Hypertension

Question 1

How do you confirm white coat HTN

Answer 1

The American Heart Association recommends that a diagnosis of white coat hypertension based on home blood pressure monitoring be confirmed with 24-hour ambulatory blood pressure monitoring

Question 2

what are the four ACC/AHA categories for blood pressure

Answer 2

Normal blood pressure: SBP <120 mm Hg and DBP <80 mm Hg
Elevated blood pressure: SBP 120–129 mm Hg and DBP <80 mm Hg
Stage 1 hypertension: SBP 130–139 or DBP 80–89 mm Hg
Stage 2 hypertension: SBP >140 mm Hg or DBP >90 mm Hg

see: https://www.aafp.org/afp/2018/0315/p413.html

Question 3

According to currently accepted criteria, hypertension in children is defined as repeated blood pressure measurements at or above a threshold of which one of the following percentiles for age, sex, and height?

Answer 3

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 4

Name a condition that is associated with isolated systolic hypertension?

Answer 4

Isolated elevation of systolic blood pressure is secondary to decreased elasticity/compliance of arterial system. It is most commonly secondary to old age.
It can be secondary to conditions associated with elevated cardiac output, such as anemia, Paget’s disease, hyperthyroidism, arteriovenous fistula, and aortic insufficiency. Rarely other cause such as chronic kidney disease, peripheral vascular disease, diabetes mellitus, atherosclerotic renal artery stenosis.

Question 5

According to the National Cholesterol Education Program Adult Treatment Panel III diagnostic criteria, metabolic syndrome may be diagnosed if 3 of these 5 conditions are met.

Answer 5

Obesity, with a waist circumference exceeding 102 cm (40 in) in men or 88 cm (35 in) in women
A blood pressure ≥130 mm Hg systolic and/or ≥85 mm Hg diastolic
A fasting glucose level ≥110 mg/dL
A serum triglyceride level ≥150 mg/dL
An HDL-cholesterol level <40 mg/dL in men or <50 mg/dL in women

Question 6

What are the commonly used nondihydropyridine calcium channel blockers?

Answer 6

diltiazem, cardizem

Question 7

What medication should generally not be used in combination with nondihydropyridine calcium channel blockers

Answer 7

Beta blockers

Too much AV node blockade. Increased risk for bradycardia and heart block.

Question 8

What is the definition of albuminuria

Answer 8

albuminuria, defined as >30 mg of albumin/g of creatinine on a urine test- regardless of GFR

Question 9

If a patient is hypertensive and has evidence of early chronic kidney disease, what would be an HTN agent that should be used first, or added?

Answer 9

(ACE) inhibitor or ARB
ACE inhibitors are first-line therapy in all patients who have HF or asymptomatic LV systolic dysfunction, in all patients who have had an ST elevation MI, in patients with a non-ST elevation MI who have had an anterior infarction, diabetes, or systolic dysfunction, and in patients with proteinuric chronic kidney disease. JNC 8 panel recommends initial (or add-on) antihypertensive treatment with an ACE inhibitor or angiotensin receptor blocker to improve kidney outcomes, regardless of ethnicity or diabetes status (SOR B).

Question 10

As a first line agent for HTN, which is better, a thiazide-like diuretic or Thiazide- type diuretics

Answer 10

Thiazide like diuretics are more potent and last longer
Chlorthalidone vs Hydrochlorthiazide
However, Chlorthalidone (hygroton) may cause hypokalemia

Question 11

Why are betablockers not considered first line initial monotherapy in treatment of HTN

Answer 11

Inferior protection against stroke risk

Often associated with symptoms of fatigue, weakness

Question 12

The prevalence of HTN is greater overall in men or women? After age 60?

Answer 12

Greater in men overall but after 60yrs old, greater in women

Question 13

Do men or women have a higher risk of ACE inhibitor related cough?

Answer 13

The risk for ACE inhibitor–associated cough appears higher in women, as does the risk of ankle edema occurring with the use of a calcium channel blocker.
Men have more gout from diuretics!

Question 14

What antihypertensive agent should be stopped immediately if a pregnant patient is on it, and has preeclampsia?

Answer 14

diuretics should be discontinued immediately if superimposed preeclampsia develops, because of the potential for reduced uteroplacental blood flow due to reduced plasma volume in women with this complication.

They also should be off ACE and ARB

Question 15

What tests are recommended by the AAP for patients with hypertension

Answer 15

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

For adolescents and pediatric patients who have obesity and hypertension, recommended tests also include hemoglobin A1c, 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.

Question 16

What is the most common cause of secondary hypertension in preadolescent children?

Answer 16

renal parenchymal disease is the most common secondary cause of elevated blood pressure. Less common causes include renovascular hypertension, coarctation of the aorta, and endocrine abnormalities.

Question 17

What is the predominant form of HTN in older patients over the age of 60

Answer 17

isolated systolic hypertension, generally defined as a systolic blood pressure >160 mm Hg with a diastolic blood pressure <90 mm Hg, is the predominant form of hypertension seen in older persons.

Question 18

What is the major predictor of ischemic heart disease before the age of 50?
What about after 60yrs old?

Answer 18

diastolic BP

Systolic BP

Question 19

Is it normal for BP to go up with age?

Answer 19

Both systolic and diastolic blood pressure increase linearly with age up to the fifth or sixth decade of life.

Question 20

Does lowering blood pressure with medication in patients over the age of 80yrs decrease cardiovascular risk?

Answer 20

(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.

Question 21

name the dietary approach that has the greatest impact on BP reduction

Answer 21

DASH diet- 11%

Question 22

What BP medications can reduce Uric Acid levels

Answer 22

Losartan, Calcium Channel blockers

Question 23

What supplement is recommended for the primary prevention of hypertension and has also been shown to significantly lower blood pressure in patients who have hypertension?

Answer 23

Potassium

Question 24

Does aerobic exercise reduce BP in hypertensive patients? Normotensive patients?

Answer 24

Both 5-8 mmHg

Question 25

What type of people can get a decrease in insulin resistance with regular exercise?

Answer 25

Hypertensive patients

Question 26

do sedentary individuals have a higher risk of HTN?

Answer 26

Sedentary individuals have been found to have a 30%–50% higher risk of developing hypertension compared to those who exercise regularly.

Question 27

T/F Dynamic resistance training can reduce BP

Answer 27

True

Question 28

What is the recommended salt reduction level for reduction of BP.

Answer 28

Although the optimal goal for sodium consumption is ≤1500 mg daily, the American Heart Association recommends aiming for a reduction of at least 1000 mg daily in most adults.

Question 29

Is alcohol avoidance recommended for BP reduction

Answer 29

Limited consumption of alcohol (two drinks per day in men and one drink per day in women) may lower systolic blood pressure by 2–4 mm Hg.

Question 30

Name 5 anti-hypertensive medication classes that have been shown to reduce cardiovascular events in patients with diabetes

Answer 30

The use of ACE inhibitors, ARBs, β-blockers, diuretics, and calcium channel blockers has been shown to be effective in reducing cardiovascular events in patients with diabetes mellitus.

Question 31

the The ALTITUDE study showed that Aliskiren (a renin inhibitor) should not be prescribed simultaneously with what two meds

Answer 31

(ARBs) or ACE inhibitors

Question 32

What is the target systolic BP when treating the average patient over the age of 60yrs old for hypertension

Answer 32

This is quite controversial. However,
JNC 8 panel recommends a goal SBP of <150 mm Hg and a goal diastolic blood pressure of <90 mm Hg in those age 60 or over. The AAFP and the ACP encourage a treatment goal of <150 mm Hg in most patients age 60 or older with consideration of treatment to lower targets for some patients in the context of shared decision-making. The ACC/AHA disagree

Question 33

What anti-hypertensives should be avoided in patients with Ischemic systolic HF?

Answer 33

Diltiazem, Veramamil
Certain drug classes should be avoided in patients who have ischemic systolic heart failure with hypertension. Nondihydropyridine calcium channel blockers such as diltiazem and verapamil should not be prescribed because of their negative inotropic properties and the increased likelihood of exacerbating heart failure symptoms. Clonidine should be avoided in these patients, even though it is effective for treating hypertension, because monoxidine, a drug in the same class, has been associated with increased mortality in patients with heart failure.

Question 34

What is not considered a first line, or first choice anti-hypertensive agent any longer

Answer 34

Beta-blocker. JNC 8 panel recommend that for the general non–African-American 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 35

What is generally considered first-line pharmacologic treatment of hypertension for black patients?

Answer 35

includes thiazide diuretics or calcium channel blockers.

Question 36

What is included in the differential diagnosis of true drug-resistant hypertension

Answer 36

obstructive sleep apnea, primary hyperaldosteronism, pheochromocytoma, Cushing syndrome, chronic kidney disease, renal artery stenosis, and thyroid disease.

Question 37

What is recommended as the 4th add on medication class when a patient is resistant to a 3 class anti-hypertensive regimen?

Answer 37

An angiotenson antagonist. spironolactone was the most effective add-on drug for treatment of resistant hypertension.

Question 38

Inadequate diuretic dosing is common in resistant HTN. If 25mg daily of HCTZ is not being effective with other combination meds, what can you switch to?

Answer 38

the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend switching to chlorthalidone or indapamide, based on comparative studies showing significant blood pressure reduction by switching from hydrochlorothiazide to the same daily dose of chlorthalidone. Also could use a mineralcorticoid antaganist like spironolactone if K+ is not an issue

Question 39

JNC8 recommends that clinicians rely primarily on agents on what four drug classes that have been shown to have the most beneficial effect on overall mortality and cardiovascular, cerebrovascular, and kidney outcomes in patients with hypertension

Answer 39

ACE, ARB,

Thiazides, CCB

Question 40

the presence of heart block greater than first degree would contraindicate the use of what two antihypertensive classes?

Answer 40

β-blockers and nondihydropyridine calcium channel blockers in this patient.

Question 41

What antihypertensive can reduce the occurrence of calcium kidney stones by up to 50%?

Answer 41

Thiazide diuretics

Question 42

What anti hypertensive may lead to toxic lithium levels

Answer 42

Thiazide diuretics may reduce renal clearance of lithium

Question 43

If a patient’s renal function declines after initiation of effective BP medication with good control, what should you do?

Answer 43

Continue the medication. 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.

Question 44

What anti hypertensive agent can be helpful in patients that also have urinary flow problems from BPH

Answer 44

selective alpha-1 Blockers, such as terazosin, doxazosin, or prazosin, are particularly helpful in hypertensive patients with urinary flow obstruction.

Question 45

What anti hypertensive agents can increase risk of hyperkalemia?

Answer 45

clearly aldosterone inhibitors such as spironolactone, amiloride and triamterene. But by virtue of their actions on the angiotensin-renin-aldosterone system, ACE inhibitors, angiotensin receptor blockersand direct renin inhibitors such as aliskiren impair aldosterone release and increase the risk for developing hyperkalemia.

Question 46

Which common antidepressant agent is associated with a dose-dependent rise in blood pressure?

Answer 46

Effexor (Venlafaxine)

Question 47

Name and uncommon cause of secondary HTN that can be paroxysmal

Answer 47

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.

Question 48

What is the best test to diagnose pheochromocytoma?

Answer 48

24 hour urine for metanephrines

Plasma metanephrines are often ordered for convenience. They have a sensitivity of 97% for pheochromocytoma, which is significantly higher than the sensitivity of other measurements. But low specificity.

Question 49

What is Conn’s syndrome?

Fatigue, hypokalemia, hypertension

Answer 49

Primary hyperaldosteronism. It is twice as common in women as in men, and usually occurs between 30 and 50 years of age. In the past, it was estimated that approximately 1% of unselected hypertensive patients had hyperaldosteronism, but more recent data indicates that the prevalence is around 6% in patients with uncomplicated hypertension and as high as 20% in those with resistant hypertension.

Question 50

What is Addison’s disease

Answer 50

Adrenal insufficiency, too little cortisol
Autoimmune destruction of the Adrenal cortex

characterized by progressive anemia, low blood pressure, great weakness, and bronze discoloration of the skin.

Question 51

what antihypertensive is contraindicated in pregnancy, but decrease uric acid levels

Answer 51

ARB- losartan

Question 52

which antihypertensives reduce LVH

Answer 52

ACE/ARB, Beta-blocker, CCB

Question 53

what is the mechanism of action of clonidine

Answer 53

Clonidine- Central acting alpha-2 agonist stimulates alpha-adrenoreceptors in the brain stem. This action results in reduced sympathetic outflow from the central nervous system and in decreases in peripheral resistance, renal vascular resistance, heart rate, and blood pressure. CATAPRES tablets act relatively rapidly.

Question 54

what anti-hypertensive is known to cause peripheral edema?

Answer 54

CCB, diltiazem less than amlodipine

Question 55

best tests for diagnosing RAS - renal artery stenosis

Answer 55

US, may also do CTA or MRI

Question 56

Secondary causes of HTN - endocrine x4

- vascular x3

Answer 56

Thyroid RAS
Hyperaldosteronism Coarctation Aorta
Cushing syndrome Intrinsic renal Dx
Pheochromocytoma

Question 57

First, second and third line drug choices for Hypertension in diabetics

Answer 57

First-line drug - ACE/ARB Second-line drugs -
CCB (non-dihydropyridine), Alpha1 blockers (osins)

Third-line drugs
Thiazides

Beta blockers

Question 58

What are examples of Alpha 1 blockers?

Answer 58

Selective alpha-1 blocker ends with the suffix “-osin.” These medications include alfuzosin, doxazosin, terazosin, tamsulosin, and prazosin.
norepinephrine cannot bind the receptor, causing the blood vessels to dilate. Alpha-1 blocker, blocks alpha receptors and it relaxes the smooth muscles in the bladder.

Question 59

What class of medication is Hydralazine (apressoline)

Answer 59

Vasodilator

Question 60

What is aldomet (methyldopa)

Answer 60

Aldomet belongs to a class of drugs called Alpha2 Agonists, Central-Acting. similar to catapres
Reduces total peripheral resistance and decreased systemic blood pressure. Alpha-2 agonistic activity does not affect cardiac output or renal blood flow.; hence, this drug is useful in hypertensive patients with renal insufficiency.

Question 61

What are the two commonly used CENTRAL acting Alpha 2 agonists?

Answer 61

Clonidine (catapress) Methyldopa (aldomet)

Question 62

Other than beta blockers, what is one of the few anti-hypertensive agents used for pregnant patients

Answer 62

Aldomet (methyldopa)

Question 63

what medication that may be used for HTN can cause gynecomastia

Answer 63

Spironolactone induces gynecomastia by decreasing testosterone production, increasing peripheral conversion of testosterone to estradiol, and displacing estradiol from sex hormone-binding globulin. Generally, discontinuation of treatment results in resolution of gynecomastia.

Question 64

what is Enrtesto (sacubitril/valsartan)

Answer 64

The combination drug sacubitril/valsartan,is a treatment for heart failure. Sacubitril is a neprilysin inhibitor

Question 65

Determining a patient’s capacity to make their own medical decisions should assess what?

Answer 65

Capacity is the basis of informed consent. Patients have medical decision-making capacity if they can demonstrate understanding of the situation, appreciation of the consequences of their decision, and reasoning in their thought process, and if they can communicate their wishes.

Question 66

Breast cancer has decreased in …

Answer 66

Mortality, not incidence

Question 67

Indication for Cardiac Resynchronization Therapy (CRT)

Answer 67

The key indication for CRT is left bundle branch block (LBBB) of the heart, a cardiac abnormality leading to delayed left ventricular contraction. LBBB causes a QRS prolongation of >120 ms on the electrocardiogram, contributing to poor left ventricular coordination and reduced systolic function, thereby reduced ejection fraction (<35%).