Hypertension treatment:

a case study
Bill is a 48-year-old self-employed plumber who sees you occasionally for a recurrent cough
and upper respiratory tract infections. He:
has no significant past medical history
is taking no medicines
has no known allergies
is a regular smoker and has been since his teens
drinks a couple of stubbies a night and a bit more on the weekend .

You have recently introduced a policy in your practice of the practice nurse doing a set of
observations on a patient before the patient is called in to see the doctor.

Bill has come to see you for another cold that has gone to my chest . You note the nurse s
observations are:
temperature 37°C
Pulse rate 78, regular
blood pressure (BP) 148/94 mmHg
repeat BP 144/92 mmHg.

Does Bill have hypertension?

Bill may have hypertension, because his BP measurements are in the abnormal hypertension
range. However, the diagnosis of hypertension should be based on multiple BP
measurements taken on separate occasions.

Does Bill need BP-lowering medicine?

Before deciding whether or not to prescribe BP-lowering medicine, you need to confirm that
Bill has hypertension. To do this, Bill s BP should be measured on a subsequent visit,
preferably by the practice nurse to minimise the white coat effect.

If hypertension is confirmed from multiple BP measurements, Bill s medical history should be

recorded and he should be examined for, and investigations done to see if he has,
cardiovascular disease (CVD) or target organ damage.

In the absence of CVD or target organ damage, you should formally calculate Bill s absolute
risk score.

Regardless of whether Bill s absolute risk is low, medium or high, you should recommend
behavioural modification as the basis of his hypertension management (e.g. reduced alcohol
intake) and to reduce his risk of CVD (smoking cessation). However, if Bill s BP is still
> 140/90 mmHg, refer to the hypertension management algorithm (Figure 1 of Hypertension
treatment poster).

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What should be the first choice hypertension drug
treatment for Bill?
Assuming Bill s five-year absolute risk score is 15% or more on the Australian absolute risk
calculator, he should be prescribed medicine to reduce hypertension.

Choice of first line medicine is driven by relative and absolute indications or contraindications,
according to co-morbidity.

In Bill s case, you may consider the possibility that he has chronic obstructive pulmonary
disease (COPD) and avoid prescribing a beta-blocker. An appropriate medicine is a low-dose
ACE-inhibitor, Angiotensin II receptor blocker (ARB) or calcium channel blocker (CCB).

What BP should I aim to get Bill to?

Diagnostic and therapeutic BP goals vary according to a patient s risk status. This is because
the greater the risk, the greater the benefit of lowering BP and the greater the residual risk if
goals are not met.

According to Heart Foundation guidelines, Bill s target is < 140/90 mmHg or lower if tolerated.
If he had evident CVD, diabetes and/or significant renal disease, his target would be lower.

Want to know more?

For more information on how to manage hypertension, please see:
Guide to management of hypertension 2008 (Updated August 2009)
Quick reference guide for health professionals. Guide to management of hypertension 2008
(Updated August 2009)
Hypertension treatment wall chart
hypertension management slideshow.

For general information about hypertension and heart health, contact our Health Information
Service on 1300 36 27 87 (for the cost of a local call) or email health@heartfoundation.org.au.
You can also visit our website at www.heartfoundation.org.au.

The Heart Foundation would to thank the principle author of this case study, Professor Mark
Nelson, Chair, Discipline of General Practice; Professorial Research Fellow and Senior
Member, Menzies Research Institute, University of Tasmania.

© 2010 National Heart Foundation of Australia ABN 98 008 419 761

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