Hypertension – A Structured PACES Approach
Primary Hypertension • Secondary Hypertension • Target-Organ Damage • MRCP (UK) PACES
A comprehensive MRCP (UK) PACES guide to evaluating patients with hypertension. Learn how to distinguish primary from secondary hypertension, recognise target-organ damage, identify endocrine and renal causes, investigate appropriately and counsel patients confidently during the Long Clinical Consultation station.
At a Glance
Red Flags
PACES Approach
Causes of Secondary Hypertension
CKD • ADPKD • Renal artery stenosis • Glomerulonephritis
Conn syndrome • Cushing syndrome • Phaeochromocytoma • Thyroid disease • Acromegaly
Coarctation of the aorta • Vasculitis
Obstructive sleep apnoea
NSAIDs • Steroids • Oral contraceptives • Cocaine • Amphetamines
Pre-eclampsia • Eclampsia
Overview
Hypertension is one of the commonest medical conditions encountered in clinical practice. During the MRCP (UK) PACES Long Clinical Consultation, candidates should confirm the diagnosis, identify target-organ damage, distinguish primary from secondary hypertension and recognise clinical features suggesting renal, endocrine or vascular disease. Particular attention should be paid to young patients, resistant hypertension and those with features suggesting an underlying secondary cause. :contentReference[oaicite:1]{index=1}
Focused History
Confirm the Hypertension
- When was hypertension first diagnosed?
- Highest recorded blood pressure.
- Home blood pressure readings.
- Previous ambulatory blood pressure monitoring.
- Current antihypertensive medication.
- Medication adherence.
Symptoms Suggesting Severe Hypertension
- Headache.
- Epistaxis.
- Visual disturbance.
- Chest pain.
- Breathlessness.
- Neurological symptoms.
Screen for Secondary Causes
- Weight loss, sweating and palpitations (phaeochromocytoma).
- Weight gain, proximal muscle weakness and easy bruising (Cushing syndrome).
- Muscle weakness or cramps suggesting hypokalaemia (Conn syndrome).
- Heat intolerance, tremor or weight loss (hyperthyroidism).
- Increasing ring or shoe size (acromegaly).
- Haematuria, loin pain or renal disease.
- Loud snoring or daytime somnolence (obstructive sleep apnoea).
Assess Target-organ Damage
- Visual loss or blurred vision.
- History of stroke or transient ischaemic attack.
- Chest pain or heart failure symptoms.
- Reduced urine output or chronic kidney disease.
- Peripheral vascular symptoms.
Past Medical History
- Diabetes mellitus.
- Chronic kidney disease.
- Previous myocardial infarction or stroke.
- Pregnancy-related hypertension.
- Autoimmune disease.
Drug and Social History
- NSAIDs.
- Corticosteroids.
- Oral contraceptive pill.
- Ciclosporin.
- Cocaine or amphetamine use.
- Smoking and alcohol intake.
- Occupational stress.
- Family history of hypertension or cardiovascular disease.
Focused Examination
- Measure blood pressure correctly in both arms.
- Assess pulse rate and rhythm.
- Look for radio-radial and radio-femoral delay.
- Measure body mass index and waist circumference.
- Perform fundoscopy for hypertensive retinopathy.
- Assess for left ventricular failure.
- Palpate for enlarged kidneys (ADPKD).
- Auscultate for renal bruits.
- Look for endocrine features (Cushing syndrome, acromegaly, thyroid disease).
- Urinalysis for proteinuria and haematuria.
Differential Diagnosis
Investigations
Confirm the Diagnosis
- Ambulatory blood pressure monitoring (preferred).
- Home blood pressure monitoring if appropriate.
Baseline Investigations
- Full blood count.
- Urea, electrolytes and creatinine.
- HbA1c or fasting glucose.
- Lipid profile.
- Urinalysis and urine albumin-creatinine ratio.
- ECG.
Investigations for Secondary Hypertension
- Renal ultrasound.
- Renal artery Doppler ultrasound or CT/MR angiography when indicated.
- Plasma aldosterone-renin ratio.
- Plasma or urinary metanephrines.
- Thyroid function tests.
- Serum cortisol or dexamethasone suppression testing where appropriate.
- IGF-1 if acromegaly is suspected.
PACES Tip: Young age, resistant hypertension, hypokalaemia, sudden onset hypertension or features of endocrine disease should always prompt investigation for a secondary cause rather than assuming primary hypertension. :contentReference[oaicite:1]{index=1}
Diagnosis
Hypertension – Determine Whether Primary or Secondary
Most patients have primary (essential) hypertension. However, young patients, those with resistant hypertension, sudden onset hypertension or clinical features suggesting renal or endocrine disease require evaluation for secondary hypertension. At every consultation, assess for target-organ damage affecting the eyes, brain, heart and kidneys. :contentReference[oaicite:2]{index=2}
Explaining to the Patient
"Your blood pressure is higher than recommended. High blood pressure often causes no symptoms, but over time it can damage important organs such as the heart, brain, kidneys and eyes. We need to confirm the diagnosis, look for any underlying cause and assess whether any complications have already developed. Treatment usually combines healthy lifestyle changes with medication, depending on your blood pressure readings and overall cardiovascular risk."
Management
Examiner's Corner
What features suggest secondary hypertension?
- Age younger than 40 years.
- Resistant hypertension despite appropriate treatment.
- Sudden onset or rapidly worsening hypertension.
- Hypokalaemia.
- Features of endocrine disease.
- Renal impairment or abnormal urinalysis.
- Abdominal or renal bruit.
Which organs are damaged by long-standing hypertension?
| Organ | Typical Complication |
|---|---|
| Brain | Stroke, transient ischaemic attack, vascular cognitive impairment |
| Heart | Left ventricular hypertrophy, heart failure, myocardial infarction |
| Kidneys | Chronic kidney disease, proteinuria |
| Eyes | Hypertensive retinopathy |
| Peripheral vessels | Peripheral arterial disease, aortic aneurysm |
How is hypertension confirmed?
- Repeated clinic blood pressure measurements.
- Ambulatory blood pressure monitoring is preferred where available.
- Home blood pressure monitoring is an acceptable alternative in appropriate patients.
- Exclude white coat hypertension before making a lifelong diagnosis where appropriate.
When should secondary hypertension be investigated?
- Young-onset hypertension.
- Resistant hypertension.
- Accelerated or malignant hypertension.
- Clinical suspicion of renal or endocrine disease.
- Disproportionate target-organ damage.
- Sudden deterioration in previously controlled blood pressure.
Common PACES Viva Questions
- How do you confirm a diagnosis of hypertension?
- What are the common causes of secondary hypertension?
- Which investigations should every newly diagnosed patient undergo?
- How would you assess cardiovascular risk?
- What lifestyle advice would you give?
- Which antihypertensive drug classes are commonly used?
- How do you investigate resistant hypertension?
Important Clinical Pearls
- Most patients have primary (essential) hypertension.
- Young age or resistant hypertension should always prompt consideration of secondary causes.
- Target-organ damage may be present even in asymptomatic patients.
- Ambulatory blood pressure monitoring improves diagnostic accuracy.
- Lifestyle modification remains the cornerstone of long-term management.
Pathfinder Pearls
Common Pitfalls
- Diagnosing hypertension from a single clinic blood pressure reading.
- Failing to assess for target-organ damage.
- Missing secondary hypertension in a young patient.
- Ignoring medication adherence before escalating treatment.
- Not reviewing lifestyle factors contributing to hypertension.
- Overlooking renal impairment or proteinuria.
- Failing to arrange appropriate long-term follow-up.
Key Take-home Messages
- Confirm hypertension with repeated measurements or ambulatory monitoring whenever appropriate.
- Always assess for target-organ damage affecting the brain, heart, kidneys and eyes.
- Consider secondary causes in young patients, resistant hypertension or those with suggestive clinical features.
- Successful management combines lifestyle modification, appropriate medication and cardiovascular risk reduction.
- Regular follow-up and patient education are essential for long-term blood pressure control.
Master MRCP (UK) PACES Long Clinical Consultations
Develop a confident, structured approach to cardiovascular medicine, endocrine disorders and hypertension through examiner-led teaching, realistic mock stations, personalised feedback and the PACES Pathfinders Learning Library.