headache + sweating)
- New focal neurology with raised BP → rule out stroke (FAST)
Same-day U&Es · ECG · Urine ACR · Do NOT lower BP rapidly in community
🟢 Routine GP
- Stage 1: clinic ≥140/90 + ABPM ≥135/85 → lifestyle; drug if QRISK ≥10%
- Stage 2: clinic ≥160/100 + ABPM ≥150/95 → offer drug regardless of QRISK
- Stage 3: clinic ≥180/120 no organ damage → review within 7 days
- Known HTN: titration, monitoring, annual review
Confirm with ABPM · QRISK3 · Lifestyle first · Step therapy
🔬 2 — Diagnostic Pathway
Staging — NICE NG136
Clinic BP ≥140/90 → confirm with ABPM or HBPM (always)
ABPM <135/85 → White coat HTN. No drug. Retest in 5 years.
ABPM 135–149/85–94 (Stage 1) → Lifestyle. Drug only if QRISK ≥10% or organ damage.
ABPM ≥150/95 (Stage 2) → Offer drug regardless of QRISK.
Clinic ≥180/120 (Stage 3) → End-organ damage screen. Review within 7 days.
Secondary HTN screen if: age <40 · resistant to 3 drugs · hypokalaemia · episodic symptoms · renal bruit · sudden worsening
Baseline investigations
U&E + eGFR + K⁺ — CKD diagnosis + affects drug choice. K⁺ drives ACEi safety.
Fasting glucose + HbA1c — DM affects first-line drug (ACEi/ARB preferred).
Lipids (fasting) — QRISK3 needs cholesterol ratio. Statin if ≥10%.
12-lead ECG — LVH = target organ damage (→ treat regardless of stage).
Urine ACR — proteinuria = end-organ damage + CKD staging.
Fundoscopy — grade 3–4 retinopathy = malignant HTN → urgent.
ABPM technique: Morning + evening readings for 7 days → discard day 1 → average remainder. Target <135/85 daytime average (or <145/85 if over 80).
📊 3 — Key Numbers
≥140/90
Clinic threshold → confirm ABPM
≥135/85
ABPM Stage 1 threshold
≥180/120
Stage 3 — same-day assessment
<140/90
Clinic target (most patients)
<130/80
Target if DM, CKD, or CVD
<150/90
Target if age ≥80
QRISK ≥10%
Treat Stage 1; offer statin
K⁺ 4.5
Spiro threshold at Step 4
1–2–1 rule
1wk BP · 2wk U&Es (ACEi) · 1yr review
eGFR <30
Thiazide ineffective → loop diuretic
3 drugs
Resistant HTN → refer + secondary screen
A+C+D
Standard Step 3 triple therapy
💊 4 — Medication Decision & Choice
Step therapy — NICE NG136
Step 1 A: ACEi (ramipril) — under 55, white, not Afro-Caribbean. Step 1 C: CCB (amlodipine) — over 55, Afro-Caribbean (no DM), or if ACEi-intolerant. ARB if ACEi cough.
Step 2: ACEi/ARB + CCB (A+C). Most patients need 2 drugs to reach target BP.
Step 3: ACEi/ARB + CCB + thiazide (A+C+D). Indapamide 2.5mg OD preferred over bendroflumethiazide.
Step 4 (resistant): Add spironolactone 25mg (K⁺ <4.5) or doxazosin or BB. Refer + investigate secondary causes.
⛔ No ACEi + ARB together · ⛔ Thiazide ineffective eGFR <30 · ⛔ BB not first-line unless IHD/AF/HF · ⛔ ACEi avoid in Afro-Caribbean without DM/CKD
Drug choice by comorbidity
DM / CKD / proteinuria → ACEi/ARB (renoprotective). Monitor K⁺ + eGFR.
Afro-Caribbean (no DM) → CCB first-line. ACEi less effective (lower renin).
Angina / IHD → BB or CCB (rate-limiting). Dual benefit.
HFrEF → ACEi + BB + MRA (HF indications). Thiazide for extra BP control.
AF → BB or rate-limiting CCB for rate. ACEi/ARB for BP.
ACEi cough → Switch to ARB. Same renoprotection, no cough.
K⁺ >4.5 → Avoid spironolactone at Step 4. Use doxazosin or BB instead.
Pregnancy → Labetalol, nifedipine, methyldopa. No ACEi/ARB (teratogenic).
⚠ 5 — Safety Netting & Follow-Up
🔴 Emergency — all hypertensive patients
"If you develop a sudden severe headache unlike any before, vision changes, weakness or numbness on one side, chest pain, or difficulty breathing — call 999 immediately. Your blood pressure medication does not fully remove that risk."
💊 Starting antihypertensive — all patients
"This tablet works gradually — you won't feel it working, but it's protecting your heart, brain, and kidneys. Don't stop it without telling us. If you feel dizzy in the first week, call us and we'll review the dose — don't stop it yourself."
🟠 ACEi/ARB — U&Es monitoring
"We'll do a blood test 2 weeks after starting this tablet to check your kidneys and potassium are handling it well. If you get any muscle weakness or notice you're passing much less urine — call us the same day."
Follow-up — 1–2–1 rule
1
1 week: BP check after any drug start or dose change. Symptoms of hypotension or dizziness.
2
2 weeks (ACEi/ARB): U&Es + K⁺ + eGFR mandatory. K⁺ >5.5 or Cr ↑>30% → stop + specialist.
3
4–8 weeks: BP target reached? Tolerability. Titrate up or add next step. HBPM results reviewed.
4
3–6 months: Target BP confirmed. Adherence assessed. QRISK reassessed. Lifestyle reinforced.
5
Annual: BP · U&Es · eGFR · Lipids · HbA1c · BMI · Urine ACR · Medication review · Lifestyle · CVD risk
📌 HBPM: morning + evening for 7 days. Discard day 1. Average the rest. Target <135/85.
🔬 6 — Monitoring & Safety
| Drug class | Test | Timing | Action threshold |
|---|---|---|---|
| ACEi (ramipril) | U&E + K⁺ + eGFR | 1–2 weeks post start/change | K⁺ >5.5 → STOP. Cr ↑>30% → stop + specialist. K⁺ 5.0–5.5 → halve + recheck. Dry cough → switch to ARB. |
| ARB (losartan) | U&E + K⁺ + eGFR | 1–2 weeks post start/change | Same thresholds as ACEi. Never combine ACEi + ARB — hyperkalaemia + AKI risk. |
| CCB (amlodipine) | BP + symptoms | 4–8 weeks | Ankle oedema (up to 30%) → reduce dose or switch to diltiazem. Flushing usually settles. No renal monitoring. |
| Thiazide (indapamide) | U&E + K⁺ + uric acid | 4–8 weeks post start | K⁺ <3.5 → supplement or switch. Uric acid ↑ → gout risk. Ineffective if eGFR <30. |
| Spironolactone (Step 4) | K⁺ + eGFR | 1 week then 1 month | K⁺ must be <4.5 to start. K⁺ >5.5 → STOP. Gynaecomastia → eplerenone. |
| Beta-blocker | HR + BP | 4–8 weeks | HR <50 → reduce dose. Never stop abruptly. Masks hypoglycaemia in DM. |
| All patients | BP + QRISK3 | Annual | Target: <140/90 (most); <130/80 (DM/CVD/CKD); <150/90 (age ≥80). QRISK may cross 10% with age — reassess annually. |
999 red flags: BP ≥180/120 + headache/visual/neuro/chest · FAST · Tearing chest/back → aortic dissection · Eclampsia
🛡️ Safeguarding: Non-adherence (cognitive impairment, cost, complex regimen) · White coat misclassification · Secondary cause missed in young · Pregnancy HTN · Elderly: postural hypotension + falls
SCA Exam Quick Reference
SCA Consultation Blueprint
Tasks · Relating to Others · Global Skills · RAG guide
expand
🕐 12-Minute Consultation Flow — with Domain Scoring
0–2 min
Open & ICE
"I can see from the notes your blood pressure has been raised on a couple of readings. Before I explain anything — how are you feeling about that, and what has been going through your mind?"
"What do you think might be causing it? Is there anything specific you are worried about?"
Explore family history fear (stroke/heart attack at young age). Ask about expectations re treatment today.
Relating to OthersGlobal Skills
✗ Starting with BP numbers or drug options · Not exploring fear · Re-asking info already in notes
2–5 min
Safety Screen
"Before anything else — have you had any severe headaches, changes in your vision, weakness or numbness, or any chest pain recently?"
Name red flags aloud: hypertensive emergency, stroke FAST, aortic dissection
Secondary HTN screen: age <40, resistant to drugs, episodic symptoms, hypokalaemia
TasksGlobal Skills
✗ Going to drug choice without red flag screen · Not verbalising safety check aloud
5–7 min
Context & Risk
QRISK3 factors: smoking, DM, lipids, family history, ethnicity, CKD, AF
Lifestyle: salt, alcohol, BMI, exercise, caffeine, stress, NSAIDs/OCP raising BP
Psychosocial: driving job, medication barriers, health beliefs, work stress
Confirm BP stage needs ABPM/HBPM — not clinic reading alone
TasksRelating to Others
✗ Treating on clinic BP without ABPM · Generic lifestyle advice · Missing secondary cause screen
7–10 min
Explain & Plan
"Blood pressure is the force of blood pushing against the artery walls. When it stays high, it silently damages the heart, brain, and kidneys. Your QRISK score is X%, which means a X in 100 chance of a heart attack or stroke in the next 10 years without treatment."
ABPM as "the truer picture" — not affected by clinic anxiety
Correct drug for age/ethnicity/comorbidity. Explain why that specific tablet.
TasksRelating to Others
✗ Wrong drug for ethnicity · QRISK not shared as a number · Jargon without explanation
10–12 min
Plan & Close
"Sudden severe headache, weakness one side, or chest pain — call 999. Dizziness on standing — call us, do not stop the tablet yourself."
1-2-1 rule: 1 week BP · 2 weeks U&Es (ACEi/ARB) · 1 year annual review
HBPM instructions · specific lifestyle targets · "Anything else?"
TasksRelating to OthersGlobal Skills
✗ Vague safety-net · No 1-week review named · No HBPM technique · No closing question
🔴🟠🟢 RAG Scoring — All 3 Domains
Tasks Domain
🟢
ABPM planned with explanation · QRISK shared as number · Correct drug for age/ethnicity/comorbidity · Secondary HTN screened · Red flags named aloud · 1-2-1 rule stated · U&Es within 2 weeks of ACEi/ARB · Lifestyle advice specific
🟠
Correct drug but comorbidity not considered · ABPM mentioned but not explained · QRISK done but not shared · Safety-net present but 999 symptoms not specific
🔴
Treats on clinic BP alone · Wrong drug (BB first-line; ACEi in Afro-Caribbean without DM) · No ABPM planned · No red flag screen · No safety-net · No follow-up named
Relating to Others
🟢
Family history fear explored and addressed in plan · QRISK shared as "your personal X% risk" · Lifestyle specific and measurable · Drug explained in plain language · Barriers to adherence explored · "Anything else?"
🟠
ICE asked but not deeply explored · Family fear acknowledged but not named in plan · Generic lifestyle advice · Drug explanation present but jargon used
🔴
Jumps to drug without ICE · Family fear not acknowledged · Lectures on lifestyle · No drug rationale · No shared decision
Global Skills
🟢
Used notes before asking · Open Q first · Data gathering complete by 6-7 min · Clear lay language · Responsive to cues (anxiety, denial, family fear) · Efficient progression through all domains
🟠
Re-asks some noted information · Some jargon · Data gathering slightly overruns · Misses one key cue
🔴
Re-asks everything · Rigid BP-focused agenda · Jargon throughout · Misses patient cues · Data gathering not complete before management
💬 Key Phrases — ICE, Diagnosis & Plan
💭 Ideas
"What do you think is causing your blood pressure to be raised? Do you have any ideas about why it might have gone up?"
😟 Concerns — family history
"You mentioned your father had a stroke — I can understand why that would be frightening. Can you tell me more about what specifically worries you about your own blood pressure?"
🎯 Expectations
"Were you expecting we might start a tablet today, or were you hoping it might be manageable with lifestyle changes alone? Let me explain how we decide that — it depends on a risk calculation we do together."
🗣️ Lay diagnosis — artery wall pressure
"Blood pressure is the force of blood pushing against the artery walls — like water pressure in a pipe. When it stays high for too long, it gradually damages those walls and the organs they supply: the brain, heart, and kidneys. The danger is that it often causes no symptoms until something serious happens."
📊 ABPM explanation + QRISK
"The reading we take here in the surgery can be falsely high due to the stress of being in a clinic — we call it white coat effect. The 24-hour monitor gives us the true picture of what your blood pressure is doing in everyday life. That is the reading we use to make the treatment decision. Your personal 10-year risk of a heart attack or stroke is X%."
✅ Closing
"Sudden severe headache unlike any before, weakness on one side, vision changes, or chest pain — call 999. Dizziness when standing — call us, do not stop the tablet yourself. I will see you in one week to check the blood pressure reading. Is there anything else on your mind today?"
🚫 9 Danger Zones — Instant Deductions
✗
Treating on clinic BP without planning ABPM/HBPM
→ Always plan ABPM for new HTN. "The surgery reading can be falsely high — the 24h monitor gives the true picture."
→ Always plan ABPM for new HTN. "The surgery reading can be falsely high — the 24h monitor gives the true picture."
✗
Starting with drugs before open Q and ICE
→ Open Q first. Explore family history fear before any clinical agenda. Then ABPM, then treatment.
→ Open Q first. Explore family history fear before any clinical agenda. Then ABPM, then treatment.
✗
Wrong first-line drug for age / ethnicity
→ Under-55 white = ACEi. Over-55 or Afro-Caribbean (no DM) = CCB. BB is NOT first-line unless IHD/AF/HFrEF.
→ Under-55 white = ACEi. Over-55 or Afro-Caribbean (no DM) = CCB. BB is NOT first-line unless IHD/AF/HFrEF.
✗
ACEi in Afro-Caribbean without DM or CKD
→ Lower renin = ACEi less effective AND higher angioedema risk. CCB first-line in this group.
→ Lower renin = ACEi less effective AND higher angioedema risk. CCB first-line in this group.
✗
Not ordering U&Es within 2 weeks of ACEi/ARB
→ Mandatory. K+ >5.5 or Cr rise >30% = STOP + specialist. Do not skip this safety check.
→ Mandatory. K+ >5.5 or Cr rise >30% = STOP + specialist. Do not skip this safety check.
✗
Not sharing QRISK as an actual percentage
→ "Your 10-year risk is X%." Without the number, shared decision making is not possible.
→ "Your 10-year risk is X%." Without the number, shared decision making is not possible.
✗
Generic lifestyle advice without specific targets
→ "Less than 6g of salt per day — about one teaspoon." "30 minutes brisk walking, 5 days a week." Not just "eat less salt."
→ "Less than 6g of salt per day — about one teaspoon." "30 minutes brisk walking, 5 days a week." Not just "eat less salt."
✗
Missing secondary HTN screen in young or resistant patient
→ Age <40, failure of 3 drugs, hypokalaemia, episodic symptoms → screen for Conn's, phaeochromocytoma, renal artery stenosis.
→ Age <40, failure of 3 drugs, hypokalaemia, episodic symptoms → screen for Conn's, phaeochromocytoma, renal artery stenosis.
✗
Vague safety-net without 999 named with specific symptoms
→ "Sudden severe headache, weakness one side, vision loss → 999. Dizziness on standing → call us, do not stop the tablet."
→ "Sudden severe headache, weakness one side, vision loss → 999. Dizziness on standing → call us, do not stop the tablet."
💊 Drug Quick-Pick
Under 55, white, no comorbidity (Step 1)
→
ACEi (Ramipril)
U&Es 2 wks
Over 55 OR Afro-Caribbean (no DM, no CKD)
→
CCB (Amlodipine)
Ankle oedema?
DM / CKD / proteinuria (any age)
→
ACEi/ARB
Renoprotective
ACEi cough → switch to
→
ARB (Losartan)
No cough with ARB
Step 2 — most patients
→
ACEi/ARB + CCB
A + C
Step 3 — triple therapy
→
A + C + D (indapamide)
Prefer over bendro
Resistant (Step 4, K+ <4.5)
→
+ Spironolactone
K+ must be <4.5
⛔ BB NOT first-line for HTN alone · ⛔ No ACEi + ARB · ⛔ Thiazide ineffective eGFR <30 · ⛔ ACEi avoid Afro-Caribbean without DM/CKD