Cases/Cardiovascular Health

Blood Pressure Above 180/100 Despite Ramipril, Previous Reaction to Amlodipine — Free SCA Practice Case

Man with blood pressure above 180/100 despite ramipril, previous reaction to amlodipine

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Gareth Pryce

Age

53 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"My home monitor keeps reading really high — I've had it up at 184 over 102. I stopped the last tablet you gave me because my ankles blew up like balloons. I'm not sure what I'm meant to be doing."

Medical Records

●PMH: Hypertension (diagnosed 2 years ago). Otherwise well.
●Medications: Ramipril 10 mg OD. (Amlodipine 5 mg started 4 months ago, discontinued by patient after 3 weeks — free-text note: "stopped, marked ankle oedema.")
●Allergies: NKDA.
●Recent results (routine bloods 6 weeks ago): U&E normal (eGFR >90, K⁺ 4.3). HbA1c 38 mmol/mol. Total cholesterol 5.1. Urine ACR normal.
●Home BP readings brought to consult: Averaging around 178–184 / 98–104 over the past week.

Patient Script

For the friend playing the patient role

Character Overview: You are Gareth, a 53-year-old self-employed electrician. You are practical and a bit blunt, and you are frustrated because you feel you are "doing everything right" and the numbers still will not come down. You are not unwell in yourself. You are wary of tablets after the last one caused a problem. You want a straight answer about what to take and whether these numbers are dangerous.

Opening Sentence: "Right, Doc — my blood pressure's all over the place, keeps coming up around 180 over 100 on the machine at home. I stopped the amlodipine because my ankles swelled right up, couldn't get my boots on. So now I'm just on the ramipril and it's not doing the job."

History if Asked (Data Gathering Phase)

●The readings: "I've been checking most mornings and evenings with a proper arm cuff — my brother-in-law's a nurse, he showed me. It's consistently high, 178 to 184 on top, around 100 underneath. Been like that a good couple of weeks."
●The amlodipine reaction: "Within a couple of weeks of starting it my ankles and lower legs puffed right up. Not itchy, no rash — just swollen and heavy. I stopped it and after a week or so the swelling went. So I've been scared to try anything new since."
●Adherence to ramipril: "I take the ramipril every morning, ten milligrams, never miss it. Had it about two years."
●Symptoms now: "I feel fine, honestly. That's why I don't really get it. No headaches, no chest pain, my eyesight's normal."
●Lifestyle: "I could eat better, I'll admit. Bit of a takeaway habit. I have a few beers at the weekend. Work's physical so I'm on my feet all day, but I don't do proper exercise."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

●Ideas: Gareth thinks the ramipril simply "isn't strong enough" and that he needs the dose put up. He does not realise a second, different type of tablet is the usual next step. "I figured you'd just up the ramipril. Isn't that how it works — bump up the dose till it works?"
●Concerns: He is quietly worried that a number that high means he could have a stroke or heart attack, especially as his father had a stroke in his sixties. He is also anxious that whatever he takes next will cause the same swelling. "My dad had a stroke at sixty-odd. A hundred-and-eighty — that's stroke territory, isn't it? And I really don't want my legs swelling up again."
●Expectations: He wants his medication sorted so the numbers come down, and reassurance about whether this is an emergency. "I just want to get on top of it. And I need to know — is 180 something I should be panicking about right now?"

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●Hypertension: "Diagnosed about two years ago at a work medical. Started on ramipler — ramipril — and it was okay-ish at first."
●Other conditions: "Nothing else. No diabetes, no kidney problems that I know of."
●The amlodipine: "Five milligrams, once a day. Stopped it about three, four months ago after the swelling."
●Other tablets or supplements: "Nothing. No painkillers regularly, no herbal stuff."
●Family history: "Dad had a stroke in his sixties. Mum's got high blood pressure too."

Social History and Lifestyle Impact

Gareth is a self-employed electrician. He lives with his wife; two grown-up children have left home.

●Work: "Self-employed, so if I'm not working I'm not earning. On my feet all day, lots of driving between jobs."
●Diet and alcohol: "Too many takeaways, if I'm honest. Salt on everything. Four or five beers on a Friday and Saturday."
●Smoking: "Gave up about ten years ago. Was twenty a day before that."
●Exercise: "Nothing planned. Work keeps me moving but I don't go to a gym or anything."

If Asked — Associated Symptoms

The patient answers these only when directly asked.

●If asked about headache: "No, no headaches."
●If asked about visual disturbance (blurring, spots): "No, eyesight's fine."
●If asked about chest pain or breathlessness: "No chest pain. I get a bit puffed on stairs but nothing new."
●If asked about palpitations: "No, heart feels steady."
●If asked about ankle swelling now: "No, that all settled once I stopped the amlodipine."
●If asked about snoring or daytime sleepiness: "My wife says I snore like a train, and I do nod off in front of the telly. Never thought anything of it."
●If asked about NSAID or decongestant use: "No, I don't take ibuprofen or anything like that regularly."

Responses to Management (The Negotiation Phase)

●If the Doctor suggests adding a thiazide-like diuretic (e.g. indapamide): "A water tablet? Is that going to have me running to the loo all day when I'm out on jobs with no toilet? And will it swell my ankles like the last one?" (The tested point is whether the candidate can explain that indapamide is the appropriate step-2 add-on when a calcium-channel blocker is not tolerated, and address the practical concern.)
●If the Doctor suggests simply increasing the ramipril: "So just more of the same? My brother-in-law said one tablet often isn't enough — is that right?"
●If the Doctor explains the reading is not an immediate emergency: "So I don't need to go to A&E? How do you know it's safe to just sort it with tablets?"
●If the Doctor raises snoring / possible sleep apnoea: "What's my snoring got to do with my blood pressure?"
●If the Doctor raises lifestyle change: "I know, I know — less salt, less beer. But honestly, is that really going to shift a number that high?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Domain 2: Clinical Management and Medical Complexity

0 / 24 indicators checked+0−0

Positive (0/12)

Negative (0/12)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

The Stepwise Approach to Hypertension (NICE NG136)

●Step 1: For patients aged under 55 and not of Black African or African-Caribbean origin, an ACE inhibitor or ARB is first-line. For patients aged 55 or over, or of Black African/African-Caribbean origin of any age, a calcium-channel blocker (CCB) is first-line.
●Step 2: Add the complementary agent — typically ACE inhibitor/ARB plus CCB, or ACE inhibitor/ARB plus a thiazide-like diuretic.
●Step 3: Combine all three — ACE inhibitor/ARB plus CCB plus thiazide-like diuretic.
●Step 4 (resistant hypertension): Confirm adherence and true resistance, then add spironolactone if potassium is ≤4.5 mmol/L, or an alternative (e.g. alpha- or beta-blocker) if potassium is higher; seek specialist advice.
●This patient is on maximal step-1 ACE inhibitor and needs a second agent added, not a dose increase alone.

When the Calcium-Channel Blocker Cannot Be Used

●The usual step-2 add-on to an ACE inhibitor is a CCB, but where a CCB is not tolerated or is contraindicated, NG136 directs the use of a thiazide-like diuretic (e.g. indapamide 2.5 mg OD or chlortalidone) as the alternative second agent.
●Indapamide and chlortalidone (thiazide-like) are preferred over bendroflumethiazide (thiazide-type) for hypertension.
●Recognising this substitution is the core learning point: intolerance of one class does not mean abandoning the guideline — it means choosing the guideline's specified alternative.

Amlodipine-Induced Ankle Oedema — Effect, Not Allergy

●Peripheral (ankle) oedema is a common, dose-related effect of dihydropyridine CCBs such as amlodipine, caused by preferential arteriolar dilatation raising capillary pressure. It is not an allergic reaction and does not respond to diuretics well.
●Options if a CCB is otherwise needed include a lower dose or combining with an ACE inhibitor/ARB (which can offset the oedema) — but where a good alternative exists, as here, moving to a thiazide-like diuretic is reasonable.
●Correctly labelling this as a side effect rather than an allergy keeps future options open and avoids inappropriate class avoidance.

Distinguishing Severe Hypertension from a Hypertensive Emergency

●A clinic reading of ≥180/120 mmHg prompts assessment for target-organ damage. Same-day specialist assessment or admission is needed if there are signs of a hypertensive emergency: retinal haemorrhages or papilloedema, or life-threatening symptoms such as new chest pain, breathlessness (heart failure), or neurological features.
●In the absence of these features, severe hypertension is managed by prompt investigation for target-organ damage and rapid outpatient treatment optimisation — not emergency admission.
●Home/ambulatory readings averaging around 180/100 in an asymptomatic patient fall into this second category and are managed in primary care.

Confirming and Interpreting Home Blood-Pressure Readings

●Reliable home monitoring uses a validated upper-arm device, with readings taken twice daily (morning and evening) over several days, discarding the first day and averaging the rest.
●Home/ambulatory targets are lower than clinic targets: for people under 80, aim for below 135/85 on home/ambulatory monitoring (below 140/90 clinic).

Monitoring When Starting a Thiazide-Like Diuretic

●Check U&E and renal function before starting and after initiation/dose change: watch for hyponatraemia and hypokalaemia.
●Advise morning dosing to limit disruption from diuresis; the diuretic effect of low-dose indapamide is modest.
●Review response at follow-up and titrate the overall regimen towards target.

Resistant Hypertension and Secondary Causes

●Suspect a secondary or contributory cause when blood pressure is hard to control: obstructive sleep apnoea (snoring, witnessed apnoeas, daytime somnolence — relevant here), excess alcohol, high salt intake, NSAIDs, and endocrine causes (e.g. primary hyperaldosteronism).
●Screen for and address these alongside pharmacological escalation; refer for sleep assessment where OSA is suspected.

Lifestyle Measures That Genuinely Lower Blood Pressure

●Salt reduction, weight loss, reduced alcohol, regular aerobic activity, and increased fruit and vegetable intake each produce measurable reductions and are part of every management plan.
●Set realistic expectations: lifestyle change is valuable and additive but is unlikely to control a pressure of 180/100 alone — medication remains necessary.

Whole-Person Cardiovascular Risk

●Blood pressure is one component of cardiovascular risk. Review smoking status, lipids, glucose/HbA1c, family history, and renal function/ACR together, and address each — treating the number in isolation misses the point of the intervention.

Common Candidate Mistakes in This Case

●Just increasing the ramipril: the patient is already on 10 mg and needs a second agent added under the stepwise approach.
●Rechallenging with a CCB or mislabelling the reaction as allergy: failing to recognise that a thiazide-like diuretic is the correct guideline alternative when a CCB is not tolerated.
●Over-triaging to A&E: sending an asymptomatic patient with stable home readings to hospital, or conversely failing to know the threshold and symptoms that would require same-day assessment.
●Missing obstructive sleep apnoea: overlooking snoring and daytime somnolence as a treatable contributor to resistant hypertension.
●Ignoring the side-effect fear: prescribing the next tablet without addressing why he stopped the last one, undermining adherence.

Free MRCGP SCA practice case for GP registrars covering Blood Pressure Above 180/100 Despite Ramipril, Previous Reaction to Amlodipine — Cardiovascular Health. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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