Hypertension is a massive topic for the AKT, and NICE (NG136) has a very specific "recipe" for how they want you to diagnose and manage it. It’s all about the steps—from that first high reading in the clinic to picking the right drug based on age and ethnicity.

Let's start with how we actually confirm the diagnosis and what investigations we need to run to look for end-organ damage.

1. Diagnosis & Investigations

If a patient has a clinic blood pressure (BP) between 140/90 mmHg and 179/120 mmHg, you don't diagnose them on the spot. You offer Ambulatory Blood Pressure Monitoring (ABPM) or Home Blood Pressure Monitoring (HBPM) to confirm.

Once confirmed, we need to look for "target organ damage" and assess cardiovascular risk:

• Urine ACR: Check for albuminuria (kidney damage).
• Blood tests: Electrolytes, Creatinine, eGFR, Fasting Glucose (or HbA1c), and Lipid profile.
• Fundoscopy: Look for hypertensive retinopathy.
• 12-lead ECG: Check for Left Ventricular Hypertrophy (LVH) or arrhythmias.
• QRISK3: To calculate their 10-year cardiovascular risk.

2. Treatment Thresholds

• Stage 1 Hypertension (Clinic 140/90 or ABPM/HBPM 135/85): Treat if <80 years old AND they have target organ damage, CVD, renal disease, diabetes, or a QRISK3 score $\ge$ 10%.
• Stage 2 Hypertension (Clinic 160/100 or ABPM/HBPM 150/95): Treat everyone regardless of age.
• Stage 3 (Severe) (Clinic $\ge$ 180/120): Start treatment immediately.

I've put together a flowchart of the NICE drug pathway, as this is the "bread and butter" of hypertension questions.

The flowchart above summarizes the standard "A-C-D" pathway. A few high-yield "pro-tips" for the AKT:

• ACEi vs ARB: NICE now suggests that if a patient is of Black African or African-Caribbean family origin, an ARB (Angiotensin Receptor Blocker) is preferred over an ACE inhibitor if they need an "A" drug (like in Step 2 or if they have Type 2 Diabetes).
• Diuretics: When we say "D", NICE specifically recommends thiazide-like diuretics (e.g., Indapamide) rather than conventional thiazides like Bendroflumethiazide.
• Targets:
  • < 80 years: Target is < 140/90 mmHg (Clinic) or < 135/85 mmHg (ABPM/HBPM).
  • > 80 years: Target is < 150/90 mmHg (Clinic) or < 145/85 mmHg (ABPM/HBPM).

To help you lock this in, I've found some relevant lessons and flashcards that cover these specific NICE criteria and the common pitfalls.

I've also pulled some flashcards to help you memorize those tricky Step 4 rules and the specific BP targets for different age groups.

Those lessons and flashcards should give you a solid foundation for the AKT.

One last thing to remember: White Coat Effect. If the clinic BP is high but the ABPM/HBPM is normal, that's white coat hypertension—no treatment needed, just lifestyle advice and annual monitoring.

Would you like to try a quick quiz to see how well you've got the drug steps down, or should we look at some clinical cases?