Blood Pressure

Question 1

A 60-year-old female presents to the emergency department after developing confusion with severe headache and nausea. Shortly after arrival she has a generalized tonic-clonic seizure lasting less than 30 seconds. She has a blood pressure of 220/130 mm Hg, a pulse rate of 85 beats/min, and an oxygen saturation of 98% on room air. Cardiac enzymes are negative. Noncontrast CT of the head is negative for hemorrhage and contrast CT of the chest and abdomen reveals no aortic dissection. Based on guidelines from the American Heart Association, the patient’s blood pressure is lowered by approximately 20% during the first hour of treatment.

Assuming the patient remains clinically stable, the goal over the next 2–6 hours is to lower her blood pressure to:

Answer 1

160/100

This patient is having a hypertensive emergency with encephalopathy and the goal is to lower her blood pressure by no more than 25% in the first hour. Over the next 2–6 hours, her blood pressure should be lowered to 160/100 mm Hg. After that level is achieved, her blood pressure may be cautiously lowered to normal over the ensuing 24–48 hours. Lowering blood pressure too aggressively can lead to cerebral ischemia and should be avoided.

Question 2

A 70-year-old male with a past medical history significant for long-standing diabetes mellitus and hypertension presents with a stroke. CT of the head shows mild atrophy, with no acute bleeding.

In the first 24 hours after his stroke, starting treatment to control his blood pressure is recommended if it reaches what threshold level? (check one)
- 150/90 mm Hg
- 160/100 mm Hg
- 180/100 mm Hg
- 200/110 mm Hg
- 220/120 mm Hg

Answer 2

220/120

Elevated blood pressure may have a protective effect in the initial period after an ischemic stroke, and studies have shown adverse outcomes when it is lowered in the acute period. Blood pressure usually will spontaneously decrease without treatment in the first several hours after presentation, and antihypertensive treatment should not be started in the first 24 hours after an acute stroke unless blood pressure exceeds 220/120 mm Hg, or treatment is warranted because of another medical condition such as acute myocardial infarction. Tighter blood pressure control becomes more important after the first 24 hours.

Question 3

An otherwise healthy 55-year-old female is diagnosed with hypertension, based on multiple measurements of systolic blood pressures ranging from 142 to 148 mm Hg and diastolic blood pressures in the range of 90–96 mm Hg over the past 4 months. You are now discussing medication options. The patient exercises regularly and conscientiously adheres to a very healthy diet, and has a BMI of 20 kg/m2. She is concerned with the potential long-term adverse side effects of medication in general, and asks if any agents have potential advantages.

Which one of the following medications has been shown to reduce bone loss and may reduce her risk of future hip fractures? (check one)
- Amlodipine (Norvasc)
- Hydrochlorothiazide
- Lisinopril (Prinivil, Zestril)
- Losartan (Cozaar)
- Metoprolol (Lopressor, Toprol-XL)

Answer 3

Hydrochlorothiazide

Thiazide diuretics have proven efficacy in the treatment of hypertension in all age groups and sexes. When used as antihypertensive agents, the reduction in adverse cardiovascular outcomes equals that of a-blockers, calcium channel blockers, and ACE inhibitors. Successful thiazide treatment of hypertension is especially effective in preventing heart failure or strokes. Unlike the other options listed, thiazide diuretics have also been shown to slow cortical bone loss in postmenopausal females and to reduce the incidence of osteoporosis and hip fractures in those who take it continuously. This protective beneficial side effect disappears within 4 months following discontinuation of thiazide therapy. As with all medications there are potential disadvantages of thiazide use, including excessive urinary losses of potassium and sodium and possible increases in serum glucose levels.

Question 4

A 75-year-old female with no significant past medical history presents to your office with a recent onset of postural dizziness and lightheadedness. An evaluation reveals a diagnosis of orthostatic hypotension with no underlying etiology identified. After an unsuccessful trial of managing her symptoms with nonpharmacologic measures, she returns to discuss additional treatment options.

Which one of the following oral medications would be the preferred initial treatment? (check one)
Atomoxetine (Strattera)
Clonidine
Midodrine
Phenylephrine
Pyridostigmine (Mestinon)

Answer 4

Midodrine

Treatment of orthostatic hypotension begins with identifying and addressing the underlying cause(s) when possible. This may include correcting a reversible medical condition or discontinuing an offending medication. Nonpharmacologic measures should be initiated next and typically include increasing fluid and sodium intake, improving physical fitness, wearing compression garments, and avoiding hot and humid environments. When additional treatment is needed, first-line medication options include midodrine or droxidopa, which act by increasing peripheral vascular resistance. Off-label use of atomoxetine or pyridostigmine may be considered as adjunct therapy but these medications are not part of the initial management. The α-antagonist clonidine typically causes a decrease in blood pressure through central action on the sympathetic nervous system. In patients with autonomic dysfunction, however, clonidine can increase venous return without a blood pressure–lowering effect and therefore improve orthostatic hypotension, but it should only be considered a supplementary treatment. The α-sympathomimetic medication phenylephrine may also be considered as a second-line option, but it is not part of the initial management of orthostatic hypotension.

Question 5

A 54-year-old male sees you for a 6-month follow-up visit for hypertension. He feels well, but despite the fact that he takes his medications faithfully, his blood pressure averages 150/90 mm Hg. He has had an intensive workup for hypertension in the recent past, with normal repeat laboratory results, including a CBC, serum creatinine, an electrolyte panel, and a urinalysis. His medications include chlorthalidone, 12.5 mg daily; carvedilol (Coreg), 25 mg twice daily; amlodipine (Norvasc), 10 mg daily; and lisinopril (Prinivil, Zestril), 40 mg daily. He has been intolerant to clonidine (Catapres) in the past.

Which one of the following medication changes would be most reasonable? (check one)
Adding isosorbide mononitrate (Imdur)
Adding spironolactone (Aldactone)
Substituting furosemide (Lasix) for chlorthalidone
Substituting losartan (Cozaar) for lisinopril

Answer 5

Adding spironolactone (Aldactone)

Spironolactone is now recommended for treating resistant hypertension, even when hyperaldosteronism is not present. A longer-acting diuretic such as chlorthalidone is also recommended for treating hypertension, particularly in resistant cases with normal renal function. There is no benefit to switching from an ACE inhibitor to an ARB. Nitrates have some effect on blood pressure but are recommended only for patients with coronary artery disease.

Question 6

For several years, a hypertensive 65-year-old female has been treated with hydrochlorothiazide, 25 mg/day; atenolol (Tenormin), 100 mg/day; and hydralazine, 50 mg 4 times/day. Her blood pressure has been well controlled on this regimen. Over the past 2 months she has experienced malaise, along with diffuse joint pains that involve symmetric sites in the fingers, hands, elbows, and knees. A pleural friction rub is noted on examination. Laboratory testing shows that the patient has mild anemia and leukopenia, with a negative rheumatoid factor and a positive antinuclear antibody (ANA) titer of 1:640.

Which one of the following would be the most appropriate INITIAL step? (check one)
Replace hydrochlorothiazide with furosemide (Lasix)
Discontinue hydralazine
Start prednisone, 40 mg/day orally
Start hydroxychloroquine (Plaquenil), 400 mg/day
Order renal function studies and anticipate that a renal biopsy will be needed

Answer 6

Discontinue hydralazine

There are many drugs that can induce a syndrome resembling systemic lupus erythematosus, but the most common offenders are antiarrhythmics such as procainamide. Hydralazine is also a common cause. There is a genetic predisposition for this drug-induced lupus, determined by drug acetylation rates. Polyarthritis and pleuropericarditis occur in half of patients, but CNS or renal involvement is rare. While all patients with this condition have positive antinuclear antibody titers and most have antibodies to histones, antibodies to double-stranded DNA and decreased complement levels are rare, which distinguishes drug-induced lupus from idiopathic lupus.

The best initial management for drug-induced lupus is to withdraw the drug, and most patients will improve in a few weeks. For those with severe symptoms, a short course of corticosteroids is indicated. Once the offending drug is discontinued, symptoms seldom last beyond 6 months.

Question 7

You suspect orthostatic hypotension in an elderly male who reports “dizziness” when standing up, and you decide to obtain recumbent and standing blood pressure measurements. After the patient rests in a supine position for 5 minutes, you measure his baseline blood pressure and then ask him to stand, which he does without a problem.

For how long should his blood pressure be periodically measured before considering the test complete? (check one)
30 seconds
60 seconds
90 seconds
3 minutes
5 minutes

Answer 7

3 minutes

Orthostatic hypotension is defined as a documented drop in blood pressure of at least 20 mm Hg systolic or 10 mm Hg diastolic that occurs within 3 minutes of standing. When symptomatic it is often described as lightheadedness or dizziness upon standing. Etiologies to consider include iatrogenic, neurologic, cardiac, and environmental causes, plus many others alone or in combination. Since orthostatic hypotension may result in syncope, leading to falls and substantial injury, identifying it and taking corrective steps can produce a significant benefit.

Question 8

An 11-year-old male is brought to your clinic for follow-up after a recent well child visit revealed elevated blood pressure. The parents have restricted his intake of sodium and fatty foods during the last several weeks. His blood pressure today is 140/92 mm Hg, which is similar to the reading at his last visit. The parents checked the child’s blood pressure with a home unit several times and found it consistently to be in the 130s systolic and low 80s diastolic. The child had a normal birth history and has no known chronic medical conditions. Both of his parents and his two younger siblings are healthy. He is at the 75th percentile for both height and weight with a BMI in the normal range. He eats a balanced diet and is active.

What should be the next step for this patient?
(check one)
Reassurance that this is likely white-coat hypertension
A goal weight loss of at least 5 lb
Evaluation for causes of secondary hypertension
Hydrochlorothiazide
Lisinopril (Prinivil, Zestril)

Answer 8

Evaluation for causes of secondary hypertension

The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents defines hypertension in children as a systolic or diastolic blood pressure above the 95th percentile for the patient’s sex, age, and height on several different readings. Although it is appropriate to have this finding confirmed in the outpatient setting, 130 mm Hg is still at the 99th percentile for systolic blood pressures in this patient. Hypertension in a patient this young should prompt a search for secondary causes, which are more common in young hypertensive patients than in adults with hypertension. The recommended workup includes blood and urine testing, as well as renal ultrasonography. An evaluation for end-organ damage is also recommended, including retinal evaluation and echocardiography.

Question 9

Which one of the following is a preferred first-line agent for managing hypertension in patients with stable coronary artery disease? (check one)
A thiazide diuretic
An angiotensin receptor blocker
A β-blocker
A long-acting calcium channel blocker
A long-acting nitrate

Answer 9

A β-blocker

American Heart Association guidelines recommend treating hypertension in patients with stable heart failure with ACE inhibitors and/or β-blockers. Other agents, such as thiazide diuretics or calcium channel blockers, can be added if needed to achieve blood pressure goals (SOR B). β-Blockers with intrinsic sympathomimetic activity should be avoided, as they increase myocardial oxygen demand.

While thiazide diuretics are often a first choice for uncomplicated hypertension, this is not the case for patients with coronary artery disease. Long-acting calcium channel blockers may be used in patients who do not tolerate β-blockers, but short-acting calcium channel blockers should be avoided because they increase mortality. ACE inhibitors are recommended as antihypertensive agents in patients already on β-blocker therapy (especially following myocardial infarction), in diabetics, and in patients with left ventricular dysfunction. Although angiotensin receptor blockers have indications similar to those of ACE inhibitors, the American Heart Association recommends using them only in patients who do not tolerate ACE inhibitors. Long-acting nitrates are used for their anti-anginal properties and have no role in the management of hypertension.

Question 10

A 48-year-old female presents as a new patient to your office. She has not seen a physician for several years and her medical history is unknown. Her BMI is 24.4 kg/m2 and she is not taking any medication. Her blood pressure is 172/110 mm Hg in the left arm sitting and 176/114 mm Hg in the right arm sitting; her cardiovascular examination is otherwise unremarkable. A baseline metabolic panel reveals a creatinine level of 0.68 mg/dL (N 0.6–1.1) and a potassium level of 3.3 mEq/L (N 3.5–5.5).

If the patient’s hypertension should prove refractory to treatment, which one of the following tests is most likely to reveal the cause of her secondary hypertension?
(check one)
A 24-hour urine catecholamine level
A plasma aldosterone/renin ratio
MRA of the renal arteries
Echocardiography
A sleep study (polysomnography)

Answer 10

A plasma aldosterone/renin ratio

Primary hyperaldosteronism is the most common cause of secondary hypertension in the middle-aged population, and can be diagnosed from a renin/aldosterone ratio. This diagnosis is further suggested by the finding of hypokalemia, which suggests hyperaldosteronism even though it is not present in the majority of cases.

An echocardiogram would help make a diagnosis of coarctation of the aorta, but this is more common in younger patients. Renal MRA may demonstrate renal artery stenosis, but this condition is more common in older patients. Sleep apnea is increasing in prevalence along with the rise in obesity, but it is not suggested by this case. A 24-hour urine catecholamine test is used to diagnose pheochromocytoma, which is not suggested by this patient’s findings. Pheochromocytoma is also less common than aldosteronism (SOR C).

Question 11

A 55-year-old female comes to your clinic for follow-up of her poorly controlled hypertension. Her medical history also includes type 2 diabetes and worsening obstructive sleep apnea (OSA). Her BMI is 52 kg/m2. Her heart rate is 62 beats/min and regular. Her blood pressure in the clinic today is 160/96 mm Hg, and she reports similar average readings at home. She is asymptomatic and says she has been following lifestyle modifications including a low-salt diet. She also reports that she has been adherent with her current antihypertensive regimen, which includes the following:
Amlodipine (Norvasc), 10 mg daily
Carvedilol (Coreg), 25 mg twice daily
Chlorthalidone, 25 mg daily
Losartan (Cozaar), 100 mg daily
Which one of the following antihypertensive medication changes would benefit both her blood pressure and her OSA? (check one)
Switching chlorthalidone to hydrochlorothiazide, 25 mg daily
Switching carvedilol to an equivalent dosage of metoprolol tartrate (Lopressor)
Switching losartan to an equivalent dosage of an ACE inhibitor
Increasing the current dosage of losartan to 100 mg twice daily
Adding a low dosage of spironolactone (Aldactone) to her current regimen

Answer 11

Adding a low dosage of spironolactone (Aldactone) to her current regimen

Secondary forms of hypertension are common in patients with resistant hypertension, and sleep-disordered breathing is an important cause of resistant hypertension. Multiple studies have shown that excess aldosterone plays a key role in the association between the two. As rates of obesity and obstructive sleep apnea (OSA) have increased, the prevalence of resistant hypertension has also increased. It is estimated that almost 17%–22% of patients with resistant hypertension may have undiagnosed primary hyperaldosteronism. The increased expression of mineralocorticoid receptors in patients with a high BMI contributes to hyperaldosteronism, and blockage of these receptors with medications such as spironolactone has been shown to provide benefit in reducing the severity of OSA as well as hypertension in these patients.

Substituting one thiazide for another does not have a beneficial effect in patients with resistant hypertension. Switching β-blockers in this case is unlikely to have a significant impact on blood pressure and might have an adverse impact, as carvedilol has been shown to have more favorable effects on glycemic control and other components of metabolic syndrome relative to metoprolol tartrate in patients with diabetes. Increasing the angiotensin receptor blocker dosage or substituting an ACE inhibitor will not be as beneficial in controlling this patient’s blood pressure.

Question 12

An 8-year-old female is brought to your office by her parents for follow-up 6 months after you recommended a DASH diet and 1 hour of physical play daily to address her BMI and blood pressure, which were both greater than the 95th percentile for her age and height. Her mother also has a history of obesity and hypertension. The patient otherwise has an unremarkable past medical history. Although she has lost 1.4 kg (3 lb) her blood pressure remains at 125/77 mm Hg. You diagnose stage 1 hypertension and recommend management with medication.

In addition to a CBC; electrolyte, BUN, and creatinine levels; a urinalysis; and a lipid panel, you recommend (check one)
no further testing
serum or urine catecholamine measurement
renal Doppler ultrasonography
CT angiography of the kidneys
echocardiography

Answer 12

echocardiography

Echocardiography should be performed to assess for cardiac target end-organ damage, such as left ventricular hypertrophy, when medication is being considered in children with hypertension. Evaluation for secondary causes of hypertension is not needed in children >6 years of age with stage 1 hypertension if they are overweight or have a positive family history of hypertension and there are no physical examination findings indicative of a secondary cause. Renal imaging, catecholamine and steroid levels, and renin activity are indicated in children <6 years of age or patients with stage 2 hypertension (≥95th percentile plus 12 mm Hg systolic or diastolic blood pressure or ≥140/90 mm Hg, whichever is lower).

Question 13

A 32-year-old gravida 2 para 1 with long-standing untreated hypertension presents at 8 weeks gestation for prenatal care. Her physical examination is normal except for a blood pressure of 156/114 mm Hg.

Which one of the following would be most appropriate as initial treatment?
(check one)
Labetalol (Trandate)
Lisinopril (Prinivil, Zestril)
Losartan (Cozaar)
Metoprolol (Lopressor, Toprol-XL)
Nifedipine, immediate release (Procardia)

Answer 13

Labetalol (Trandate)

The drug most often recommended as first-line therapy for hypertension in pregnancy is labetalol. Reports of an association of metoprolol with fetal growth restriction have given rise to the recommendation to avoid its use in pregnancy. Both ACE inhibitors and angiotensin-receptor blockers are contraindicated in pregnancy because of the risk of birth defects and fetal or neonatal renal failure. Immediate-release nifedipine is not recommended due to the risk of hypotension.

Question 14

According to the 2022 American Academy of Family Physicians clinical practice guideline, treatment to a blood pressure target of <135/85 mm Hg in adults who have hypertension reduces which one of the following? (check one)
All-cause mortality
Cardiovascular mortality
Risk of myocardial infarction
Risk of stroke

Answer 14

Risk of myocardial infarction

The 2022 American Academy of Family Physicians clinical practice guideline recommends treating adults who have hypertension to a standard target of <140/90 mm Hg based on high-quality evidence. Moderate-quality evidence showed that treating adults to a lower blood pressure target of <135/85 mm Hg further reduced the risk of myocardial infarction compared to the standard target, with a number needed to treat of 137 over 3.7 years. There was no benefit in mortality or stroke risk. Of note, treating to a lower target blood pressure does increase the absolute risk of serious adverse events by 3%, with a number needed to harm of 33 over 3.7 years.

Question 15

A 72-year-old white male has new-onset hypertension with a current blood pressure of 190/110 mm Hg. Which one of the following agents can be used as part of a test for diagnosing renovascular hypertension, but would also increase the risk for azotemia if used for treatment? (check one)
Captopril (Capoten)
Metoprolol (Lopressor)
Clonidine (Catapres)
Furosemide (Lasix)
Amlodipine (Norvasc)

Answer 15

Captopril (Capoten)

ACE inhibitors can significantly worsen renal failure in patients with hypertension caused by renovascular disease. Hyperkalemia is an associated problem. Captopril renography is a useful diagnostic screening test. The other agents are useful for lowering blood pressure but may cause mild creatinine elevations. They do not, however, cause the significant elevations of creatinine seen with ACE inhibitors in cases of significant renovascular disease.

Question 16

A 70-year-old male with hypertension sees you because of a syncopal episode. During the examination you ask him to move from a supine position to standing.

Which one of the following results of this maneuver would confirm a diagnosis of orthostatic hypotension? (check one)
He becomes lightheaded
He feels chest pain
His systolic blood pressure decreases by at least 10 mm Hg
His systolic blood pressure decreases by at least 20 mm Hg

Answer 16

His systolic blood pressure decreases by at least 20 mm Hg

Orthostatic hypotension, which is more prevalent in older adults, is defined as a decrease of at least 20 mm Hg in systolic blood pressure or a drop of at least 10 mm Hg in diastolic blood pressure within 3 minutes of standing from the supine position. There are multiple etiologies, both neurogenic and nonneurogenic. Clinical symptoms are not a preferred method of diagnosing orthostatic hypotension.

Question 17

You recently initiated treatment for hypertension in a 65-year-old male. One week later his creatinine level has increased from 1.2 to 2.4 mg/dL (N 0.6–1.2). You consider renal artery stenosis as an etiology because you are treating his hypertension with which one of the following medications? (check one)
Amlodipine (Norvasc)
Chlorthalidone
Lisinopril (Zestril)
Metoprolol
Spironolactone (Aldactone)

Answer 17

Lisinopril (Zestril)

A creatinine elevation can occur as a result of decreased glomerular pressure, which can follow the initiation of an ACE inhibitor or an angiotensin receptor blocker. According to the American College of Cardiology/American Heart Association, renal artery stenosis should be considered when this elevation is >50% of the initial creatinine value. Amlodipine, chlorthalidone, metoprolol, and spironolactone would not cause a significant rise in creatinine levels related to renal artery stenosis.

Question 18

A 65-year-old female develops gram-negative septicemia from a urinary tract infection. Despite the use of fluid resuscitation she remains hypotensive, with a mean arterial pressure of 50 mm Hg. Which one of the following would be the most appropriate treatment for this patient? (check one)
Vasopressin (Pitressin)
Phenylephrine (Neo-Synephrine)
Epinephrine
Norepinephrine (Levophed)
Low-dose dopamine

Answer 18

Norepinephrine (Levophed)

In a patient with sepsis, vasopressors are indicated when fluid resuscitation does not restore organ perfusion and blood pressure. Norepinephrine and dopamine currently are the preferred pressor agents; however, norepinephrine appears to be more effective and has a lower mortality rate. Phenylephrine, epinephrine, or vasopressin should not be used as first-line therapy. Vasopressin is employed after high-dose conventional vasopressors have failed. The use of low-dose dopamine is no longer recommended based on a clinical trial showing no benefit in critically ill patients at risk for renal failure. If an agent is needed to increase cardiac output, dobutamine is the agent of choice.

Question 19

A 78-year-old female has chronic symptomatic orthostatic hypotension, likely related to diabetic autonomic dysfunction, which has failed to respond to nonpharmacologic treatment. Her current medications include metformin (Glucophage), 1000 mg twice daily; atorvastatin (Lipitor), 40 mg daily; aspirin, 81 mg daily; and insulin glargine (Lantus), 24 units at bedtime.

Which one of the following would be the most effective therapy for her orthostatic hypotension?
(check one)
Clonidine (Catapres)
Midodrine
Pseudoephedrine
Terbutaline
Theophylline

Answer 19

Midodrine

Effective treatments for chronic orthostatic hypotension include fludrocortisone, midodrine, and physostigmine (SOR B). Clonidine, pseudoephedrine, terbutaline, and theophylline are not appropriate therapies.

Question 20

You are treating a patient for hypertension and opt to start an ACE inhibitor. Six weeks later the patient’s blood pressure is at goal, but the serum creatinine level has increased from 1.0 to 1.2 mg/dL (N 0.7–1.0).

Which one of the following would be the most appropriate next step? (check one)
Continuing the ACE inhibitor with close monitoring of renal function
Discontinuing the ACE inhibitor immediately
Ordering ultrasonography to evaluate for renal artery stenosis
Referring the patient to a nephrologist

Answer 20

Continuing the ACE inhibitor with close monitoring of renal function

The renal protective effects of ACE inhibitors have been shown to be so efficacious in long-term trials as to warrant tolerating up to a 30% increase in baseline serum creatinine level within the first 6–8 weeks of therapy, assuming blood pressure goals are reached. The degree of long-term renal protection is a high priority in patients with diabetes mellitus, but this is not part of the decision-making process for cessation of ACE inhibitors.

Many patients with a severe increase in serum creatinine levels have renal artery stenosis and may require renal artery ultrasonography, and ACE inhibitors would need to be stopped in these patients.

Question 21

A 47-year-old female sees you for routine follow-up. Her past medical history is significant for hypertension, hyperlipidemia, depression, and osteoarthritis. She tells you that she has noticed her ankles swelling over the past few months. In addition to a physical examination and other indicated evaluations, you also review her medications, which include the following:

Acetaminophen
Amlodipine (Norvasc)
Atorvastatin (Lipitor)
Escitalopram (Lexapro)
Lisinopril (Zestril)

Which one of her medications is most likely to cause edema? (check one)
Acetaminophen
Amlodipine
Atorvastatin (Lipitor)
Escitalopram
Lisinopril

Answer 21

Amlodipine

Edema is a common clinical condition in the primary care setting and may indicate numerous pathologies. Medications, including many antihypertensives, anti-inflammatory medications, hormones, gabapentinoids, and chemotherapy, can be a contributing factor and should be reviewed in the evaluation and management of edema. Of the agents in this patient’s medication regimen, amlodipine is the most likely to cause or contribute to her edema. Acetaminophen, atorvastatin, escitalopram, and lisinopril are not likely the cause of her edema.

Question 22

A 54-year-old male comes to your office to establish care. He has a past history of hypertension treated with lisinopril (Prinivil, Zestril) and hydrochlorothiazide but has not taken his medications for over a year. He does not have any symptoms, including chest pain, shortness of breath, or headache. On examination his blood pressure is 200/115 mm Hg on two separate readings taken 5 minutes apart. The remainder of the physical examination is normal.

Which one of the following management options would be most appropriate? (check one)
Institute out-of-office monitoring with an ambulatory device and follow up in 2 weeks
Restart the patient’s previous antihypertensive medications and follow up within 1 week
Administer a short-acting antihypertensive medication in the office to lower his blood pressure to <160/100 mm Hg
Hospitalize for hypertensive emergency

Answer 22

Restart the patient’s previous antihypertensive medications and follow up within 1 week

This patient has severe asymptomatic hypertension (systolic blood pressure 180 mm Hg or diastolic blood pressure 110 mm Hg). If there were signs or symptoms of acute target organ injury, such as neurologic deficits, altered mental status, chest pain, shortness of breath, or oliguria, hospitalization for a hypertensive emergency would be indicated. Because this patient was asymptomatic and has a known history of hypertension, restarting his prior antihypertensive regimen and following up in 2 weeks would be the most appropriate management option. If he had no past history of hypertension it would be reasonable to consider out-of-office monitoring with an ambulatory device for 2 weeks before initiating treatment. In the absence of acute target organ injury, blood pressure should be gradually lowered to less than 160/100 mm Hg over several days to weeks. Aggressively lowering blood pressure can lead to adverse events such as myocardial infarction, cerebrovascular accident, or syncope, so administering a short-acting antihypertensive medication in the office should be reserved for the management of hypertensive emergencies.

Question 23

A 21-year-old female is being evaluated for secondary causes of refractory hypertension. Which one of the following would be most specific for fibromuscular dysplasia? (check one)
A serum creatinine level
An aldosterone:renin ratio
24-hour urine for metanephrines
Renal ultrasonography
Magnetic resonance angiography of the renal arteries

Answer 23

Magnetic resonance angiography of the renal arteries

In young adults diagnosed with secondary hypertension, evaluation for fibromuscular dysplasia of the renal arteries with MR angiography or CT angiography is indicated (SOR C). The aldosterone/renin ratio is the most sensitive test to diagnose primary hyperaldosteronism. Renal ultrasonography is an indirect test that is not as sensitive or specific for fibromuscular dysplasia. Serum creatinine elevation shows renal involvement but does not identify the cause. Testing for metanephrines is indicated only if a pheochromocytoma is suspected.

Question 24

A 61-year-old white male with type 2 diabetes mellitus sees you for a follow-up visit. His blood pressure is 156/94 mm Hg. At a visit 1 week ago his blood pressure was 150/92 mm Hg. Laboratory studies obtained prior to this visit show a BUN of 16 mg/dL (N 6–20), a serum creatinine level of 0.9 mg/dL (N 0.7–1.3), and microalbuminuria on a urinalysis. His diabetes is well controlled with metformin (Glucophage) and he is taking aspirin.

Which one of the following would you recommend? (check one)
Observation only
An ACE inhibitor
A β-blocker
A calcium channel blocker
A diuretic

Answer 24

An ACE inhibitor

The panel members of the Eighth Joint National Committee for the management of blood pressure recommended that ACE inhibitors should be initiated for renal protection in adults with diabetes mellitus, hypertension, and microalbuminuria. This patient appears to be in an early stage of nephropathy, and ACE inhibitors will reduce the decline in renal function. β-Blockers are no longer recommended for first-line treatment. In white patients who do not have diabetes, therapy may be started with ACE inhibitors, thiazide diuretics, or calcium channel blockers.

Question 25

Which one of the following antihypertensive drugs may reduce the severity of sleep apnea? (check one)
Amlodipine (Norvasc)
Hydralazine
Lisinopril (Prinivil, Zestril)
Metoprolol
Spironolactone (Aldactone)

Answer 25

Spironolactone (Aldactone)

Diuretics lessen the severity of obstructive sleep apnea and reduce blood pressure. Aldosterone antagonists offer further benefit beyond that of traditional diuretics. Resistant hypertension is common in patients with obstructive sleep apnea. Resistant hypertension is also associated with higher levels of aldosterone, which can lead to secondary pharyngeal edema, increasing upper airway obstruction.

Question 26

A 50-year-old female sees you for follow-up of her hypertension. At her last visit 4 weeks ago you started her on lisinopril (Prinivil, Zestril), 10 mg daily, because of a blood pressure of 158/92 mm Hg and confirmed hypertension on ambulatory blood pressure monitoring. She is tolerating the medication well and has no side effects. She does not take any other medications. Today her blood pressure is 149/90 mm Hg, which you confirm on repeat measurement. This is also consistent with her home measurements. At her last visit a basic metabolic panel was normal.

You repeat a basic metabolic panel today and the results are normal except for a BUN of 25 mg/dL (N 8–23) and a creatinine level of 1.5 mg/dL (N 0.6–1.1). At her last visit her BUN was 12 mg/dL and her creatinine level was 0.7 mg/dL.

Which one of the following would be most appropriate at this time? (check one)
Continue her current treatment regimen
Increase lisinopril to 20 mg daily
Continue lisinopril at the current dosage and add amlodipine (Norvasc), 5 mg daily
Discontinue lisinopril and begin amlodipine, 5 mg daily
Discontinue lisinopril and begin losartan (Cozaar), 25 mg daily

Answer 26

Discontinue lisinopril and begin amlodipine, 5 mg daily

This patient has essential hypertension and her goal blood pressure is <140/90 mm Hg based on JNC 8 guidelines, or 130/80 mm Hg based on the more recent recommendations of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Until recently, it was recommended that physicians should tolerate a rise of <30% in serum creatinine after ACE inhibitor or angiotensin receptor blocker (ARB) initiation. Rises in serum creatinine of >30% from baseline increase the risk of renal failure, adverse cardiac outcomes, and death. A recent study suggests that rises in serum creatinine of <30% also put patients at risk for these outcomes, with a dose-response relationship between the magnitude of creatinine change and the risk of adverse outcomes.

This patient has more than a 30% rise in creatinine and has no other factors, such as diabetes mellitus, heart failure, or chronic kidney disease, that would indicate a need for ACE or ARB therapy for her hypertension. Discontinuing her ACE inhibitor and starting a medication from a different class is the most appropriate treatment at this time. Based on JNC 8 guidelines, additional options for blood pressure medications include thiazide diuretics and calcium channel blockers.

Question 27

A 45-year-old African-American male returns to your clinic to evaluate his progress after 6 months of dedicated adherence to a diet and exercise plan you prescribed to manage his blood pressure. His blood pressure today is 148/96 mm Hg. He is not overweight and he does not have other known medical conditions or drug allergies.

Which one of the following would be the most appropriate initial antihypertensive treatment option for this patient? (check one)
Chlorthalidone
Hydralazine
Lisinopril (Prinivil, Zestril)
Losartan (Cozaar)
Metoprolol

Answer 27

Chlorthalidone

Lifestyle modifications addressing diet, physical activity, and weight are important in the treatment of hypertension, particularly for African-American and Hispanic patients. When antihypertensive drugs are also required, the best options may vary according to the racial and ethnic background of the patient. The presence or absence of comorbid conditions is also important to consider. For African-Americans, thiazide diuretics and calcium channel blockers, both as monotherapy and as a component in multidrug regimens, have been shown to be more effective in lowering blood pressure than ACE inhibitors, angiotensin II receptor blockers, or β-blockers, and should be considered as first-line options over the other classes of antihypertensive drugs unless a comorbid condition is present that would be better addressed with a different class of drugs. Racial or ethnic background should not be the basis for the exclusion of any drug class when multidrug regimens are required to reach treatment goals.

Question 28

A 55-year-old male comes to your office for a routine visit due to an insurance change. He has no health complaints and the physical examination is unremarkable except for some seborrheic keratoses, onychomycosis, and a blood pressure of 171/90 mm Hg. On two subsequent visits his blood pressure is 168/92 mm Hg and 171/91 mm Hg and you recommend treatment. The patient states that he will not take any prescription medications, as he believes they are harmful.

Which one of the following nonpharmacologic measures would be appropriate to recommend for this patient? (check one)
Limiting sodium intake to 4 g per day
Limiting alcohol to no more than 3 drinks per day
Daily coenzyme Q10
Daily magnesium supplements
Moderate physical activity for 150 minutes or more per week

Answer 28

Moderate physical activity for 150 minutes or more per week

Although pharmacologic therapy is the mainstay of treatment for hypertension in adults, there are several nonpharmacologic options that have been shown to lower blood pressure. Moderate exercise 3–4 times per week for 40 minutes or more has been shown to lower high blood pressure, with the greatest effect seen when patients exercise 150 minutes or more per week. Limiting sodium intake to 2400 mg/day decreases blood pressure, and further effects are seen when it is limited to 1500 mg/day. Alcohol should be limited to no more than two drinks per day in men, and one drink per day in women. Magnesium and coenzyme Q10 do not lower blood pressure.

Question 29

A 48-year-old male presents for follow-up of his hypertension. His medications include generic amlodipine, 10 mg; lisinopril (Zestril), 20 mg; and hydrochlorothiazide, 25 mg. His blood pressure today is 156/92 mm Hg. He says that he forgot to take his medications this morning, and reports that he often forgets to take them. He does not have any specific concerns about side effects.

Which one of the following would be most likely to increase this patient’s medication adherence? (check one)
Taking his medications before bed
Changing generic amlodipine to branded Norvasc
Changing generic amlodipine to generic nifedipine
Replacing lisinopril and hydrochlorothiazide with combination lisinopril/hydrochlorothiazide (Zestoretic)
Adding metoprolol

Answer 29

Replacing lisinopril and hydrochlorothiazide with combination lisinopril/hydrochlorothiazide (Zestoretic)

Simplifying medication regimens, including using combination medications to decrease the number of pills a patient must take, has been shown to improve medication adherence in clinical trials (SOR B). Taking antihypertensive medications before bed has not been shown to improve adherence. Prescribing brand name medications increases costs, which may decrease adherence. Unless specific side effects are a concern, changing medications or adding another agent would not be likely to improve adherence.

Question 30

A 65-year-old female develops gram-negative septicemia from a urinary tract infection. Despite the use of fluid resuscitation she remains hypotensive, with a mean arterial pressure of 50 mm Hg.

Which one of the following would be the most appropriate treatment for this patient? (check one)
Vasopressin
Phenylephrine (Neo-Synephrine)
Epinephrine
Norepinephrine (Levophed)
Low-dose dopamine

Answer 30

Norepinephrine (Levophed)

In a patient with sepsis, vasopressors are indicated when fluid resuscitation does not restore organ perfusion and blood pressure. Norepinephrine and dopamine are the preferred pressor agents; however, norepinephrine appears to be more effective and has a lower mortality rate. Norepinephrine is the preferred drug for shock due to sepsis. Its relative safety suggests that it be used as an initial vasopressor. It is a potent vasoconstrictor and inotropic stimulant and is useful for shock. As a first-line therapy norepinephrine is associated with fewer adverse events, including arrhythmia, compared to dopamine. Phenylephrine, epinephrine, or vasopressin should not be used as first-line therapy. Vasopressin is employed after high-dose conventional vasopressors have failed. The use of low-dose dopamine is no longer recommended based on a clinical trial showing no benefit in critically ill patients at risk for renal failure. If an agent is needed to increase cardiac output, dobutamine is the agent of choice.

Question 31

A 33-year-old female with a BMI of 35.2 kg/m2 presents to your office for follow-up of her recently documented blood pressure elevation. Her blood pressure is elevated again today. You diagnose hypertension and decide to start pharmacologic therapy in addition to lifestyle modifications.

Which one of the following agents would be the best first-line choice for this patient? (check one)
Verapamil (Calan)
Clonidine (Catapres)
Hydrochlorothiazide
Metoprolol tartrate (Lopressor)
Spironolactone (Aldactone)

Answer 31

Hydrochlorothiazide

The 2014 evidence-based guideline from the panel members appointed to the Eighth Joint National Committee (JNC 8) makes few suggestions regarding preferred initial agents for the treatment of hypertension. Of the options listed, only hydrochlorothiazide is a reasonable option for first-line treatment. Verapamil is rarely used for blood pressure control.

Question 32

A 53-year-old male sees you for follow-up of his hypertension. His medical history includes prediabetes and gout, and he is currently taking lisinopril (Prinivil, Zestril), 40 mg daily, to control his blood pressure. His blood pressure after resting is 148/86 mm Hg. Laboratory findings include a serum creatinine level of 0.8 mg/dL (N 0.6–1.2) and a serum potassium
level of 4.5 mEq/L (N 3.5–5.1).

Which one of the following would be the most appropriate management of this patient’s hypertension? (check one)
No change in medication
Add amlodipine (Norvasc)
Add hydrochlorothiazide
Add losartan (Cozaar)
Add metoprolol succinate (Toprol-XL)

Answer 32

Add amlodipine (Norvasc)

First-line agents for hypertension include ACE inhibitors, angiotensin receptor blockers, thiazide diuretics, and calcium channel blockers. Hydrochlorothiazide would be relatively contraindicated due to the patient’s gout. Losartan, an angiotensin receptor blocker, should not be added because the patient is taking an ACE inhibitor. Metoprolol succinate, a β-blocker, is not a first-line agent for blood pressure unless there is another indication such as systolic heart failure or migraine prophylaxis.

Question 33

An otherwise asymptomatic 7-year-old male has a blood pressure above the 95th percentile for gender, age, and height on serial measurements. Which one of the following studies would be most appropriate at this time? (check one)
Renin and aldosterone levels
24-hour urinary fractionated metanephrines and normetanephrines
Renal ultrasonography
Doppler ultrasonography of the renal arteries
A sleep study

Answer 33

Renal ultrasonography

Renal parenchymal diseases such as glomerulonephritis, congenital abnormalities, and reflux nephropathy
are the most common cause of hypertension in preadolescent children. Preadolescent children with
hypertension should be evaluated for possible secondary causes and renal ultrasonography should be the
first choice of imaging in this age group.
Renin and aldosterone levels are indicated if there is a reason to suspect primary hyperaldosteronism, such
as unexplained hypokalemia. Measurement of 24-hour urinary fractionated metanephrines and
normetanephrines is used to diagnose pheochromocytomas, which are rare and usually present with a triad
of symptoms including headache, palpitations, and sweating. Doppler ultrasonography of the renal arteries
is useful for diagnosing renal artery stenosis, which should be suspected in patients with coronary or
peripheral atherosclerosis or young adults, especially women 19–39 years of age, who are more at risk for
renal artery stenosis due to fibromuscular dysplasia. Sleep studies are indicated in patients who are obese
or have signs or symptoms of obstructive sleep apnea.

Question 34

According to the most recent American College of Cardiology/American Heart Association guidelines, hypertension is defined as a blood pressure reading greater than (check one)
120/80 mm Hg
130/80 mm Hg
135/85 mm Hg
140/90 mm Hg
150/90 mm Hg

Answer 34

130/80 mm Hg

The latest American College of Cardiology/American Heart Association guidelines promote a radical
change in the management of hypertension, which they now define as a blood pressure 130/80 mm Hg.
Elevated blood pressure is defined as a systolic pressure of 120–129 mm Hg and a diastolic pressure <80
mm Hg. A blood pressure of 130–139/80–89 mm Hg is classified as stage 1 hypertension and a systolic
pressure 140 mm Hg or a diastolic pressure 90 mm Hg is classified as stage 2 hypertension.

Question 35

Which one of the following regimens is recommended for the treatment of hypertension in a patient with stage 3 chronic kidney disease and proteinuria? (check one)
A loop diuretic and a β-blocker
An ACE inhibitor and an angiotensin receptor blocker
An ACE inhibitor and a thiazide diuretic
A calcium channel blocker and a thiazide diuretic
A potassium-sparing diuretic and a thiazide diuretic

Answer 35

An ACE inhibitor and a thiazide diuretic

Based on a reduction in all-cause mortality, JNC 8 advises more intensive blood pressure control in patients with chronic kidney disease (CKD) and proteinuria. This is most often achieved with combination therapy, with either an ACE inhibitor or an angiotensin receptor blocker (ARB), plus either a thiazide diuretic or a calcium channel blocker. ACE inhibitors and ARBs both slow the progression of CKD to end-stage renal disease and reduce morbidity and mortality in patients with CKD (SOR A). However, combining an ACE inhibitor and an ARB actually increases the risk of end-stage renal disease, so these drugs should not be used simultaneously.

The other combinations listed may be effective in improving blood pressure control, but in patients with CKD and proteinuria the combination of an ACE inhibitor or an ARB with a diuretic or calcium channel blocker is most effective for lowering morbidity and mortality.