7.2 Hypertension & Dyslipidemia Management

Measuring and Diagnosing Hypertension

Diagnosis drives years of therapy, so measurement quality matters. Counsel on correct technique: seated, back supported, arm at heart level, correct cuff size, no caffeine, smoking, or exercise within 30 minutes, and two readings taken at least one minute apart. A clinic reading of ≥140/90 mmHg suggests hypertension, but NICE-style guidance requires confirmation with ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM): a daytime ABPM average or HBPM average of ≥135/85 mmHg confirms the diagnosis. HBPM counseling is a pharmacist staple — measure morning and evening, seated after 5 minutes of rest, duplicate readings each occasion, for at least 4–7 days, discarding day one.

Severity staging on clinic readings: stage 1 is 140/90–159/99, stage 2 is 160/100–179/109, and severe is ≥180/110 mmHg (the latter, or any reading with acute symptoms, warrants same-day medical review rather than a routine appointment).

Treatment Thresholds and Targets

Offer antihypertensive drug treatment to all patients with stage 2 hypertension and to stage 1 patients who are under 80 with target organ damage, established cardiovascular disease, diabetes, chronic kidney disease, or a 10-year cardiovascular risk ≥10%. Above age 80 with stage 1, treat if similar comorbidities exist. The general on-treatment clinic target is <140/90 mmHg; for patients aged 80 and over the target relaxes to <150/90 mmHg, and frailty, postural hypotension, and falls risk should always individualize the goal. Targets are tighter when confirmed by ABPM/HBPM (roughly 135/85, or 145/85 over 80).

The ACD First-Line Algorithm

NICE-style sequencing — heavily examined — is built on age and ethnicity:

The pharmacology behind the algorithm: younger patients tend toward renin-driven hypertension responsive to renin-angiotensin blockade, while older patients and those of black African/Caribbean origin more often have low-renin, salt-sensitive hypertension that responds better to calcium channel blockers and diuretics. Beta-blockers are not routine first-line unless there is a compelling indication (post-MI, heart failure, rate control in atrial fibrillation). Do not combine an ACE inhibitor with an ARB.

Monitoring and the Resistant-Hypertension Step

After starting or up-titrating an ACE inhibitor or ARB, check serum creatinine/eGFR and potassium within roughly 2 weeks. Accept up to a 30% rise in creatinine and potassium up to 5.9 mmol/L before adjusting; investigate or stop if creatinine rises more than 30% (think bilateral renal artery stenosis) or potassium reaches ≥6.0 mmol/L. An ACE-inhibitor cough (dry, persistent) justifies switching to an ARB; prior angioedema on an ACE inhibitor contraindicates the class.

Resistant hypertension is blood pressure above target despite three agents at optimal doses including a diuretic. Before labeling it, confirm adherence (the commonest cause of apparent resistance), repeat ABPM to exclude white-coat effect, and review the drug cabinet for pressor agents — NSAIDs, combined oral contraceptives, corticosteroids, decongestants, and excess licorice. Step 4 adds spironolactone 25 mg when potassium is ≤4.5 mmol/L; if potassium is higher or spironolactone is not tolerated, an alpha-blocker (doxazosin) or beta-blocker is used. Screen for secondary causes: renal artery stenosis (young patients, flash pulmonary edema, abdominal bruit), primary aldosteronism (hypokalemia, especially with resistant hypertension), obstructive sleep apnea (snoring, daytime somnolence, obesity), CKD, thyroid disease, and coarctation in the young.

Dyslipidemia: Primary vs Secondary Prevention

Secondary prevention (established ASCVD: prior MI, stroke, peripheral arterial disease, angina) means high-intensity statin therapy for essentially everyone, typically atorvastatin 80 mg, aiming for at least a 50% LDL-C reduction (ESC) with the lowest achieved LDL guiding add-on therapy. Primary prevention is risk-stratified with a validated tool — QRISK3 in NICE practice, SCORE2 in ESC practice — and statins are offered when the 10-year cardiovascular risk is ≥10%, or at lower thresholds with risk modifiers (familial hypercholesterolemia, CKD, diabetes with additional factors). The primary-prevention intensity target to quote in the exam: atorvastatin 20 mg aiming for a ≥40% reduction in non-HDL cholesterol (and LDL-C).

Statin Monitoring: Lipids, LFTs, and CK

The monitoring rules are classic exam fodder:

• Baseline: full lipid profile, ALT/AST, renal and thyroid function, HbA1c; check CK only if the patient has pre-existing muscle symptoms or high-risk features.
• Lipids: repeat at ~3 months to confirm the ≥40% non-HDL/LDL reduction and reinforce adherence, then annually.
• LFTs: repeat at 3 months and 12 months; stop the statin if ALT/AST exceeds 3× the upper limit of normal.
• CK: not routinely monitored. Measure it if the patient reports muscle pain or weakness; stop if CK exceeds 5× the upper limit of normal (with severe symptoms or renal compromise, stop regardless). If CK is 5× or less with tolerable symptoms, trial continued or reduced dosing.

For statin intolerance, trial three different statins or alternate-day dosing before labeling the patient intolerant; ezetimibe is the standard add-on or alternative. Counsel on interactions: avoid clarithromycin/erythromycin and systemic azoles with simvastatin/atorvastatin, cap simvastatin doses with amlodipine and diltiazem, and warn about large quantities of grapefruit juice with simvastatin.

Lifestyle and When to Refer

Lifestyle counseling underpins both conditions: salt restriction below ~5–6 g/day, DASH-style diet rich in fruit, vegetables, and low-fat dairy, weight loss, ≥150 minutes of weekly aerobic activity, alcohol within limits, and smoking cessation (the single largest cardiovascular risk modifier). Lipids: replace saturated with unsaturated fats, increase soluble fiber, and consider plant sterol spreads as adjuncts. Refer promptly for suspected familial hypercholesterolemia (LDL-C persistently >4.9 mmol/L with family history or tendon xanthomas), fasting triglycerides above ~10 mmol/L (pancreatitis risk), severe hypertension (≥180/110), suspected secondary hypertension, and recurrent statin-associated muscle symptoms with elevated CK.