ABPM Confirmation Before Fourth Agent CKD — ESENeph MCQ

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ModerateHypertensionABPM Confirmation Before Fourth Agent CKDESENeph

A 55-year-old man with CKD G3b (eGFR 36 mL/min/1.73m2) and persistent hypertension on ramipril 10 mg, amlodipine 10 mg, and indapamide 2.5 mg has office BP readings of 142/88 mmHg. He has never had ambulatory BP monitoring. What should be done before intensifying therapy?

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Correct answer: D — Confirm with ABPM or home BP monitoring before changing treatment

NICE NG136 and KDIGO 2024 both emphasise that treatment decisions should be based on out-of-office BP measurements (ABPM or validated home BP monitoring) rather than clinic readings alone. Up to 30% of patients with apparent resistant hypertension actually have white coat effect, and treatment intensification based on clinic readings alone risks over-treatment with associated falls, AKI, and electrolyte disturbances. Before adding a fourth antihypertensive, ABPM (or 7-day HBPM) should be performed. If ABPM confirms resistant hypertension (daytime average ≥135/85), then spironolactone is the evidence-based fourth-line agent (PATHWAY-2 trial). Medication adherence should also be assessed.

Reference: NICE 2019 – NG136 Hypertension; KDIGO 2024 – CKD Guideline; Williams et al 2015 – PATHWAY-2