HTN
● Target: <140/90mmHg or lower if tolerated
● Dx: multiple measurements at least 1wk apart, SBP >140mmHg
● Investigations: BP, renin/aldosterone ratio (primary hyperaldosteronism), fasting
glucose, cholesterol, ECG, urine analysis, U&E, Ca
● Mx:
○ Try lifestyle changes 1st for 3 months - exercise, alcohol, Na intake, diet,
weight loss
○ 1st line - ACEi/ARB → perindopril; Ca channel blocker
(amlodipine)/thiazides (hydrochlorothiazide) - ACEi/ARB first used
■ ACEi/ARB can cause cough (ACEi only), angioedema, renal
insufficiency
● Contraindications: pregnancy - increased foetal renal damage
risk during 2nd/3rd trimester, angioedema, hyperkalaemia,
bilateral renal artery stenosis
■ Thiazide can cause hyponatraemia, gout
● Contraindications: gout; age - increased diabetes risk
→ only used in older patients when benefits of HTN Mx
outweighs diabetes risk
■ Ca channel blockers can cause peripheral oedema
● Possible contraindications: HF
○ 2nd line - beta blockers, spironolactone
■ Beta blockers contraindications: asthma, bradycardia, AV block,
uncontrolled HF
○ Refractory HTN: 3+ drugs on max doses and uncontrolled HTN →
review for other causes, non-adherence, alcohol, high salt intake →
specialist referral
○ Combinations to avoid: ACEi + ARB → renal dysfunction; verapamil
+ beta blocker → heart block
○ Combinations use with care: diltiazem + beta blockers → heart
block; ACEi + K sparing diuretics → hyperkalaemia
, ● Broader GP Mx:
○ Yearly monitoring required for well managed HTN: UEC, urinary
microalbumin, fasting BGL/HBA1C, lipid panel ECG
○ Home BP monitoring
○ Tx:
1. Start with low-moderate dose 1st line drug → not well
tolerated → switch drug class
2. Target not reached after 3 months → add 2nd drug from
different class - low-moderate dose
3. Target not reached increase dose of one drug incrementally to max
before increasing dose of other drug
4. Target not reached after max dose of both → start 3rd drug
class at low-moderate dose
5. Target not reached → seek specialist advice
○ Review regularly for adherence, adverse effects, target:
■ Every 2 yrs for low CVD risk
■ Every 6-12 months for 10-15% CVD risk
■ Review 6-12 weeks for >15% CVD risk
○ If patient not tolerate initial drug, change to drug from differnet class
ACUTE CORONARY SYNDROME, eg, unstable angina, NSTEMI, STEMI
● Symptoms: severe crushing chest pain exacerbated by exertion, radiates to
arms/neck/jaw, sweating, nausea, dyspnoea
● Risk factors: Fx IHD, smoking, HTN, hyperlipidaemia
● O/E: often normal
● Investigations: ECG asap, troponin
● Mx:
○ if symptoms precede 24hrs refer to ED immediately
○ Aspirin and GTN sublingual in meantime
● Broader GP Mx:
● Target: <140/90mmHg or lower if tolerated
● Dx: multiple measurements at least 1wk apart, SBP >140mmHg
● Investigations: BP, renin/aldosterone ratio (primary hyperaldosteronism), fasting
glucose, cholesterol, ECG, urine analysis, U&E, Ca
● Mx:
○ Try lifestyle changes 1st for 3 months - exercise, alcohol, Na intake, diet,
weight loss
○ 1st line - ACEi/ARB → perindopril; Ca channel blocker
(amlodipine)/thiazides (hydrochlorothiazide) - ACEi/ARB first used
■ ACEi/ARB can cause cough (ACEi only), angioedema, renal
insufficiency
● Contraindications: pregnancy - increased foetal renal damage
risk during 2nd/3rd trimester, angioedema, hyperkalaemia,
bilateral renal artery stenosis
■ Thiazide can cause hyponatraemia, gout
● Contraindications: gout; age - increased diabetes risk
→ only used in older patients when benefits of HTN Mx
outweighs diabetes risk
■ Ca channel blockers can cause peripheral oedema
● Possible contraindications: HF
○ 2nd line - beta blockers, spironolactone
■ Beta blockers contraindications: asthma, bradycardia, AV block,
uncontrolled HF
○ Refractory HTN: 3+ drugs on max doses and uncontrolled HTN →
review for other causes, non-adherence, alcohol, high salt intake →
specialist referral
○ Combinations to avoid: ACEi + ARB → renal dysfunction; verapamil
+ beta blocker → heart block
○ Combinations use with care: diltiazem + beta blockers → heart
block; ACEi + K sparing diuretics → hyperkalaemia
, ● Broader GP Mx:
○ Yearly monitoring required for well managed HTN: UEC, urinary
microalbumin, fasting BGL/HBA1C, lipid panel ECG
○ Home BP monitoring
○ Tx:
1. Start with low-moderate dose 1st line drug → not well
tolerated → switch drug class
2. Target not reached after 3 months → add 2nd drug from
different class - low-moderate dose
3. Target not reached increase dose of one drug incrementally to max
before increasing dose of other drug
4. Target not reached after max dose of both → start 3rd drug
class at low-moderate dose
5. Target not reached → seek specialist advice
○ Review regularly for adherence, adverse effects, target:
■ Every 2 yrs for low CVD risk
■ Every 6-12 months for 10-15% CVD risk
■ Review 6-12 weeks for >15% CVD risk
○ If patient not tolerate initial drug, change to drug from differnet class
ACUTE CORONARY SYNDROME, eg, unstable angina, NSTEMI, STEMI
● Symptoms: severe crushing chest pain exacerbated by exertion, radiates to
arms/neck/jaw, sweating, nausea, dyspnoea
● Risk factors: Fx IHD, smoking, HTN, hyperlipidaemia
● O/E: often normal
● Investigations: ECG asap, troponin
● Mx:
○ if symptoms precede 24hrs refer to ED immediately
○ Aspirin and GTN sublingual in meantime
● Broader GP Mx:
