Hypertension, dyslipidaemia and preventive cardiology
This domain rewards precise thresholds, correct screening for secondary causes and evidence-based lipid targets. It also tests when prevention does not work.
Hypertension
- Office BP 140/90 mmHg or higher suggests hypertension; confirm with ambulatory or home monitoring (24-hour threshold 130/80, home 135/85).
- Screen for secondary causes when onset is young, hypertension is resistant or there is hypokalaemia (aldosterone-renin ratio), renal bruit or flash pulmonary oedema (renal artery stenosis), paroxysmal symptoms (metanephrines), or radio-femoral delay (coarctation).
- Resistant hypertension: three drugs including a diuretic at optimal dose; add spironolactone.
- Hypertensive emergency is severe BP with target organ damage, treated with intravenous therapy; hypertensive urgency without injury is treated orally and does not require admission.
Lipids
- LDL cholesterol is causal; lower is better. Very high risk: LDL below 1.4 mmol/L (55 mg/dL) and at least 50% reduction from baseline. High risk: below 1.8 mmol/L (70 mg/dL).
- Statin first; add ezetimibe, then a PCSK9 inhibitor, bempedoic acid or inclisiran.
- Suspect familial hypercholesterolaemia with LDL 8.5 mmol/L or more, or 4.9 mmol/L or more with family history; use the Dutch Lipid Clinic Network score and cascade screening.
Prevention
- Smoking cessation, blood pressure control, SGLT2 inhibitors or GLP-1 receptor agonists in type 2 diabetes with atherosclerotic disease.
- Aspirin is not routine primary prevention.
Worked example
A 55-year-old after myocardial infarction has LDL 3.2 mmol/L on atorvastatin 40 mg. Add ezetimibe, recheck lipids at 4-6 weeks, and escalate to a PCSK9 inhibitor if the target of 1.4 mmol/L is not met.
Traps
- Diagnosing hypertension from a single reading.
- Treating hypertensive urgency with intravenous drugs.
- Accepting a statin alone when the LDL target is unmet.