ABFM KSA - Hypertension

Question 1

Question: 1 of 60

A 65-year-old male comes to your office for an initial visit. He has a 5-year history of type 2 diabetes mellitus treated with glipizide (Glucotrol), 10 mg/day. A physical examination is notable for a blood pressure of 142/92 mm Hg and nonproliferative diabetic retinopathy with scattered microaneurysms and cotton-wool spots. On laboratory evaluation he is found to have a hemoglobin A1c of 8.4%, a serum creatinine level of 1.3 mg/dL, and modest persistent albuminuria (30–299 mg/24 hr).

You consider prescribing an antihypertensive agent. Agents that have been shown to slow the progression of microalbuminuria (30–299 mg/24 hr) to macroalbuminuria (≥300 mg/24 hr) in this situation, independent of blood pressure reduction, include which of the following? (Mark all that are true.)

1. ACE inhibitors
2. Dihydropyridine calcium channel blockers
3. Angiotensin receptor blockers
4. Hydrochlorothiazide
5. β-Blockers

Answer 1

1. ACE inhibitors
2. Dihydropyridine calcium channel blockers
3. Angiotensin receptor blockers
4. Hydrochlorothiazide
5. β-Blockers

Critique:

Once macroalbuminuria develops in a patient with nephropathy due to type 2 diabetes mellitus, creatinine clearance declines an average of 10–12 mL/min/year in untreated patients. In patients with hypertension, type 2 diabetes, and microalbuminuria, both ACE inhibitors and angiotensin receptor blockers have been shown to delay the progression to macroalbuminuria, independent of a reduction in blood pressure.

Question 2

Question: 2 of 60

In a hypertensive patient with atrial fibrillation, which of the following antihypertensive agents will also help control the ventricular rate? (Mark all that are true.)

1. Metoprolol tartrate (Lopressor)
2. Verapamil (Calan)
3. Amlodipine (Norvasc)
4. Diltiazem (Cardizem)
5. Nifedipine (Adalat, Procardia)

Answer 2

1. Metoprolol tartrate (Lopressor)
2. Verapamil (Calan)
3. Amlodipine (Norvasc)
4. Diltiazem (Cardizem)
5. Nifedipine (Adalat, Procardia)

Critique:

Both β-blockers (e.g., metoprolol) and non-dihydropyridine calcium channel blockers (e.g., verapamil, diltiazem) slow sinus and AV node conduction and can aid in controlling the ventricular rate in patients with atrial fibrillation.

Amlodipine and nifedipine are dihydropyridine calcium channel blockers and do not have a significant effect on cardiac conduction.

Question 3

Question: 3 of 60

An 83-year-old male sees you for a health maintenance visit. He is a retired college professor and has not seen a physician for more than 10 years. He says that he has always been healthy, and his past medical history is notable only for a tonsillectomy when he was a child. His only medication is an occasional aspirin for headache.

The physical examination is unremarkable except for a blood pressure of 175/84 mm Hg and a hint of copper wiring noted on a funduscopic examination. An EKG shows a normal sinus rhythm with a rate of 84 beats/min and possible left atrial enlargement.

True statements regarding the treatment of hypertension in patients in this age group include which of the following? (Mark all that are true.)

1. It reduces the risk of mortality due to stroke
2. Studies have consistently shown that it reduces the risk of incident dementia and cognitive dysfunction
3. It reduces the risk of mortality due to heart failure
4. The JNC-8 panel recommends a target systolic blood pressure of <140 mm Hg
5. Initial therapy should consist of a thiazide diuretic followed by a β-blocker if needed

Answer 3

1. It reduces the risk of mortality due to stroke
2. Studies have consistently shown that it reduces the risk of incident dementia and cognitive dysfunction
3. It reduces the risk of mortality due to heart failure
4. The JNC-8 panel recommends a target systolic blood pressure of <140 mm Hg
5. Initial therapy should consist of a thiazide diuretic followed by a β-blocker if needed

Critique:

The Hypertension in the Very Elderly Trial (HYVET) was a landmark study that provided clear evidence that lowering blood pressure with antihypertensive medications is associated with definite cardiovascular benefits in patients 80 years of age or older. The study randomly assigned 3845 patients >80 years of age with stage 2 hypertension (i.e., sustained systolic blood pressure ≥160 mm Hg) to receive either indapamide or placebo, with an ACE inhibitor (perindopril) or matching placebo added if necessary to achieve the target blood pressure of 150/80 mm Hg. Antihypertensive therapy was associated with a reduction in the rate of death due to stroke and heart failure, as well as a reduction of rate of death from any cause. Compared to placebo, however, drug treatment has NOT consistently been associated with a lower incidence of dementia or cognitive dysfunction.

While JNC-7 recommended a goal blood pressure of 140/90 mm Hg or less for all patients, JNC 8 recommends a target systolic blood pressure of <150 mm Hg and a target diastolic blood pressure of <90 mm Hg for patients over age 60. In addition, the American College of Cardiology Foundation and the American Heart Association released an expert consensus paper in 2011 recommending that octogenarians with systolic pressures >150 mm Hg be regarded as candidates for antihypertensive drugs, with a target systolic blood pressure of 140–145 mm Hg if the medications are tolerated.

This recommendation is based on more current data, including the findings of the HYVET trial. This paper also recommended low-dose thiazide diuretics, calcium channel blockers, and ACE inhibitors or angiotensin receptor blockers as the preferred agents in this age group.

Although the 2017 ACC/AHA guidelines recommend a target systolic blood pressure of <130 mm Hg even in adults >65 years of age, caution is advised for patients in nursing homes and assisted living facilities, as well as in those with prevalent and frequent falls, advanced cognitive impairment, multiple comorbidities, or orthostatic hypotension.

Question 4

Question: 4 of 60

According to National Cholesterol Education Program guidelines, criteria for the diagnosis of metabolic syndrome include which of the following? (Mark all that are true.)

1. A waist circumference >40 inches in a male
2. An HDL-cholesterol level <50 mg/dL in women
3. An LDL-cholesterol level >160 mg/dL
4. Serum triglycerides ≥150 mg/dL
5. Blood pressure ≥130 mm Hg systolic and/or ≥85 mm Hg diastolic

Answer 4

1. A waist circumference >40 inches in a male
2. An HDL-cholesterol level <50 mg/dL in women
3. An LDL-cholesterol level >160 mg/dL
4. Serum triglycerides ≥150 mg/dL
5. Blood pressure ≥130 mm Hg systolic and/or ≥85 mm Hg diastolic

Critique:

Metabolic syndrome is a constellation of cardiovascular risk factors related to hypertension, abdominal obesity, dyslipidemia, and insulin resistance. According to the National Cholesterol Education Program (Adult Treatment Panel III Guidelines), diagnostic criteria for metabolic syndrome include the presence of three or more of the following: (1) obesity, with a waist circumference exceeding 102 cm (40 in) in men or 88 cm (35 in) in women; (2) blood pressure ≥130 mm Hg systolic and/or ≥85 mm Hg diastolic; (3) fasting glucose ≥110 mg/dL; (4) a serum triglyceride level ≥150 mg/dL; and (5) an HDL-cholesterol level <40 mg/dL in men or <50 mg/dL in women. LDL-cholesterol elevation is not one of the criteria for this syndrome.

Question 5

Question: 5 of 60

You see a 65-year-old African-American female for her annual physical examination. Her past medical history is notable for a 15-year history of hypertension and a 10-year history of type 2 diabetes mellitus.

To assess for possible end-organ effects of her hypertension and diabetes mellitus, you order an EKG, which is shown below. Abnormalities shown on the EKG include which of the following? (Mark all that are true.)

1. Left ventricular hypertrophy
2. Left bundle branch block
3. Anteroseptal infarct, age undetermined
4. Inferior infarct, age determined
5. Lateral wall infarct, age undetermined

Answer 5

1. Left ventricular hypertrophy
2. Left bundle branch block
3. Anteroseptal infarct, age undetermined
4. Inferior infarct, age determined
5. Lateral wall infarct, age undetermined

Critique:

The electrocardiogram demonstrates deep QS complexes and slight ST-segment elevation in leads V1–V3, consistent with an anteroseptal myocardial infarction of indeterminate age.

Additionally, the tracing demonstrates findings consistent with left ventricular hypertrophy as assessed using the Estes criteria scoring system. The tracing demonstrates ST forces in a direction opposite to the R wave in the lateral chest leads (3 points) and left axis deviation greater than –15° (2 points). The other Estes scoring criteria include

1. 3 points if the largest R or S wave in the limb leads is 20 mm or more, or if the largest S wave in V1, V2, or V3 is 25 mm or more;
2. 1 point if the QRS duration is 0.09 or more;
3. 1 point if the intrinsicoid deflection in V5–V6 is 0.04 sec or later;
4. 3 points if the p-terminal force in lead V1 is 0.04 mm/sec or more.

A score of 5 or more points indicates left ventricular hypertrophy, and a score of 4 points indicates probable left ventricular hypertrophy.

Additionally, the tracing meets the Cornell voltage criteria (RaVL+SV3 >28 mm in men, >20 mm in women).

Question 6

Question: 6 of 60

A 39-year-old white male sees you for evaluation of high blood pressure. His past medical history is unremarkable. Examination reveals an obese male with a round face and plethoric complexion. His blood pressure is 150/98 mm Hg, his pulse rate is 88 beats/min, and his respiratory rate is 16/min. Other notable findings include a prominent dorsal cervical fat pad and supraclavicular fat pads, as well as violaceous striae on his trunk. A laboratory evaluation is notable only for a fasting glucose level of 114 mg/dL.

What is the most likely cause of his hypertension?

1. Primary hyperaldosteronism
2. Pheochromocytoma
3. Hemochromatosis
4. Cushing’s syndrome
5. Addison’s disease

Answer 6

1. Primary hyperaldosteronism
2. Pheochromocytoma
3. Hemochromatosis
4. Cushing’s syndrome
5. Addison’s disease

Critique:

This patient’s clinical findings are consistent with Cushing’s syndrome, or hyperadrenalcorticalism. Cushing’s syndrome is a clinical syndrome and metabolic disorder resulting from chronic excess of glucocorticoids. The most common etiology is corticosteroid use, but adrenal neoplasms accounting for 20%–25% of cases. Findings include general weakness, osteoporosis, moon facies, facial plethora, ecchymoses, truncal obesity, violaceous striae of the abdomen, deposition of adipose tissue in the interscapular area (“buffalo hump”), and glucose intolerance.

Question 7

Question: 7 of 60

A 55-year-old male sees you for a follow-up visit for resistant hypertension. His blood pressure has remained elevated despite treatment with

1. hydrochlorothiazide, 25 mg/day;
2. lisinopril (Prinivil, Zestril), 40 mg twice daily; and
3. amlodipine (Norvasc), 7.5 mg/day.

His past medical history is notable for a history of chronic hypertension, impaired fasting glucose, and hypercholesterolemia. His only medication other than antihypertensive drugs is simvastatin (Zocor), 40 mg/day. He drinks 1 or 2 beers per day and does not smoke.

On examination his blood pressure is 155/95 mm Hg, his BMI is 29.5 kg/m2, and he has trace to 1+ ankle edema. Laboratory tests are unremarkable other than a serum aldosterone/plasma renin activity ratio of 31 ng/dL:ng/mL/hr.

Which one of the following interventions is most likely to be beneficial in this patient?

1. Candesartan (Atacand)
2. Diltiazem (Cardizem)
3. Spironolactone (Aldactone)
4. Abstinence from alcohol

Answer 7

1. Candesartan (Atacand)
2. Diltiazem (Cardizem)
3. Spironolactone (Aldactone)
4. Abstinence from alcohol

Critique:

Resistant hypertension is defined as blood pressure that remains above the target level despite treatment with a combination of three or more antihypertensive agents of different classes (one of which is usually a diuretic). The initial evaluation should assess the patient for drug-related hypertension, pseudoresistance due to inaccurate blood pressure measurement and the “white coat” effect, inadequate adherence to lifestyle measures (e.g., weight loss, sodium intake, excessive alcohol consumption), and nonadherence to the antihypertensive drug regimen.

The differential diagnosis of truly drug-resistant hypertension includes obstructive sleep apnea, primary hyperaldosteronism, pheochromocytoma, Cushing’s syndrome, chronic kidney disease, renal artery stenosis, and thyroid disease.

Recent studies indicate a significant antihypertensive effect when an aldosterone antagonist is added (i.e. K-STAE) in patients with uncontrolled hypertension despite a multidrug regimen. An elevated plasma aldosterone/plasma renin activity ratio supports the diagnosis of primary hyperaldosteronism, and indicates that the patient is likely to respond to a mineralocorticoid antagonist. There is insufficient evidence that using same-class combinations (if using maximal doses of either of the combined agents) provides significant additional antihypertensive benefit compared to monotherapy with different agents. Although heavy alcohol intake has been shown to increase blood pressure, moderate alcohol intake (no more than 1–2 drinks/day in men and 1 drink/day in women) has been associated with a reduction in blood pressure.

Question 8

Question: 8 of 60

A 47-year-old African-American female with a 5-year history of type 2 diabetes is diagnosed with hypertension. The physical examination is notable only for a blood pressure of 144/88 mm Hg. Laboratory findings include a hemoglobin A1c of 6.7%, a normal serum creatinine level, and the absence of albuminuria.

JNC 8 recommends which of the following drug classes as initial therapy for patients such as this? (Mark all that are true.)

1. ACE inhibitors
2. Angiotensin II antagonists
3. β-Blockers
4. Calcium channel blockers
5. Thiazide diuretics

Answer 8

1. ACE inhibitors
2. Angiotensin II antagonists
3. β-Blockers
4. Calcium channel blockers
5. Thiazide diuretics

Critique:

When used as monotherapy, thiazide diuretics and calcium channel blockers have been found to be more effective for reducing blood pressure in African-American patients than β-blockers, ACE inhibitors, or angiotensin receptor blockers.

The ALLHAT trial found thiazide diuretics to be more effective than ACE inhibitors for improving heart failure and cardiovascular outcomes in African-American patients. Calcium channel blockers have been found to be more effective than ACE inhibitors for reducing stroke in African-American patients.

JNC 8 recommends that for the general African-American population, including those with diabetes mellitus, initial antihypertensive treatment should include a thiazide diuretic or a calcium channel blocker (SOR B).

Question 9

Question: 9 of 60

An agent other than a thiazide diuretic should be considered for initial antihypertensive therapy in patients with which of the following? (Mark all that are true.)

1. Recurrent calcium kidney stones
2. Diabetes mellitus
3. Bipolar disorder treated with lithium
4. Chronic renal insufficiency, with a serum creatinine level of 2.6 mg/dL
5. A past history of stroke

Answer 9

1. Recurrent calcium kidney stones
2. Diabetes mellitus
3. Bipolar disorder treated with lithium
4. Chronic renal insufficiency, with a serum creatinine level of 2.6 mg/dL
5. A past history of stroke

Critique:

Thiazide diuretics are ineffective in patients with renal insufficiency. In addition, by their enhancement of renal tubular resorption of lithium, diuretics can raise serum lithium levels and increase the risk for toxicity.

Thiazide-type diuretics have been shown to improve clinical outcomes in patients with diabetes mellitus, as well as following a stroke.

In addition, by reducing urine calcium excretion, thiazide-type diuretics have been shown to significantly reduce recurrence rates of calcium stones by up to 50% over a 3-year period.

Question 10

Question: 10 of 60

According to JNC-8, pharmacologic therapy is indicated for which of the following patients? (Mark all that are true.)

1. A 61-year-old Asian male with a blood pressure of 150/72 mm Hg
2. A 73-year-old African-American male with a blood pressure of 148/88 mm Hg
3. A 58-year-old Hispanic female with type 2 diabetes and a blood pressure of 136/86 mm Hg
4. A 69-year-old white female with type 2 diabetes and a blood pressure of 142/82 mm Hg
5. A 40-year-old white male with chronic kidney disease and a blood pressure of 136/84 mm Hg
6. A 65-year-old African-American male with chronic kidney disease and a blood pressure of 148/84 mm Hg

Answer 10

1. A 61-year-old Asian male with a blood pressure of 150/72 mm Hg
2. A 73-year-old African-American male with a blood pressure of 148/88 mm Hg
3. A 58-year-old Hispanic female with type 2 diabetes and a blood pressure of 136/86 mm Hg
4. A 69-year-old white female with type 2 diabetes and a blood pressure of 142/82 mm Hg
5. A 40-year-old white male with chronic kidney disease and a blood pressure of 136/84 mm Hg
6. A 65-year-old African-American male with chronic kidney disease and a blood pressure of 148/84 mm Hg

Critique:

JNC 8 recommends the initiation of pharmacologic therapy for hypertension in the following groups of patients:

• Young (<60yo): >140/90 mmHg
• Old (>60yo): >150/90 mmHg
• Sick (CKD, DM): same as old

Question 11

Question: 11 of 60

A patient with bipolar disorder that is well controlled by lithium is diagnosed with essential hypertension. Which of the following antihypertensive agents should be avoided because they can raise serum lithium levels? (Mark all that are true.)

1. Hydrochlorothiazide
2. Propranolol
3. Clonidine (Catapres)
4. Ramipril (Altace)
5. Doxazosin (Cardura)

Answer 11

1. Hydrochlorothiazide
2. Propranolol
3. Clonidine (Catapres)
4. Ramipril (Altace)
5. Doxazosin (Cardura)

Critique:

Diuretic-induced sodium loss can reduce the renal clearance of lithium, thereby increasing serum lithium levels and the risk of lithium toxicity. There is also evidence that ACE inhibitors can substantially increase steady-state plasma lithium levels and sometimes result in lithium toxicity. In a population-based, nested, case-control study, a 7.6-fold increased risk for lithium toxicity was seen within 1 month of starting an ACE inhibitor.

Question 12

Question: 12 of 60

True statements regarding home blood pressure monitoring include which of the following? (Mark all that are true.)

1. It can foster patient adherence
2. It may be useful for assessing white coat hypertension
3. Wrist blood pressure devices are as accurate as arm-cuff devices
4. Home blood pressure devices should be regularly checked against the family physician’s office blood pressure unit
5. Ambulatory blood pressure monitoring has a stronger association with cardiovascular disease outcomes than clinical blood pressure measurement

Answer 12

1. It can foster patient adherence
2. It may be useful for assessing white coat hypertension
3. Wrist blood pressure devices are as accurate as arm-cuff devices
4. Home blood pressure devices should be regularly checked against the family physician’s office blood pressure unit
5. Ambulatory blood pressure monitoring has a stronger association with cardiovascular disease outcomes than clinical blood pressure measurement

Critique:

In addition to being a useful tool for improving patient compliance with recommended therapy, home blood pressure monitoring also provides information about the possibility of white coat hypertension.

The technique requires a properly calibrated device, and patients should be encouraged to bring in their home units on a regular basis so they can be checked against the physician’s office unit.

Only properly sized arm-cuff devices should be used, since wrist and finger blood pressure devices are not as accurate.

Both ambulatory blood pressure monitoring and home blood pressure monitoring have a stronger association with cardiovascular disease outcomes than blood pressure measurement in a clinical setting.

Question 13

Question: 13 of 60

A 65-year-old African-American male is diagnosed with hypertension. He has a history of coronary heart disease and heart failure, with a left ventricular ejection fraction of 38% (HRrEF).

Which of the following blood pressure medications should be AVOIDED? (Mark all that are true.)

1. Diltiazem (Cardizem)
2. Clonidine (Catapres)
3. Metoprolol succinate (Toprol-XL)
4. Doxazosin (Cardura)
5. Hydralazine

Answer 13

1. Diltiazem (Cardizem)
2. Clonidine (Catapres)
3. Metoprolol succinate (Toprol-XL)
4. Doxazosin (Cardura)
5. Hydralazine

Critique:

Certain classes of drugs should be avoided in patients with ischemic systolic heart failure with hypertension.

1. Nondihydropyridine calcium channel blockers should not be prescribed because of their negative inotropic properties and the increased likelihood of exacerbating heart failure symptoms.
2. Since clonidine falls in the same class of agents as moxonidine, which has been associated with increased mortality in patients with heart failure, both of these drugs should be avoided as well.
3. In the ALLHAT trial, doxazosin was associated with a doubled risk of developing heart failure compared to chlorthalidone; α-blockers should therefore be used with caution in patients with heart failure.

Drugs that have been shown to improve outcomes and lower blood pressure include β-blockers, diuretics, ACE inhibitors, angiotensin receptor blockers, and aldosterone receptor antagonists. The combination of hydralazine and nitrates has been shown to confer benefit in African-American patients with advanced heart failure.

Question 14

Question: 14 of 60

An obese 14-year-old female is diagnosed with stage 1 hypertension. Her previous medical history and family history are unremarkable. A physical examination is notable only for a blood pressure of 134/84 mm Hg.

Which of the following studies should be routinely obtained in this situation? (Mark all that are true.)

1. A urinalysis
2. A fasting lipid profile
3. Serum creatinine
4. Hemoglobin A1c
5. An echocardiogram
6. Renal ultrasonography

Answer 14

1. A urinalysis
2. A fasting lipid profile
3. Serum creatinine
4. Hemoglobin A1c
5. An echocardiogram (if cardiac target organ damage)
6. Renal ultrasonography (patients <6 years of age with hypertension)

Critique:

For children >13 years of age, the American Academy of Pediatrics (AAP) defines stage 1 hypertension as a blood pressure of 130/80–139/89 mm Hg and stage 2 hypertension as a blood pressure ≥140/90 mm Hg.

The AAP recommends that all pediatric patients with hypertension be evaluated with a urinalysis, a chemistry panel (including electrolytes, BUN, and creatinine), and a lipid profile.

Renal ultrasonography is recommended for patients <6 years of age with hypertension, as well as those with abnormal findings on a urinalysis or renal function studies.

For adolescents and obese pediatric patients with hypertension, recommended tests also include hemoglobin A_1c, aspartate transaminase (AST) and alanine transaminase (ALT), and a fasting lipid panel.

Echocardiography is recommended to assess for cardiac target organ damage if pharmacologic treatment of hypertension is being considered. An extensive evaluation for secondary causes of hypertension is not recommended for children older than 6 years if they have a family history of hypertension, or if they are overweight or obese, and the history and physical examination do not suggest a secondary cause for their hypertension.

Question 15

Question: 15 of 60

True statements regarding the effect of aerobic exercise on blood pressure include which of the following? (Mark all that are true.)

1. Aerobic exercise reduces blood pressure in both hypertensive and normotensive patients
2. Aerobic exercise has been shown to lower systolic blood pressure by 4–9 mm Hg
3. Aerobic exercise has been shown to reduce insulin resistance in hypertensive patients
4. The beneficial impact of aerobic exercise on blood pressure is dependent on weight loss
5. Sedentary individuals have a 30%–50% higher risk of developing hypertension compared to those who exercise regularly

Answer 15

1. Aerobic exercise reduces blood pressure in both hypertensive and normotensive patients
2. Aerobic exercise has been shown to lower systolic blood pressure by 4–9 mm Hg
3. Aerobic exercise has been shown to reduce insulin resistance in hypertensive patients
4. The beneficial impact of aerobic exercise on blood pressure is dependent on weight loss
5. Sedentary individuals have a 30%–50% higher risk of developing hypertension compared to those who exercise regularly

Critique:

Engaging in regular aerobic exercise is associated with a reduction in systolic blood pressure of 4–9 mm Hg. Aerobic exercise has been found to reduce blood pressure in both hypertensive and normotensive individuals, and has been shown to reduce insulin resistance in hypertensive patients.

The beneficial impact of exercise on blood pressure is not dependent on weight loss. Sedentary individuals have been found to have a 30%–50% higher risk of developing hypertension compared to those who exercise regularly.

Question 16

Question: 16 of 60

A 62-year-old homeless male has a long history of hypertension treated with clonidine (Catapres), 0.6 mg twice a day. You see him at the clinic at the homeless shelter, and he tells you that he ran out of his medication 2 days ago. He reports no complaints other than feeling “sort of on edge.” A physical examination is notable only for a blood pressure of 170/105 mm Hg.

Which of the following classes of antihypertensive agents can increase the severity of his rebound hypertension? (Mark all that are true.)

1. Thiazide diuretics
2. ACE inhibitors
3. Angiotensin II antagonists
4. β-Blockers
5. Long-acting dihydropyridine calcium channel blockers

Answer 16

1. Thiazide diuretics
2. ACE inhibitors
3. Angiotensin II antagonists
4. β-Blockers
5. Long-acting dihydropyridine calcium channel blockers

Critique:

The sudden cessation of clonidine, a centrally-acting α₂-agonist, can result in an abrupt rise in hypertension as a result of a rebound phenomenon causing sympathetic overactivity.

In this state of increased levels of catecholamines, β-blockers will neutralize the vasodilatory effects of peripheral vascular β-receptors. This effectively leaves the vasoconstrictor α-receptors unopposed and can result in a further rise in blood pressure.

Question 17

Question: 17 of 60

A 75-year-old male with a history of hypertension sees you for a follow-up visit. His current medications are

1. lisinopril (Prinivil, Zestril), 40 mg daily, and
2. chlorthalidone, 25 mg daily.

His blood pressure is 136/84 mm Hg. You tell him this level is acceptable and he comments that he read on the internet that the SPRINT study recommended his blood pressure be lower.

Which one of the following statements would be an accurate explanation of the SPRINT trial findings?

1. Lowering blood pressure to a target of <120/80 mm Hg was beneficial only in patients with type 2 diabetes
2. Lowering blood pressure to a target of <120/80 mm Hg was beneficial in patients with type 2 diabetes, as well as patients who did not have diabetes
3. The SPRINT trial was limited to patients determined to be at high cardiovascular risk
4. Intensive blood pressure lowering was associated with an absolute cardiovascular risk reduction of 15%
5. The number of patients who benefited from intensive blood pressure therapy exceeded those who suffered significant adverse events

Answer 17

1. Lowering blood pressure to a target of <120/80 mm Hg was beneficial only in patients with type 2 diabetes
2. Lowering blood pressure to a target of <120/80 mm Hg was beneficial in patients with type 2 diabetes, as well as patients who did not have diabetes
3. The SPRINT trial was limited to patients determined to be at high cardiovascular risk
4. Intensive blood pressure lowering was associated with an absolute cardiovascular risk reduction of 15%
5. The number of patients who benefited from intensive blood pressure therapy exceeded those who suffered significant adverse events

Critique:

The Systolic Blood Pressure Intervention Trial (SPRINT) included 9361 adults age 50 or older who were at high hisk for cardiovascular disease but did not have a previous history of diabetes mellitus or stroke. Subjects were randomly assigned to either intensive lowering of systolic blood pressure (SBP) to 120 mm Hg, or to a lower goal systolic pressure of 140 mm Hg. High cardiovascular risk was defined as one of the following: clinical or subclinical cardiovascular disease other than stroke; chronic kidney disease (eGFR 20–59 ml/min/1.73 m², excluding those with polycystic kidney disease), a 10-year risk of cardiovascular disease of 15% or greater on the basis of the Framingham risk score, or an age of 75 years or older.

After a median follow-up of 3.26 years, a 25% relative risk reduction in primary composite outcome (myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes) was demonstrated in the intensive SBP-lowering treatment group (1.65% per year vs. 2.19% per year; hazard ratio with intensive treatment, 0.75; 95% confidence interval [CI], 0.64 to 0.89; P<0.001). The corresponding absolute risk reduction was only 1.6 % (primary composite outcome was seen in 5.2% of intensive treatment group versus 6.8% in the standard therapy group) resulting in a number needed to treat (NNT) of 61. Rates of serious adverse events of hypotension, syncope, electrolyte abnormalities, and acute kidney injury or failure were higher in the intensive-treatment group than in the standard-treatment group. A total of 220 participants in the intensive-treatment group (4.7%) and 118 participants in the standard treatment group (2.5%) had serious adverse events that were classified as possibly or definitely related to the intervention, which corresponds to an absolute risk increase in adverse events of 2.2% in the intensive-therapy group. Thus, the number needed to harm (NNH) in the SPRINT trial was 45.

Although 2017 ACC/AHA hypertension guidelines recommending a target SBP of <130 mm Hg for adults >65 years of age is supported by the findings of the SPRINT trial, it is important to note that a 2017 clinical practice guideline jointly developed by the American College of Physicians and the American Academy of Family Physicians recommends an SBP treatment threshold of 150 mm Hg in adults aged 60 years or older, and that a target SBP of <140 mm Hg be a consideration in older adults who either have a history of cerebrovascular disease or who have a high cardiovascular risk. Regardless of the guideline followed, decisions regarding treatment and specific blood pressure targets should reflect shared decision-making between clinicians and patients, with due consideration of the potential benefits and harms.

Question 18

Question: 18 of 60

A 22-year-old secretary is referred to you for evaluation of high blood pressure. Her past medical history is unremarkable and she is on no prescriptions or over-the-counter medications. Her review of systems reveals only a chronic history of mild fatigue and episodic muscle cramping. Her physical examination is normal except for a blood pressure of 156/100 mm Hg in both arms without significant orthostatic changes.

Laboratory Findings

CBC…………normal
Urinalysis…………normal
Serum sodium………...145 mEq/L (N 135–145)
Serum potassium…………2.9 mEq/L (N 3.5–5.0)
Serum chloride…………100 mEq/L (N 100–108)
Serum bicarbonate…………25 mEq/L (N 22–26)
Serum creatinine…………0.7 mg/dL (N 0.6–1.5)
BUN…………10 mg/dL (N 8–25)
Serum glucose…………90 mg/dL

What is the most likely cause of her hypertension?

1. Addison’s disease
2. Bartter’s syndrome
3. Chronic licorice ingestion
4. Renovascular hypertension
5. Primary hyperaldosteronism

Answer 18

1. Addison’s disease
2. Bartter’s syndrome
3. Chronic licorice ingestion
4. Renovascular hypertension
5. Primary hyperaldosteronism (CONN’s SYNDROME)

Critique:

Primary hyperaldosteronism, also known as Conn’s syndrome, is associated with hypersecretion of aldosterone, a mineralocorticoid.

It is twice as common in women as in men, and usually occurs between 30 and 50 years of age. It is present in approximately 1% of unselected hypertensive patients. Symptoms are largely related to the associated hypertension, hypokalemia, or alkalosis, and include headaches, polyuria, polydipsia, muscle weakness and fatigue, and intermittent paresthesias.

Question 19

Question: 19 of 60

A 47-year-old male is seen in the emergency department after awakening with an abrupt onset of severe chest pain, described as an intense burning sensation radiating to the interscapular area. A physical examination reveals a blood pressure of 220/150 mm Hg in the right arm and 190/130 mm Hg in the left arm, and a grade I/VI early diastolic decrescendo murmur heard best in the third intercostal space along the left sternal border.

What is the most likely diagnosis?

1. Dissection of the aorta
2. Coarctation of the aorta
3. Subclavian steal syndrome
4. Deep-vein thrombosis of the upper extremity
5. Myocardial infarction

Answer 19

1. Dissection of the aorta
2. Coarctation of the aorta
3. Subclavian steal syndrome
4. Deep-vein thrombosis of the upper extremity
5. Myocardial infarction

Critique:

Dissection of the aorta is a hypertensive emergency that begins as a tear in the intima of the artery, often in the aortic arch just above the aortic valve, or more distally in the ascending or proximal descending portion. Clinical features of aortic dissection include the occurrence of severe chest and/or upper back pain with or without radiation to the arms or upper abdomen. Other possible findings include the presence of aortic regurgitation, palpable differences in pulsation between the two carotid arteries, and differences in the blood pressure between the two arms.

Question 20

Question: 20 of 60

A 52-year-old male who is an avid golfer and tennis player is diagnosed with stage 1 hypertension. His past medical history is unremarkable except for a history of mild hypercholesterolemia treated with diet. His EKG is shown below.

Given the EKG findings, which of the following drugs would be safe to use in this patient? (Mark all that are true.)

1. Dihydropyridine calcium channel blockers
2. Nondihydropyridine calcium channel blockers
3. β-Blockers
4. Central α2-agonists

Answer 20

1. Dihydropyridine calcium channel blockers
2. Nondihydropyridine calcium channel blockers
3. β-Blockers
4. Central α2-agonists

Critique:

The presence of first degree atrioventricular block, as shown in the EKG, does not contraindicate the use of any of these options.

However, β-blockers and nondihydropyridine calcium channel blockers should not be used in patients with heart block greater than first degree.

Question 21

Question: 21 of 60

A 62-year-old male has had consistently elevated blood pressure at three consecutive visits. His past medical history is notable only for a history of a single episode of gout 9 months ago. He does not take any medications. A physical examination is normal except for a blood pressure of 145/92 mm Hg. Laboratory findings are within the normal range except for a serum uric acid level of 8.9 mg/dL (N 4.5–8.0).

Which one of the following antihypertensive agents would also help to prevent future gout attacks by reducing the patient’s uric acid levels?

1. Furosemide (Lasix)
2. Hydrochlorothiazide
3. Lisinopril (Prinivil, Zestril)
4. Losartan (Cozaar)
5. Metoprolol succinate (Toprol-XL)

Answer 21

1. Furosemide (Lasix)
2. Hydrochlorothiazide
3. Lisinopril (Prinivil, Zestril)
4. Losartan (Cozaar)
5. Metoprolol succinate (Toprol-XL)

Critique:

Losartan is the only angiotensin receptor blocker that has consistently been shown to lower serum uric acid levels, and there is evidence that it reduces the risk for incidents of gout as well.

Calcium channel blockers also appear to have urate-lowering properties and may also reduce the risk of gout.

Thiazide diuretics, loop diuretics, and β-blockers have all been shown to raise uric acid levels. Furthermore, a higher risk for incident gout has been reported for patients treated with diuretics, β-blockers, ACE inhibitors, and angiotensin II receptors other than losartan.

Question 22

Question: 22 of 60

Conditions associated with isolated systolic hypertension include which of the following? (Mark all that are true.)

1. Hypothyroidism
2. Anemia
3. Aortic insufficiency
4. Paget’s disease
5. Severe osteoporosis

Answer 22

1. Hypothyroidism
2. Anemia
3. Aortic insufficiency
4. Paget’s disease
5. Severe osteoporosis

Critique:

Isolated elevation of systolic blood pressure can be secondary to conditions associated with elevated cardiac output. Such conditions include

• anemia,
• Paget’s disease,
• hyperthyroidism,
• arteriovenous fistula, and
• aortic insufficiency.

Question 23

Question: 23 of 60

A 59-year-old African-American male with a history of hypercholesterolemia and gout sees you for an annual visit. The physical examination is notable only for a blood pressure of 144/85 mm Hg.

Laboratory Findings

Serum triglycerides…………134 mg/dL
LDL-cholesterol…………82 mg/dL
HDL-cholesterol…………47 mg/dL
Liver panel…………normal
Serum creatinine…………1.7 mg/dL
Estimated glomerular filtration rate…………56 mL/min/1.73 m2

According to JNC 8, which one of the following would be recommended as initial management of this patient’s blood pressure elevation?

1. Losartan (Cozaar)
2. A calcium channel blocker
3. Hydralazine
4. Hydrochlorothiazide
5. No drug treatment

Answer 23

1. Losartan (Cozaar)
2. A calcium channel blocker
3. Hydralazine
4. Hydrochlorothiazide
5. No drug treatment

Critique:

JNC 8 recommends the initiation of pharmacologic treatment to lower blood pressure in patients ≥18 years of age with a systolic blood pressure ≥140 mm Hg or a diastolic blood pressure ≥ 90 mm Hg if they have chronic kidney disease (defined as an estimated or measured glomerular filtration rate <60 mL/min/1.73 m2).

Treatment is recommended for patients of any age with these blood pressure values who have albuminuria (defined as >30 mg of albumin/g of creatinine at any level of GFR) (SOR C).

Although a thiazide diuretic or a calcium channel blocker is recommended as first-line antihypertensive therapy in the general African-American population, in patients ≥18 years of age who have chronic kidney disease, JNC 8 recommends initial (or add-on) antihypertensive treatment with an ACE inhibitor or angiotensin receptor blocker (ARB) to improve kidney outcomes, regardless of ethnicity or diabetes status (SOR B).

Losartan has been shown to consistently lower serum uric acid, which is not true of other ARBs, which may actually increase gout attacks. ACE inhibitors increase uric acid levels and the likelihood of gout attacks.

Question 24

Question: 24 of 60

A 68-year-old white male is diagnosed with uncomplicated hypertension, with blood pressures consistently in the range of 140–145/90–94 mm Hg. Based on the current evidence, which one of the following agents would be LEAST preferred as first-line therapy?

1. A thiazide diuretic
2. A β-blocker
3. A dihydropyridine calcium channel blocker
4. An ACE inhibitor
5. An angiotensin receptor blocker

Answer 24

1. A thiazide diuretic
2. A β-blocker (least potency)
3. A dihydropyridine calcium channel blocker
4. An ACE inhibitor
5. An angiotensin receptor blocker

Critique:

The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) found that β-blockers were less effective than thiazide diuretics, and the Losartan Intevention for Endpoint Reduction Trial (LIFE) found β-blockers to be less effective than an angiotensin receptor blocker.

Based on this and similar evidence, the British Hypertension Society and the National Institute for Health and Clinical Excellence in the United Kingdom modified their guidelines to remove β-blockers as first-line therapy for uncomplicated hypertension.

In addition, the members of the JNC 8 panel recommend that for the general nonblack population, including those with diabetes mellitus, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker, ACE inhibitor, or angiotensin receptor blocker.

Question 25

Question: 25 of 60

Which one of the following statements is NOT true regarding prehypertension?

1. It was first defined by JNC-7 as a systolic blood pressure of 120–139 mm Hg or a diastolic blood pressure of 80–89 mm Hg
2. A systolic blood pressure of 130–139 mm Hg or a diastolic blood pressure of 80–89 mm Hg is classified as stage 1 hypertension by the 2017 ACC/AHA guidelines
3. It is associated with an increased risk of cardiovascular disease
4. Lifestyle modification is recommended for all patients with prehypertension
5. The 2017 ACC/AHA guidelines recommend drug therapy for all patients with an average blood pressure >130 mm Hg systolic or >80 mm Hg diastolic despite a trial of lifestyle modification

Answer 25

1. It was first defined by JNC-7 as a systolic blood pressure of 120–139 mm Hg or a diastolic blood pressure of 80–89 mm Hg
2. A systolic blood pressure of 130–139 mm Hg or a diastolic blood pressure of 80–89 mm Hg is classified as stage 1 hypertension by the 2017 ACC/AHA guidelines
3. It is associated with an increased risk of cardiovascular disease
4. Lifestyle modification is recommended for all patients with prehypertension
5. The 2017 ACC/AHA guidelines recommend drug therapy for all patients with an average blood pressure >130 mm Hg systolic or >80 mm Hg diastolic despite a trial of lifestyle modification

Critique:

JNC-7 introduced a new blood pressure category called prehypertension, largely due to new data on the lifetime risk of hypertension and evidence that the risk of death from ischemic heart disease and stroke rises progressively and linearly from what have been regarded as “normal” blood pressure values. Prehypertension is defined as a systolic blood pressure (SBP) of 120–139 mm Hg and/or a diastolic blood pressure (DBP) of 80–89 mm Hg. Although the cardiovascular risk for patients with prehypertension is higher than that of patients with lower blood pressures, JNC-7 recommended that prehypertension should not be viewed as a disease category but as a designation for identifying individuals at high risk of developing hypertension.

The 2017 ACC/AHA hypertension guidelines do not include prehypertension as a blood pressure category. Instead, an SBP of 120–129 mm Hg and a DBP <80 mm Hg is classified as elevated blood pressure. An SBP of 130–139 mm Hg or a DBP of 80–89 mm Hg is classified as stage 1 hypertension, and an SBP >140 mm Hg or a DBP > 90 mm Hg is classified as stage 2 hypertension.

Although JNC-7 did not recommend antihypertensive drug therapy for patients who continued to have prehypertension despite a trial of lifestyle modification, the 2017 ACC/AHA guidelines recommend drug therapy for primary prevention in adults with an average SBP ≥130 mm Hg or an average DBP >80 mm Hg if they have an estimated 10-year atherosclerotic cardiovascular disease risk ≥10%.

Question 26

Question: 26 of 60

Antihypertensive agents recommended for initiating drug therapy for hypertension during pregnancy include which of the following? (Mark all that are true.)

1. α-Methyldopa
2. Atenolol (Tenormin)
3. Labetalol (Trandate)
4. Thiazide diuretics

Answer 26

1. α-Methyldopa
2. Atenolol (Tenormin) - intrauterine growth retardation
3. Labetalol (Trandate)
4. Thiazide diuretics - not first line

Critique:

Antihypertensive therapy during pregnancy should be prescribed only for maternal safety, since it does not improve perinatal outcomes and may adversely affect uteroplacental blood flow.

Although α-methyldopa is generally regarded as a first-line agent on the basis of available studies, labetalol is also acceptable.

Atenolol has been associated with intrauterine growth retardation, as well as decreased placental growth and weight when prescribed during pregnancy. Although regarded in JNC-7 as probably safe, thiazide diuretics are not recommended as first-line therapy.

Question 27

Question: 27 of 60

A 19-year-old male college student sees you for follow-up of an emergency department (ED) visit. He says he was told that his symptoms were due to a panic attack. His past medical history is notable only for migraine headaches.

On the day of his ED visit he was started on propranolol for the headaches. The initial physical examination in the ED was notable for a blood pressure of 198/114 Hg supine, dropping to 150/98 mm Hg on standing, and a heart rate of 112 beats/min. He reports that his symptoms improved after a couple hours in the ED and the record from the visit notes that his blood pressure was 140/90 mm Hg at the time of discharge.

In your office the patient says that he has always been an anxious person but has never experienced a similar attack in the past. He notes that his blood pressure has always been on the “high side” and his blood pressure in your office today is 144/86 mm Hg.

Which one of the following is the most likely cause of his blood pressure elevations?

1. Primary hyperaldosteronism
2. Hyperthyroidism
3. Pheochromocytoma
4. Carcinoid syndrome
5. Panic disorder

Answer 27

1. Primary hyperaldosteronism
2. Hyperthyroidism
3. Pheochromocytoma
4. Carcinoid syndrome
5. Panic disorder

Critique:

Pheochromocytomas are catecholamine-producing neuroendocrine tumors, and the majority arise from the adrenal medulla. They are a rare but important secondary cause of hypertension, whether sustained or paroxysmal. Paroxysmal hypertension with sweating, headaches, and palpitations is the usual presentation of pheochromocytoma. Other clinical clues to its presence include unexplained tachycardia, weight loss, episodic diaphoresis, unexplained orthostatic hypotension on a background of paroxysmal or refractory hypertension, and feelings of anxiety or panic attacks. β-adrenergic blockers have been implicated in precipitating adverse reactions in patients with pheochromocytoma. The mechanism for β-blocker-associated adverse events is generally ascribed to inhibition of β₂-adrenoceptor-mediated vasodilation, leaving adrenoceptor-mediated vasoconstriction unopposed. If a hypertensive crisis occurs in a patient on β-blockers, the presence of a pheochromocytoma should be suspected. Furthermore, the Hypertension Canada 2017 guidelines recommend that the possibility of pheochromocytoma be considered in patients with hypertension triggered by β-blockers as well by monoamine oxidase inhibitors, micturition, changes in abdominal pressure, surgery, or anesthesia.

Question 28

Question: 28 of 60

Some interventions recommended for the primary prevention of hypertension have also been shown to significantly lower blood pressure in patients who have hypertension. These include which of the following? (Mark all that are true.)

1. Relaxation therapies
2. Regular aerobic exercise
3. Fish oil supplements
4. Calcium supplementation
5. Acupuncture

Answer 28

1. Relaxation therapies
2. Regular aerobic exercise
3. Fish oil supplements
4. Calcium supplementation
5. Acupuncture

Critique:

Physical inactivity is associated with a 30%–50% greater risk for developing hypertension. Conversely, regular aerobic exercise has been associated with a 4- to 9-mm Hg reduction in systolic blood pressure and a 2- to 3-mm Hg reduction in diastolic blood pressure.

Although adequate calcium intake, fish oil supplements, and reduced caffeine intake may be important for general health, the effect of these lifestyle modifications on blood pressure is too small to support recommending them for the primary prevention of hypertension. The American Heart Association has determined that there is currently insufficient evidence to recommend relaxation therapies or acupuncture to reduce blood pressure.

Question 29

Question: 29 of 60

Hyperkalemia is a potential side effect of which of the following? (Mark all that are true.)

1. Enalapril (Vasotec)
2. Amiloride
3. Felodipine (Plendil)
4. Atenolol (Tenormin)
5. Losartan (Cozaar)

Answer 29

1. Enalapril (Vasotec)
2. Amiloride
3. Felodipine (Plendil)
4. Atenolol (Tenormin)
5. Losartan (Cozaar)

Critique:

By inhibiting the action of aldosterone at the distal half of the convoluted renal tubule and the cortical production of the collecting duct, amiloride blocks the exchange between sodium and both potassium and hydrogen, and thus predisposes the patient to potassium retention (K-STAE).

By virtue of their actions on the angiotensin-renin-aldosterone system, ACE inhibitors (e.g., enalapril) and angiotensin receptor blockers (e.g., losartan) impair aldosterone release and also increase the risk for developing hyperkalemia.

Question 30

Question: 30 of 60

Which of the following antidepressant agents can increase the risk of hypotension by potentiating the action of agents with α1-blocking activity, such as prazosin, terazosin, doxazosin, and labetalol? (Mark all that are true.)

1. Fluoxetine (Prozac)
2. Amitriptyline
3. Nefazodone
4. Bupropion (Wellbutrin)
5. Amoxapine

Answer 30

1. Fluoxetine (Prozac)
2. Amitriptyline
3. Nefazodone
4. Bupropion (Wellbutrin)
5. Amoxapine

Critique:

By blocking α1-adrenergic receptors, amitriptyline, nefazodone, and amoxapine can potentiate the effects of agents that reduce blood pressure by α-blockade. Such agents include not only the α1-blockers (i.e., prazosin, terazosin, doxazosin) but also agents that block both α1- and β-receptors, such as labetalol and carvedilol.

Question 31

Question: 31 of 60

Which of the following classes of antihypertensive agents have been shown to produce a regression of left ventricular hypertrophy? (Mark all that are true.)

1. ACE inhibitors
2. Direct vasodilators
3. β-Blockers
4. Calcium channel blockers
5. Thiazide diuretics

Answer 31

1. ACE inhibitors
2. Direct vasodilators
3. β-Blockers
4. Calcium channel blockers
5. Thiazide diuretics

Critique:

In patients with left ventricular hypertrophy, studies have shown a reduction in left ventricular mass in those treated with

1. ACE inhibitors,
2. diuretics,
3. calcium antagonists, and
4. β-blockers,

with the most consistent reduction achieved with ACE inhibitors and the least with β-blockers. Regression of left ventricular hypertrophy has not been demonstrated with direct vasodilators such as hydralazine and minoxidil.

Question 32

Question: 32 of 60

Antidepressant agents associated with a dose-dependent rise in blood pressure include which of the following? (Mark all that are true.)

1. Venlafaxine
2. Nefazodone
3. Mirtazapine (Remeron)
4. Fluoxetine (Prozac)
5. Fluvoxamine

Answer 32

1. Venlafaxine
2. Nefazodone
3. Mirtazapine (Remeron)
4. Fluoxetine (Prozac)
5. Fluvoxamine

Critique:

Venlafaxine is associated with a dose-dependent elevation of blood pressure. Compared to patients taking placebo, those taking venlafaxine at a dosage less than 100 mg/day have a 1% increase in hypertension, and those taking more than 300 mg/day have an 11% increase in hypertension.

Question 33

Question: 33 of 60

Interventions shown to be beneficial in the management of hypertension include which of the following? (Mark all that are true.)

1. Weight loss
2. Dietary sodium restriction
3. Adequate dietary intake of potassium
4. Elimination of caffeine intake
5. Elimination of alcohol intake

Answer 33

1. Weight loss
2. Dietary sodium restriction
3. Adequate dietary intake of potassium
4. Elimination of caffeine intake
5. Elimination of alcohol intake

Critique:

Weight reduction and dietary sodium reduction have been associated with a reduction in systolic blood pressure of 5 to 20 mm Hg and 2 to 8 mm Hg, respectively.

1. Clinical trials and meta-analyses suggest that potassium supplementation may lower blood pressure; a diet rich in potassium and calcium is recommended in JNC-7.

Although there is no evidence that long-term use of coffee is associated with increased blood pressure, the 2017 ACC/AHA hypertension guidelines recommend that caffeine intake be limited to <300 mg daily. Limited consumption of alcohol (2 drinks/day in men and 1 drink/day in women) may lower systolic blood pressure by 2–4 mm Hg.

Question 34

Question: 34 of 60

Appropriate diagnostic tests for suspected renovascular hypertension include which of the following? (Mark all that are true.)

1. Duplex Doppler flow studies of the renal arteries
2. Rapid sequence intravenous pyelography
3. CT angiography of the renal artery
4. Captopril renography
5. Magnetic resonance renal angiography

Answer 34

1. Duplex Doppler flow studies of the renal arteries
2. Rapid sequence intravenous pyelography
3. CT angiography of the renal artery
4. Captopril renography
5. Magnetic resonance renal angiography

Critique:

In the hypertensive patient with suspected renovascular hypertension, appropriate diagnostic tests include duplex Doppler flow studies, CT angiography, and magnetic resonance angiography (MRA). Although it was a standard screening test for renovascular hypertension in the past, intravenous pyelography is no longer favored because of a false-positive rate of 11% and a false-negative rate of 12%. The diagnostic accuracy of captopril renography is felt to be inferior to MRA and duplex Doppler flow studies, particularly in patients with chronic kidney disease and bilateral atherosclerotic renal artery stenosis.

Question 35

Question: 35 of 60

Which of the following antihypertensive agents has NOT been shown to lower the plasma aldosterone-renin ratio?

1. Aliskiren (Tekturna)
2. Amlodipine (Norvasc)
3. Hydrochlorothiazide
4. Lisinopril (Prinivil, Zestril)
5. Losartan (Cozaar)

Answer 35

1. Aliskiren (Tekturna)
2. Amlodipine (Norvasc)
3. Hydrochlorothiazide
4. Lisinopril (Prinivil, Zestril)
5. Losartan (Cozaar)

Critique:

Primary aldosteronism is a major secondary cause of hypertension that occurs in 5%–10% of patients with hypertension and up to 20% of patients with resistant hypertension. The recommended screening test is calculation of the aldosterone:renin activity ratio (ARR), with the plasma aldosterone concentration reported in ng/dL and plasma renin activity in ng/mL/hr. Although there is no established threshold for an abnormal result, a commonly used cutoff is an ARR > 30, provided the plasma aldosterone is >10-15 ng/dL. Patients should have unrestricted salt intake and serum potassium in the normal range. Medications that can elevate the ARR include β-blockers, central α₂-agonists, direct renin inhibitors, and NSAIDs.

Medications that can lower the aldosterone:renin activity ratio include

1. potassium-sparing diuretics (K-STAE): spironolactone, eplerenone,
2. potassium-wasting diuretics (thiazides)
3. ACE inhibitors,
4. angiotensin II receptor blockers, and
5. dihydropyridine calcium channel blockers;

antihypertensive medications with minimal effect on the ARR include

• verapamil,
• hydralazine,
• prazosin,
• doxazosin, and
• terazosin.

Mineralocorticoid receptor antagonists have a particularly pronounced effect, and the American Heart Association recommends that agents such as spironolactone or eplerenone be withdrawn for at least 4 weeks before testing.

Question 36

Question: 36 of 60

You make a diagnosis of hypertension in a 69-year-old white female. Her past medical history is notable for osteoporosis and calcium oxalate kidney stones.

Which one of the following would be most appropriate for managing this patient’s hypertension?

1. An ACE inhibitor
2. An α1-blocker
3. A β-blocker
4. A calcium channel blocker
5. A thiazide-type diuretic

Answer 36

1. An ACE inhibitor
2. An α1-blocker
3. A β-blocker
4. A calcium channel blocker
5. A thiazide-type diuretic

Critique:

In the general nonblack population, including those with diabetes mellitus, JNC 8 recommends that initial antihypertensive treatment should include a

• thiazide-type diuretic, a
• calcium channel blocker, an
• ACE inhibitor, or an
• angiotensin receptor blocker.

Thiazide diuretics preserve hip and spine bone mineral density in older patients, and patients with hypertension and osteoporosis thus derive additional benefits from these agents. Thiazide diuretics also reduce renal excretion of calcium, providing added value in hypertensive patients with calcium oxalate stones.

Question 37

Question: 37 of 60

True statements regarding lowering blood pressure in patients with a hypertensive emergency include which of the following? (Mark all that are true.)

1. Blood pressure should be lowered by no more than 25% within the first hour
2. Blood pressure should generally be lowered to 160/100 mm Hg within 2–6 hours
3. Reduction of blood pressure has been shown to be beneficial in patients with acute ischemic stroke
4. Sedation with a benzodiazepine is an important component of treatment in hypertensive emergency related to cocaine abuse
5. The preferred antihypertensive agents are those with a rapid onset and short duration

Answer 37

1. Blood pressure should be lowered by no more than 25% within the first hour
2. Blood pressure should generally be lowered to 160/100 mm Hg within 2–6 hours
3. Reduction of blood pressure has been shown to be beneficial in patients with acute ischemic stroke
4. Sedation with a benzodiazepine is an important component of treatment in hypertensive emergency related to cocaine abuse
5. The preferred antihypertensive agents are those with a rapid onset and short duration

Critique:

In patients presenting with a hypertensive emergency, the goal is to lower mean arterial blood pressure by no more than 25% within minutes to 1 hour.

If the patient remains stable, the goal is to further reduce the blood pressure to 160/100–110 mmHg within the next 2–6 hours.

To achieve this, antihypertensive agents with a rapid onset and short duration are preferred.

In patients with an ischemic stroke, there is no clear evidence from clinical trials to support the use of immediate antihypertensive treatment.

Sedation with a benzodiazepine is considered important in the treatment of hypertensive emergencies related to cocaine abuse, since benzodiazepines not only reduce heart rate and systemic arterial pressure, but also attenuate cocaine’s toxic effects on the heart and the nervous system.

Question 38

Question: 38 of 60

A 68-year-old hypertensive male with a serum creatinine level of 2.2 mg/dL (N 0.6–1.5) is found to have a blood pressure of 152/96 mm Hg despite being placed on benazepril (Lotensin), 40 mg daily. Which of the following diuretic agents can be used to lower his blood pressure further? (Mark all that are true.)

1. Chlorthalidone
2. Hydrochlorothiazide
3. Metolazone (Zaroxolyn)
4. Furosemide (Lasix)
5. Bumetanide

Answer 38

1. Chlorthalidone
2. Hydrochlorothiazide
3. Metolazone (Zaroxolyn) - Only Thiazide to work in ESRD
4. Furosemide (Lasix) - LOOP DIURETIC
5. Bumetanide - LOOP DIURETIC

Critique:

Inadequate diuretic therapy is common in resistant hypertension. Volume overload, if present, can be managed by the use of appropriate diuretics.

Thiazide diuretics, which include chlorthalidone, hydrochlorothiazide, and metolazone, work by interfering with renal sodium absorption in the early distal tubule. Although this class of agents is routinely used in the majority of hypertensive patients, only metolazone retains its diuretic properties despite the presence of renal impairment.

Loop diuretics, which include furosemide, torsemide, bumetanide, and ethacrynic acid, work by interfering with sodium absorption at the loop of Henle and continue to be effective in patients with renal impairment.

Question 39

Question: 39 of 60

Following a myocardial infarction, which of the following antihypertensive agents have specifically been shown to improve cardiovascular outcomes? (Mark all that are true.)

1. Thiazide diuretics
2. β-Blockers
3. ACE inhibitors
4. Non-dihydropyridine calcium channel blockers
5. Long-acting dihydropyridine calcium channel blockers

Answer 39

1. Thiazide diuretics
2. β-Blockers
3. ACE inhibitors
4. Non-dihydropyridine calcium channel blockers
5. Long-acting dihydropyridine calcium channel blockers

Critique:

Outcome data from clinical trials supports the use of β-blockers and ACE inhibitors or angiotensin receptor blockers in stable patients following an ST-elevation myocardial infarction (STEMI). In addition, aldosterone receptor antagonists may be useful in patients with concomitant left ventricular dysfunction and heart failure. Calcium channel blockers do not reduce mortality rates in this setting and can increase mortality rates in patients with impaired left ventricular function. Although thiazide diuretics have been shown to effectively lower blood pressure and reduce overall cardiovascular risk, they have not been shown to be of particular value following a myocardial infarction.

Question 40

Question: 40 of 60

The Dietary Approaches to Stop Hypertension (DASH) diet includes which of the following? (Mark all that are true.)

1. An emphasis on fruits and vegetables
2. A low intake of low-fat dairy products
3. Restricted intake of nuts and whole grains
4. Substitution of fish and poultry for red meat
5. Limited intake of fats and sweets

Answer 40

1. An emphasis on fruits and vegetables
2. A low intake of low-fat dairy products
3. Restricted intake of nuts and whole grains
4. Substitution of fish and poultry for red meat
5. Limited intake of fats and sweets

Critique:

Compared to a control diet with a high sodium level, the low-sodium Dietary Approaches to Stop Hypertension (DASH) diet was found to lower mean systolic blood pressure 7.1 mm Hg in participants without hypertension and 11.5 mm Hg in participants with hypertension.

The DASH diet emphasizes fruits, vegetables, and low-fat dairy foods; it includes whole grains, poultry, fish, and nuts, and contains smaller amounts of red meats, sweets, and sugar-containing beverages than the typical American diet.

It also provides smaller amounts of total and saturated fat and cholesterol and larger amounts of potassium, dietary fiber, and protein.

Question 41

Question: 41 of 60

A 55-year-old female with a history of hypertension and type 2 diabetes sees you for follow-up. Despite taking hydrochlorothiazide, 50 mg/day, and lisinopril (Prinivil, Zestril), 40 mg/day, her blood pressure is 148/96 mm Hg.

She states that she continues to watch her diet closely, goes for a brisk walk for at least 30 minutes 6 times a week, and never forgets to take her blood pressure medication. Laboratory findings are notable only for a serum creatinine level of 0.7 mg/dL (estimated glomerular filtration rate 86 mL/min/1.73 m2) and persistent microalbuminuria (45 mg of albumin/g of creatinine in urine).

According to JNC 8, which one of the following would be most appropriate to add at this time?

1. Amlodipine (Norvasc), 2.5 mg/day
2. Clonidine (Catapres), 0.1 mg/day
3. Metoprolol succinate extended-release (Toprol-XL), 50 mg/day
4. Spironolactone (Aldactone), 25 mg/day
5. Valsartan (Diovan), 80 mg/day

Answer 41

1. Amlodipine (Norvasc), 2.5 mg/day
2. Clonidine (Catapres), 0.1 mg/day
3. Metoprolol succinate extended-release (Toprol-XL), 50 mg/day
4. Spironolactone (Aldactone), 25 mg/day
5. Valsartan (Diovan), 80 mg/day

Critique:

The primary objective of hypertension treatment is the attainment and maintenance of the goal blood pressure. According to data from the National Health and Nutrition Evaluation Survey (NHANES) from 2007–2010, 81.5% of those with hypertension are aware that they have it and 74.9% are being treated, but only 52.5% are under control. JNC 8 provides evidence-based guidelines for improving the pharmacologic management of hypertension, recommending that clinicians rely primarily on agents from the four drug classes which have been shown to have the most beneficial effect on overall mortality and cardiovascular, cerebrovascular, and kidney outcomes in patients with hypertension: thiazide-type diuretics, calcium channel blockers, ACE inhibitors (ACEIs), and angiotensin receptor blockers (ARBs).

Based on expert opinion, JNC 8 recommends one of three strategies for using these agents to achieving blood pressure goals in the newly diagnosed patient:

• Strategy A: Start one drug, titrate to the maximum dosage, and then add a second drug
• Strategy B: Start one drug and then add a second drug before reaching the maximum dosage of the initial drug
• Strategy C: Begin with two drugs at the same time, either as separate pills or as a single-pill combination (particularly when SBP is >160 mm Hg and/or DBP is >100 mm Hg, or if SBP is >20 mm Hg above goal and/or DBP is >10 mm Hg above goal)

If the goal blood pressure is not achieved with two drugs, JNC 8 recommends selecting a third drug from the list but avoiding the combined use of an ACEI and an ARB. JNC 8 recommends the addition of antihypertensive drugs from other classes only when the goal blood pressure cannot be achieved using the triple-therapy strategy, or when there is a contraindication to the use of these agents (SOR C).

Question 42

Question: 42 of 60

A 68-year-old male sees you for the first time. His past medical history is notable for a history of hypertension, type 2 diabetes mellitus, and an inferior myocardial infarction 5 years ago. His current medications are

1. hydrochlorothiazide, 12.5 mg once daily;
2. enalapril (Vasotec), 20 mg once daily;
3. metformin (Glucophage), 500 mg twice daily;
4. atorvastatin (Lipitor), 40 mg daily; and
5. aspirin, 81 mg daily.

A physical examination is notable only for a blood pressure of 148/86 mm Hg. A lipid profile reveals an LDL-cholesterol level of 75 mg/dL, an HDL-cholesterol level of 48 mg/dL, and a serum triglyceride level of 165 mg/dL.

Which one of the following would be most appropriate?

1. Continuation of his current therapy with no changes
2. Increasing the hydrochlorothiazide dosage to 25 mg once daily
3. Increasing the enalapril dosage to 40 mg once daily
4. Increasing the aspirin dosage to 325 mg/day
5. Starting metoprolol tartrate (Lopressor), 50 mg/day

Answer 42

1. Continuation of his current therapy with no changes
2. Increasing the hydrochlorothiazide dosage to 25 mg once daily
3. Increasing the enalapril dosage to 40 mg once daily
4. Increasing the aspirin dosage to 325 mg/day
5. Starting metoprolol tartrate (Lopressor), 50 mg/day

Critique:

Although the optimal target blood pressure for patients with coronary heart disease has yet to be determined by clinical trials, a strong log-linear association between blood pressure and cardiovascular risk is known to exist. In light of this, in 2015 the American Heart Association recommended a target blood pressure of <140/90 mm Hg for the secondary prevention of cardiovascular events in patients with hypertension and coronary artery disease (CAD) (class IIa recommendation; grade B level of evidence) and stated that a target blood pressure of <130/80 mm Hg may be appropriate in some individuals with CAD or CAD risk equivalents (carotid artery disease, peripheral artery disease, abdominal aortic aneurysm) as well as those with a history of previous myocardial infarction, stroke or transient ischemic attack.

Although a target systolic blood pressure of <120 mm Hg in patients at high risk for cardiovascular disease is supported by the SPRINT trial, it should be noted that patients with diabetes mellitus were excluded from the study.

Clinical trials provide strong support for a role for thiazide diuretics and ACE inhibitors in reducing cardiovascular risk in diabetic patients with hypertension.

If CAD also exists (particularly a prior history of myocardial infarction), the use of a β-blocker for secondary prevention is clearly indicated.

Aspirin, 81–162 mg/day, is recommended indefinitely for patients with a previous history of myocardial infarction.

Question 43

Question: 43 of 60

A 37-year-old female with a BMI of 30 kg/m2 is found to have a blood pressure of 154/100 mm Hg. She admits to using a nonprescription agent recommended to her by friends to improve her energy and help her lose weight.

Which of the following herbal agents should be considered as potential causes of her hypertension? (Mark all that are true.)

1. Ephedra
2. Ma huang
3. Evening primrose oil
4. Natural licorice
5. Ginkgo biloba

Answer 43

1. Ephedra
2. Ma huang
3. Evening primrose oil
4. Natural licorice
5. Ginkgo biloba

Critique:

When evaluating patients with elevated blood pressure, it is important to ask about use of both prescription and nonprescription medications. Over-the-counter dietary supplements and medicines, such as ephedra, ma huang, and bitter orange, have been associated with the development of hypertension. Consumption of certain foods such as natural licorice and tyramine-containing foods can also increase blood pressure.

Question 44

Question: 44 of 60

A 24-year-old male comes to the emergency department with chest pain an hour after using cocaine. A physical examination is notable for a blood pressure of 190/110 mm Hg and tachycardia. His EKG reveals sinus tachycardia with a rate of 116 beats/min and nonspecific ST- and T-wave changes.

Which of the following agents should be AVOIDED? (Mark all that are true.)

1. Nitroglycerin
2. Metoprolol tartrate (Lopressor)
3. Short-acting nifedipine (Procardia)
4. Labetalol (Trandate)
5. Lorazepam (Ativan)

Answer 44

1. Nitroglycerin
2. Metoprolol tartrate (Lopressor)
3. Short-acting nifedipine (Procardia)
4. Labetalol (Trandate)
5. Lorazepam (Ativan)

Critique:

In patients with cocaine-induced chest pain and hypertension, initial management with an intravenous benzodiazepine can relieve chest pain and produce beneficial cardiac hemodynamic effects. In addition, by reducing the central stimulatory effects of cocaine, benzodiazepines also reduce anxiety, which often leads to resolution of the hypertension and tachycardia. When sedation is not successful, recommended antihypertensive agents include nitroglycerin, phentolamine, and nitroprusside.

By blocking only β-receptors, resulting in an unopposed α-adrenergic effect, β-blockers can exacerbate vasoconstriction and should therefore be avoided. Although labetalol is both an α- and β-blocker, because it blocks β-receptors substantially more it is thought to offer no advantages over a β-blocker.

Calcium channel blockers may worsen mortality rates, and short-acting nifedipine should never be used in this situation.

Question 45

Question: 45 of 60

Currently accepted criteria define hypertension in children as a blood pressure at or above a threshold of which percentile when adjusted for age, sex, and height?

1. 80th
2. 85th
3. 90th
4. 95th
5. 99th

Answer 45

1. 80th
2. 85th
3. 90th
4. 95th
5. 99th

Critique:

In children and adolescents, hypertension is defined as blood pressure at or above the 95th percentile for age, sex, and height, on repeated measurements.

Question 46

Question: 46 of 60

Which one of the following antihypertensive agents has NOT been shown to be of benefit in a hypertensive patient with diabetes mellitus?

1. Thiazide diuretics
2. Angiotensin II receptor blockers
3. α-Blockers
4. Calcium channel blockers
5. β-Blockers

Answer 46

1. Thiazide diuretics
2. Angiotensin II receptor blockers
3. α-Blockers
4. Calcium channel blockers
5. β-Blockers

Critique:

Thiazide diuretics, angiotensin II receptor blockers, and ACE inhibitors are reasonable first-line treatments for patients with type 2 diabetes mellitus. These have been shown to prevent adverse clinical outcomes (i.e., all-cause mortality, major cardiovascular events, cardiovascular mortality, and advanced microvascular problems, including retinopathy, nephropathy, and neuropathy).

To a lesser degree, β-blockers and calcium channel blockers have also been shown to have proven efficacy compared to placebo.

Although helpful in achieving desired blood pressure control, α-blockers have not been shown to reduce microvascular or macrovascular problems in patients with diabetes.

Question 47

Question: 47 of 60

An 81-year-old male sees you for a routine visit. His past medical history is notable only for an episode of pneumonia several years ago. He is overweight, but his physical examination is otherwise remarkable only for a blood pressure of 190/78 mm Hg.

True statements regarding his blood pressure include which of the following? (Mark all that are true.)

1. Treatment of isolated systolic hypertension has been shown to reduce the risk of stroke and coronary heart disease
2. Systolic blood pressure is more important than diastolic pressure as a predictor of ischemic heart disease risk in patients over 60 years of age
3. Combination therapy with two or more drugs will likely be required to control his hypertension
4. His target systolic blood pressure is <160 mm Hg
5. Attempts to lower his systolic blood pressure should cease if his diastolic blood pressure falls below 65 mm Hg

Answer 47

1. Treatment of isolated systolic hypertension has been shown to reduce the risk of stroke and coronary heart disease
2. Systolic blood pressure is more important than diastolic pressure as a predictor of ischemic heart disease risk in patients over 60 years of age
3. Combination therapy with two or more drugs will likely be required to control his hypertension
4. His target systolic blood pressure is <160 mm Hg (should be >150)
5. Attempts to lower his systolic blood pressure should cease if his diastolic blood pressure falls below 65 mm Hg

Critique:

Isolated systolic hypertension (ISH) is the predominant form of hypertension after age 50.

• Before age 50, diastolic blood pressure is the major predictor of ischemic heart disease, whereas
• systolic blood pressure is more important after age 60.

Treatment of ISH has been shown to reduce the risk of stroke, coronary heart disease, and heart failure. Weight loss and reduced salt intake are thought to be particularly beneficial in lowering blood pressure in older people. A systolic blood pressure ≥160 mm Hg is classified as stage 2 hypertension, and combination therapy with two or more drugs will likely be required.

Although the 2017 ACC/AHA guidelines still generally favor a target systolic blood pressure of <130 mm Hg in noninstitutionalized ambulatory adults >65 years of age, JNC 8 guidelines recommend a target systolic blood pressure of <150 mm Hg in patients ≥60 years of age (SOR A) and <140 mm Hg in patients <60 years of age (SOR C).

The 2011 American Heart Association consensus document on hypertension in the elderly recommends that efforts to lower systolic blood pressure to the target level in elderly patients should cease if the diastolic blood pressure is reduced to a potentially dangerous level of <65 mm Hg.

Question 48

Question: 48 of 60

Which one of the following is the most common cause of secondary hypertension in the preadolescent child?

1. Renovascular hypertension
2. Renal parenchymal disease
3. Coarctation of the aorta
4. Congenital adrenal hyperplasia

Answer 48

1. Renovascular hypertension
2. Renal parenchymal disease
3. Coarctation of the aorta
4. Congenital adrenal hyperplasia

Critique:

In the preadolescent child, renal parenchymal disease is the most common secondary cause of elevated blood pressure.

Less common causes include renovascular hypertension, and coarctation of the aorta, as well as endocrine causes.

Question 49

Question: 49 of 60

A 58-year-old male with hypertension and type 2 diabetes mellitus has a baseline serum creatinine level of 1.7 mg/dL. His blood pressure is 147/92 mm Hg at this visit, and he is started on benazepril (Lotensin).

Two weeks later he is found to have a blood pressure of 128/80 mm Hg with a serum creatinine level of 2.1 mg/dL. A repeat serum creatinine level 1 week later is unchanged.

Which one of the following is the most appropriate course of action?

1. Continue the benazepril at the same dosage
2. Reduce the benazepril dosage
3. Discontinue benazepril
4. Recommend increased sodium intake
5. Evaluate the patient for bilateral renal artery stenosis

Answer 49

1. Continue the benazepril at the same dosage
2. Reduce the benazepril dosage
3. Discontinue benazepril
4. Recommend increased sodium intake
5. Evaluate the patient for bilateral renal artery stenosis

Critique:

An initial decline in renal function is not uncommon in the hypertensive patient whose blood pressure is brought under control. This decline is generally thought to be functional and associated with long-term renal protection. In the patient who experiences good blood pressure control with antihypertensive therapy, stabilization of serum creatinine levels after an initial 20%–30% percent rise indicates that the intraglomerular pressure has been successfully reduced.

Question 50

Question: 50 of 60

Which one of the following antihypertensive agents used to treat chronic hypertension during pregnancy should be changed immediately if superimposed preeclampsia develops?

1. Labetalol (Trandate)
2. α-Methyldopa
3. Hydrochlorothiazide
4. Nifedipine (Adalat, Procardia)
5. Metoprolol tartrate (Lopressor)

Answer 50

1. Labetalol (Trandate)
2. α-Methyldopa
3. Hydrochlorothiazide
4. Nifedipine (Adalat, Procardia)
5. Metoprolol tartrate (Lopressor)

Question 51

Question: 51 of 60

A 67-year-old male with a history of hypertension and type 2 diabetes has inadequately controlled blood pressure. His current medications are

1. lisinopril (Prinivil, Zestril), 40 mg daily;
2. hydrochlorothiazide, 25 mg daily; and
3. extended-release metformin (Gludophage XR), 1500 mg daily.

Laboratory testing reveals a hemoglobin A1C of 6.8%, normal serum electrolytes, a serum creatinine level of 1.0 mg/dL (N 0.6–1.5), and a urinary albumin-to-creatinine ratio of 80 mg/g (N <30).

Which one of the following agents should be AVOIDED in this patient?

1. Aliskiren (Tekturna)
2. Diltiazem (Cardizem)
3. Atenolol (Tenormin)
4. Felodopine (Plendil)
5. Doxazosin (Cardura)

Answer 51

1. Aliskiren (Tekturna)
2. Diltiazem (Cardizem)
3. Atenolol (Tenormin)
4. Felodopine (Plendil)
5. Doxazosin (Cardura)

Critique:

The ALTITUDE study was a randomized, double-blind, placebo-controlled international multicenter trial undertaken to determine whether the addition of the direct renin inhibitor aliskiren to standard therapy with renin–angiotensin system blockade would be beneficial for patients with type 2 diabetes who are at high risk for cardiovascular and renal events. The study was terminated prematurely after a median follow-up of 27 months when no benefit was apparent and a higher risk of hyperkalemia and hypotension was seen in patients receiving aliskiren. Based on this study, the FDA issued a drug safety warning in 2012 which announced two additions to the drug labeling of aliskiren-containing products. The first addition was a contraindication to the use of aliskiren in patients with diabetes mellitus who are taking angiotensin-receptor blockers (ARBs) or ACE inhibitors (ACEIs), because of an increased risk of renal impairment, hypotension, and hyperkalemia. The second addition was a warning to avoid the use of aliskiren with ARBs or ACEIs in patients with moderate to severe renal impairment (glomerular filtration rate < 60 mL/min).

The use of ACEIs, ARBs, β-blockers, diuretics, and calcium channel blockers has been shown to be effective in reducing cardiovascular events in patients with diabetes mellitus. Although no such benefit has been seen with doxazosin, there is no contraindication to its use in patients with diabetes.

Question 52

Question: 52 of 60

A 58-year-old male with COPD is diagnosed with stage 1 hypertension. His blood pressure is 158/100 mm Hg, and his EKG is shown below.

Which one of the following should be AVOIDED in this patient?

1. Enalapril (Vasotec)
2. Valsartan (Diovan)
3. Verapamil (Calan)
4. Amlodipine (Norvasc)
5. Clonidine (Catapres)

Answer 52

1. Enalapril (Vasotec)
2. Valsartan (Diovan)
3. Verapamil (Calan) - also avoid BB
4. Amlodipine (Norvasc)
5. Clonidine (Catapres)

Critique:

Both β-blockers such as metoprolol and nondihydropyridine calcium channel blockers such as verapamil and diltiazem slow sinus and AV node conduction.

Consequently, these agents should not be used in patients who have heart block greater than first degree. Since the EKG demonstrates bifascicular heart block, verapamil should be avoided, as its use would increase the risk for development of complete heart block.

Amlodipine is a dihydropyridine calcium channel blocker and thus can be safely used in patients with bifascicular block.

Question 53

Question: 53 of 60

Which one of the following is the most sensitive laboratory test for detecting pheochromocytoma?

1. A plasma metanephrine level
2. A plasma catecholamine level
3. 24-hour urine for catecholamines
4. 24-hour urine for metanephrines
5. 24-hour urine for vanillylmandelic acid

Answer 53

1. A plasma metanephrine level
2. A plasma catecholamine level
3. 24-hour urine for catecholamines
4. 24-hour urine for metanephrines
5. 24-hour urine for vanillylmandelic acid

Critique:

Recent findings demonstrate a high sensitivity of plasma levels of metanephrines for pheochromocytoma, possibly as high as 99%.

Reported sensitivities for plasma catecholamine (85%), urine catecholamine (83%), urine metanephrine (76%), and urine vanillylmandelic acid (63%).

Question 54

Question: 54 of 60

A 38-year-old Asian male with a chronic history of nocturia sees you for a 2-day history of gross hematuria. His past medical history is unremarkable. His father is on hemodialysis for an unknown kidney problem and he believes his brother has kidney problems as well. A physical examination reveals a blood pressure of 150/102 mm Hg. His serum creatinine level is 2.4 mg/dL.

Which one of the following is the most likely diagnosis?

1. Chronic glomerulonephritis
2. Medullary sponge kidney
3. Polycystic kidney disease
4. Chronic pyelonephritis
5. Membranous nephropathy

Answer 54

1. Chronic glomerulonephritis
2. Medullary sponge kidney
3. Polycystic kidney disease
4. Chronic pyelonephritis
5. Membranous nephropathy

Critique:

Autosomal polycystic kidney disease has a prevalence of 1:300 to 1:1000 and accounts for approximately 10% of end-stage renal disease in the United States. Significant findings include renal pain, enlarged kidneys, nocturia, gross and microscopic hematuria, elevated serum creatinine, and low urine specific gravity. The disease can present at any age, but most frequently causes symptoms in the third or fourth decade of life.

Question 55

Question: 55 of 60

Appropriate agents for the management of a hypertensive emergency associated with an acute coronary syndrome include which of the following? (Mark all that are true.)

1. Intravenous nicardipine (Cardene)
2. Intravenous esmolol (Brevibloc)
3. Intravenous enalaprilat
4. Intravenous nitroglycerin
5. Sublingual nifedipine (Adalat, Procardia)

Answer 55

1. Intravenous nicardipine (Cardene)
2. Intravenous esmolol (Brevibloc)
3. Intravenous enalaprilat
4. Intravenous nitroglycerin
5. Sublingual nifedipine (Adalat, Procardia)

Critique:

Short-acting nifedipine is no longer considered appropriate in the initial treatment of hypertensive emergencies or urgencies because of its association with excessive falls in blood pressure that may precipitate renal, cerebral, or coronary ischemia.

JNC-7 specifically recommends that intravenous enalaprilat be avoided in the setting of acute myocardial infarction. In the Cooperative New Scandinavian Enalapril Survival Study II (Consensus II), the intravenous administration of enalaprilat was associated with an excessive risk of hypotension in patients presenting within 24 hours of acute myocardial infarction. The presence of coronary ischemia is regarded as a special indication for the use of intravenous nitroglycerin. Other appropriate agents include esmolol, labetalol, clevidipine, and nicardipine.

Question 56

Question: 56 of 60

A 44-year-old African-American male has a 1-week history of generalized headaches and nonspecific dizziness. His past medical history is notable only for a 3-year history of hypertension, which has been poorly controlled because of a lack of adherence to his drug regimen. His renal status was normal 1 month ago.

On examination his blood pressure is 250/150 mm Hg, and you note “cotton wool” exudates on funduscopic examination. Laboratory evaluation reveals normal serum electrolytes, a serum creatinine level of 3.8 mg/dL (N 0.7–1.3), and a BUN level of 60 mg/dL (N 6–20). A urinalysis shows gross hematuria and 3+ proteinuria.

Which one of the following will rapidly lower his blood pressure and increase renal blood flow?

1. Nitroprusside
2. Fenoldopam (Corlopam)
3. Enalaprilat
4. Diazoxide (Proglycem)
5. Esmolol (Brevibloc)

Answer 56

1. Nitroprusside
2. Fenoldopam (Corlopam)
3. Enalaprilat
4. Diazoxide (Proglycem)
5. Esmolol (Brevibloc)

Critique:

Fenoldopam is a selective peripheral dopamine-receptor agonist used for the treatment of severe hypertension. In studies investigating its use in severe hypertension, its efficacy in lowering blood pressure was found to be comparable to that of nitroprusside. It is FDA-approved for the in-hospital management of severe hypertension when rapid but quickly reversible reduction of blood pressure is required, such as in the patient with malignant hypertension who has deteriorating end-organ function. By virtue of its actions on peripheral dopamine receptors, fenoldopam produces renal arterial vasodilation and natriuresis, and thus can provide a renal protective effect in clinical situations associated with impaired renal function. In addition, there is evidence that it may improve creatinine clearance and urine flow rates in severely hypertensive patients with either normal or impaired renal function. The 2017 ACC/AHA hypertension guidelines include fenoldopam as a preferred agent for treating hypertensive emergencies associated with acute renal failure; other options include nicardipine and clevidipine.

Question 57

Question: 57 of 60

A 64-year-old obese Hispanic female with a history of hypercholesterolemia has a blood pressure of 168/102 mm Hg, and is started on hydrochlorothiazide and amlodipine (Novasc). For this patient, the JNC 8 panel recommends treating this patient to a goal blood pressure of less than

1. 160 mm Hg systolic and 90 mm Hg diastolic
2. 150 mm Hg systolic and 90 mm Hg diastolic
3. 140 mm Hg systolic and 90 mm Hg diastolic
4. 135 mm Hg systolic and 85 mm Hg diastolic
5. 130 mm Hg systolic and 80 mm Hg diastolic

Answer 57

1. 160 mm Hg systolic and 90 mm Hg diastolic
2. 150 mm Hg systolic and 90 mm Hg diastolic
3. 140 mm Hg systolic and 90 mm Hg diastolic
4. 135 mm Hg systolic and 85 mm Hg diastolic
5. 130 mm Hg systolic and 80 mm Hg diastolic

Critique:

The target blood pressure for older patients continues to be an area of controversy, particularly as it relates to systolic blood pressure (SBP). Although a target blood pressure of <140/90 mm Hg was generally favored in the past, the JNC 8 panel found insufficient evidence to conclude that a goal SBP of <140 mm Hg in patients age 60 or over provided additional benefit compared with a goal SBP of <140–160 mm Hg or <140–149 mm Hg.

Accordingly, the JNC 8 panel recommends a goal SBP of <150 mm Hg and a goal DBP of <90 mm Hg in those age 60 or over (SOR A).

The higher target blood pressure recommended by the JNC 8 panel has generated controversy, as reflected in a special article published in the Annals of Internal Medicine, written by 5 members of the original 18-member JNC 8 panel who disagreed with lowering the target blood pressure in subjects older than 60. Subsequent support for lowering the target blood pressure can be found in the more recent SPRINT trial, which reported a significant reduction in major cardiovascular events among hypertensive patients over age 50 at high cardiovascular risk if a target systolic blood pressure of <120 mm Hg was used, when compared to a target of <140 mm Hg. Although the 2017 ACC/AHA hypertension guidelines generally support a target blood pressure of <130/80 mm Hg in ambulatory community-dwelling adults over 65 years of age, they also urge caution in older adults with a high burden of comorbidity and a limited life expectancy. On the other hand, a 2017 joint clinical practice guideline developed by the American College of Physicians and the American Academy of Family Physicians was in general agreement with JNC 8, favoring a systolic blood pressure treatment threshold of 150 mm Hg for average-risk adults over age 60.

Question 58

Question: 58 of 60

Which one of the following interventions has the greatest potential impact for lowering systolic blood pressure in a patient with hypertension?

1. Weight loss in an obese patient
2. Reduction of sodium intake to 2.4 g/day
3. Regular aerobic exercise for 30 min/day, 5–6 days/week
4. Moderation of alcohol consumption
5. Calcium supplementation

Answer 58

1. Weight loss in an obese patient
2. Reduction of sodium intake to 2.4 g/day
3. Regular aerobic exercise for 30 min/day, 5–6 days/week
4. Moderation of alcohol consumption
5. Calcium supplementation

Critique:

Weight reduction in obese patients has been associated with a 5- to 20-mm Hg reduction in systolic blood pressure. Dietary sodium reduction and regular aerobic exercise have been associated with reductions in systolic blood pressure of 2–8 mm Hg and 4–9 mm Hg, respectively. Moderation in alcohol consumption is associated with a 2- to 4-mm Hg reduction in systolic blood pressure. Calcium supplementation is felt to have a minimal overall impact on blood pressure.

Question 59

Question: 59 of 60

In hypertensive patients with urinary flow obstruction due to benign prostatic hypertrophy, which one of the following agents used to lower blood pressure can also improve bladder emptying?

1. Central α2-agonists
2. ACE inhibitors
3. β-Blockers with intrinsic sympathomimetic activity
4. Calcium channel blockers
5. α1-Blockers

Answer 59

1. Central α2-agonists
2. ACE inhibitors
3. β-Blockers with intrinsic sympathomimetic activity
4. Calcium channel blockers
5. α1-Blockers

Critique:

α-Blockers, such as terazosin, doxazosin, or prazosin, are particularly helpful in hypertensive patients with urinary flow obstruction. In addition to their blood pressure lowering effect, these agents will also indirectly dilate prostatic and urinary sphincter smooth muscle and facilitate bladder emptying.

Question 60

Question: 60 of 60

For patients with diabetes mellitus, the American Diabetes Association recommends a target blood pressure of less than _______ mm Hg systolic, _______ mm Hg diastolic.

Answer 60

140 mmHg systolic

90 mmHg diastolic

Critique:

Beginning with its 2015 guidelines, the ADA revised the goal blood pressure to <140 mmHg systolic and <90 mmHg diastolic (SOR A).

The ADA also stated that lower targets, such as <130 mm Hg systolic (SOR C) and <80 mm Hg diastolic (SOR B), may be appropriate for certain individuals, such as younger patients, if they can be achieved with no undue treatment burden.