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Accelerated hypertension — MSRA MCQ

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Moderateall topics relevant for this examAccelerated hypertensionMSRA

A 52-year-old man attends for an insurance medical. He has no previous diagnosis of hypertension and takes no regular medication. He feels well, with no chest pain, breathlessness, headache, visual disturbance, confusion or reduced urine output. His clinic blood pressure is 208/126 mmHg. After he has rested, two further correctly performed readings are 204/124 mmHg and 206/122 mmHg. Cardiovascular and neurological examinations are normal. Fundoscopy shows bilateral retinal flame haemorrhages, without papilloedema. What is the most appropriate management now?

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Correct answer: D — Refer for same-day specialist assessment

This man requires same-day specialist assessment. He has severe hypertension (clinic blood pressure at least 180/120 mmHg) together with retinal haemorrhages, which meets NICE criteria for accelerated hypertension. This indication applies even in the absence of symptoms such as chest pain, confusion, heart failure or acute kidney injury. Ambulatory blood pressure monitoring is used to confirm hypertension when clinic blood pressure is below 180/120 mmHg and is not the appropriate next step here. Repeating clinic measurement or arranging ABPM with review within 7 days is appropriate only for severe hypertension without signs requiring same-day referral and after prompt assessment for target-organ damage. Starting oral treatment without urgent specialist assessment may be appropriate when target-organ damage is identified in a person without same-day referral features, but retinal haemorrhage is specifically a same-day referral criterion. Urgent blood, urine, ECG and renal assessment will be required, but these investigations must not delay referral.

Reference: Hypertension in adults: diagnosis and management (NG136), recommendation 1.5.2 (2019; updated 2023) — https://www.nice.org.uk/guidance/ng136/chapter/Recommendations Hypertension in adults: diagnosis and management (NG136), recommendation 1.5.1 (2019; updated 2023) — https://www.nice.org.uk/guidance/ng136/chapter/Recommendations