Hypertension

Question 1

What is the normal blood pressure?

Answer 1

Normal: SBP <120 mmHg and DBP <80 mmHg

Question 2

What are the main risk factors for hypertension?

Answer 2

Family history

Black

High salt intake

Alcohol

Obesity

Inactivity

Question 3

At what blood pressure is a patient prehypertensive?

Answer 3

Elevated (Prehypertensive): SBP 120–129 mmHg and DBP <80 mmHg

Question 4

What is the workup for a patient who is prehypertensive?

Answer 4

lifestyle modification and routine follow up.

no meds.

Question 5

At what blood pressure is a patient in Stage 1 Hypertension?

Answer 5

Stage 1 Hypertension:
SBP 130–139 mmHg or DBP 80–89 mmHg

Question 6

What is the appropriate management strategy for patients in stage 1 hypertension?

Answer 6

lifestyle changes

Question 7

What lifestyle modifications are effective in lowering blood pressure, and which has the greatest impact?

Answer 7

Weight loss: Greatest reduction in BP (5–20 mmHg per 10 kg lost).

DASH diet: High fruits/vegetables, low fat (8–14 mmHg reduction).

Reduced salt intake: ≤2.4 g sodium/day (2–8 mmHg reduction).

Exercise: Aerobic activity >30 min/day (4–9 mmHg reduction).

Alcohol reduction: ≤2 drinks/day for men, ≤1 for women (2–4 mmHg reduction).

Question 8

At what blood pressure do patients get pharmacological intervention for their hypertension?

Answer 8

140/90 in an average risk patient.

130/80 in a high risk patient.

High risk patients: CAD, HF, Diabetes, CKD, Age >65, ASCVD 10 year risk >10%

Question 9

When do patients with stage 1 HTN obtain medication?

Answer 9

when there is a comorbidity such as DM, CKD, or ASCVD or a 10-year risk of ASCVD of more than 10%

Question 10

At what blood pressure is a patient in Stage 2 Hypertension?

Answer 10

Stage 2 Hypertension:
SBP ≥140 mmHg or DBP ≥90 mmHg

Question 11

What is the appropriate management strategy for patients in stage 2 hypertension?

Answer 11

lifestyle changes with 1-2 anti-hypertensive medications.

Question 12

At what blood pressure is a patient in hypertensive crisis?

Answer 12

Hypertensive Crisis:
SBP ≥180 mmHg and/or DBP >120 mmHg

Hypertensive crisis requires urgent management, with differentiation between urgency and emergency based on end-organ damage.

Question 13

What is the appropriate workup for patients in stage 1 or 2 hypertension?

Answer 13

Patients in Stage 1 or 2 hypertension require individualized treatment strategies based on cardiovascular risk factors such as ASCVD, diabetes or chronic kidney disease (CKD). With these conditions, patients will require medication, even at stage 1. Otherwise, patients are managed conservatively. Medication with 1-2 agents is normally reserved for stage 2 HTN. Every patient will require lifestyle modifications.

Question 14

What conditions may convolute the diagnosis of hypertension?

Answer 14

• White Coat Syndrome: Elevated BP in the doctor’s office.
• Masked hypertension: Falsely low in the doctor’s office.

Diagnose with a 24-hour BP monitoring system or at home monitoring.

Question 15

What is considered to be diagnostic for hypertension?

Answer 15

• 2 readings over the span of a 4 week period.
• Ambulatory or home readings are preferred for confirmation.
• A BP over 130/80 mmHg.

Question 16

What initial workup is recommended for newly diagnosed hypertension?

Answer 16

1) Rule out medication induced hypertension (steroids, NSAIDs, OCPs, or stimulants such as caffeine, nicotine,, or decongestants).

2) As part of initial workup, a fasting lipid profile should be ordered in all hypertensive patients to calculate the risk for cardiovascular events. The target blood pressure is determined, in part, by this risk, with lower targets recommended for those at increased risk. Labs include Renal function (BUN/Cr), urinalysis, CMP (electrolytes and glucose), lipid profile, TSH. An ECG is used to assess for left ventricular hypertrophy or ischemic changes.

Initial evaluation is oriented to the following objectives:
- Detecting end-organ damage that may require more aggressive management
- Assessing other cardiovascular risk factors
- Screening for common secondary causes of hypertension (eg, thyroid disorders, hyperaldosteronism)
- Identifying concurrent conditions and metabolic abnormalities that could influence the choice of antihypertensive therapy

Question 17

What is the most common cause of hypertension in a female of reproductive age?

Answer 17

OCPs

Question 18

What heart conditions are known to develop from chronic hypertension?

Answer 18

Left ventricular hypertrophy on ECG indicates chronic hypertension and an increased risk for cardiovascular complications like heart failure. Additionally, HFpEF can also develop from chronic HTN.

Question 19

What are the first-line medications for hypertension, and how are they selected?

Answer 19

ACE inhibitors/ARBs: Preferred in diabetes, CKD, or heart failure.

Thiazide diuretics: Effective for Black patients or elderly with isolated systolic hypertension.

Calcium channel blockers (CCBs): Also effective in Black patients or in combination therapy for metabolic syndrome.

Question 20

What pharmacologic measure would be appropriate for a young caucasian male with isolated hypertension?

Answer 20

In young Caucasian patients, ACE inhibitors or ARBs are preferred due to renin sensitivity.

Question 21

Can ACE inhibitors and ARBs be combined?

Answer 21

No. ACE inhibitors should not be used with ARBs because of the risk for hyperkalemia and nephrotoxicity.

Question 22

What advantage is there, if any, with combining CCB and ACE inhibitors?

Answer 22

The combination of an ACE inhibitor and a calcium channel blocker may be particularly effective with controlling hypertension and can minimize the edema associated with calcium channel.

Question 23

What pharmacologic measure would be appropriate for a young black male with isolated hypertension?

Answer 23

Black patients without CKD should receive thiazides or CCBs first-line for hypertension. Combination therapy (CCB + thiazide) is often needed for optimal BP control if monotherapy is insufficient.

Question 24

When is isosorbide dinitrate with hydralazine indicated as a first-line medication for hypertension?

Answer 24

The combination of a long-acting nitrate (eg, isosorbide dinitrate) with hydralazine is effective in controlling symptoms of heart failure in patients who cannot take ACE inhibitors or ARBs.

Question 25

Are beta-blockers used as a first line antihypertensive?

Answer 25

Only when patients also have heart failure are Beta blockers given for hypertension. Beta blockers not normally recommended for the initial management of hypertension unless there are specific indications for their use (coronary heart disease or heart failure with depressed ejection fraction).

Question 26

What is a major side effect of CCBs? How can this be mitigated?

Answer 26

Lower extremity edema associated with the use of antihypertensive therapy, specifically due to Dihydropyridine calcium channel blockers (e.g., amlodipine, nifedipine), are known to cause dose-dependent peripheral edema. The mechanism involves precapillary arteriolar dilation without a corresponding dilation in postcapillary venules. This imbalance increases capillary hydrostatic pressure, causing extravasation of fluid into the interstitial space. Adding an ACE inhibitor or ARB, can reduce the pre-capillary dilation, while dilating the post-capillary venules, mitigating edema.

Question 27

What is the "step-up" treatment approach for hypertension?

Answer 27

1) Start with one appropriate antihypertensive medication, (occasionally two medications for stage 2 HTN or high cardiovascular risk). 2) Then maximize the dose of the initial antihypertensive medication if the patient's blood pressure has not been optimally reduced. 3) Add an additional antihypertensive if the maximum dose for the first antihypertensive has been reached and when the patient's blood pressure is at or greater than 20/10 mmHg above the goal blood pressure. 4) Add a third antihypertensive if the maximum dose for the second antihypertensive has been reached. 5) If still hypertensive, evaluate for a secondary cause of hypertension.

Question 28

What *SHOULD* occur prior to the initiation of a third antihypertensive medication?

Answer 28

1) Ensure lifestyle choices are optimal 2) Ensure medication adherence

Question 29

How common is medication non-adherence a factor in uncontrolled HTN?

Answer 29

Medication nonadherence is the most common cause for uncontrolled hypertension and accounts for ~ 40% of cases. Medication nonadherence also is the most common cause for restenosis and thrombosis of heart stents following PCI.

Question 30

Often times hypertension resolves. How is step down treatment managed for patients who were on chronic antihypertensives and desire to stop medication?

Answer 30

Gradually! vvvvvvvvvvvvvv Patients with well-controlled hypertension on a single-drug regimen, who have made significant lifestyle changes—such as achieving substantial weight loss—may often taper and discontinue their medication under close blood pressure monitoring. This approach is typically reserved for individuals whose blood pressure remains well-controlled after these lifestyle modifications, demonstrating that lifelong antihypertensive therapy may not always be necessary in such cases. If no lifestyle modifications have been made, discontinuation of antihypertensive medication will typically cause blood pressure to rise t pretreatment levels. To discontinue a long-acting medication, such as amlodipine, the medication can be taken either every other day or in a lower daily dose (eg, half tablet). Amlodipine carries little risk of rebound hypertension. For short-acting medications (eg, lisinopril), the medication should be taken daily but in a smaller dose (either a half tablet or a smaller prescribe tablet). discontinuation of short-acting beta blockers, which also are only occasionally used for hypertension, can cause rebound hypertension. The blood pressure should be monitored closely over 1-2 months, and if it remains well controlled, the medication can be discontinued and the blood pressure monitored for an additional 1-2 months. All of these medications can be tapered off within a few weeks (eg, 2-3 months), and a longer taper (eg, 6 months) is unnecessary. If the blood pressure rises above the target, the previous dose of medication should be reinstated. The same approach can be used to eliminate drugs from a multidrug antihypertensive regimen.

Question 31

Why is medication usually used prior to chasing the secondary causes of hypertension?

Answer 31

Because the vast majority of causes of hypertension is essential, which means idiopathic, meaning not caused by the known secondary causes for hypertension. However, if there is no or limited response to antihypertensive medications, then the secondary causes should be investigated.

Question 32

A young patient (<35 years) with severe or refractory hypertension (on three anti-hypertensives) should be screened for ...?

Answer 32

**Secondary causes for hypertension** particularly renal artery stenosis secondary to fibromuscular dysplasia or pheochromocytoma.

Question 33

When does **TRUE** resistant HTN occur, how is it defined?

Answer 33

True resistant hypertension exists in patients whose BP remains uncontrolled despite adherence to a regimen of 3 or more antihypertensive medications (1 being a diuretic) and reasonable optimization of lifestyle changes (eg, weight loss, low-sodium diet) and lack abnormal findings (young age [< 30 years old], abrupt onset, or abnormal findings.

Question 34

What clinical findings raise suspicion for secondary hypertension and warrant further evaluation for underlying risk factors?

Answer 34

Evaluation for secondary causes of hypertension is advised for patients with **ANY** of these four conditions: 1) Have resistant hypertension (persistent hypertension despite an appropriate 3-drug regimen). 2) Have an abrupt onset of hypertension. 3) Have developed hypertension at an unusual age (eg, age <30). 4) Have specific abnormal findings on initial evaluation (eg, hypokalemia, hematuria, abdominal bruit, or evidence of end-organ damage [retinal hemorrhage or heart failure]).

Question 35

What are common causes of secondary hypertension, and how do you screen for them?

Answer 35

Renal artery stenosis: Renal Doppler ultrasound (renal artery stenosis). Aortic coarctation: Compare BP in the upper and lower extremities or weakened or delayed femoral pulses CKD: Creatinine Primary hyperaldosteronism: Plasma aldosterone/renin ratio (primary hyperaldosteronism). Pheochromocytoma: 24-hour urine metanephrines (pheochromocytoma). Cushing syndrome: Cortisol levels Obstructive sleep apnea (OSA): Polysomnography (OSA). OCPs: Look at history.

Question 36

What is used to screen for kidney damage secondary to hypertension?

Answer 36

- Frequent UTIs, increased abdominal girth, elevated creatinine, proteinuria, or hematuria, may indicate an underlying genetic cause for renal induced hypertension, requiring work-up for polycystic kidney disease starting with a renal ultrasound. - Renal artery stenosis could be implicated with elevated creatinine, but the first screening tool is with a renal ultrasound. - Diabetes may cause microalbuminuria on urinalysis indicates end-organ kidney damage and may require early ACE inhibitor or ARB therapy.Microalbuminuria is when the urine albumin/creatinine is greater than 29 mg/g.

Question 37

When should ACEi be avoided?

Answer 37

Avoid ACE inhibitors in pregnancy (teratogenic) or patients with bilateral renal artery stenosis.

Question 38

A 77-year-old man with a history of coronary artery disease presents to the emergency department for evaluation of two days of worsening shortness of breath. He has noticed decreased urine output. He has not had fevers, chest pain, or recent travel. Additional past medical history is significant for hypertension for which the patient takes amlodipine. He was also started on lisinopril two weeks ago. The patient has a 40 pack-year smoking history. Temperature is 36.8°C (98.2°F), blood pressure is 190/100 mmHg, pulse is 102/min, respiratory rate is 22/min, and oxygen saturation is 90% on room air. Physical examination reveals rales at the bilateral lung bases and an S4 heart sound. There is bilateral lower extremity pitting edema to the mid calves without overlying erythema. Laboratory findings are significant for an increase in serum creatinine level from 1.2 to 2.2 mg/dL over the past two weeks. Urinalysis reveals mild proteinuria. Chest X-ray is significant for bilateral pulmonary edema. What is the most likely diagnosis?

Answer 38

Renal artery stenosis (RAS) can cause secondary hypertension, and patients can present with symptoms of fluid overload and decreased renal function following ACE inhibitor initiation. It is caused by the narrowing of one or both renal arteries, which triggers the renin-angiotensin-aldosterone system, leading to hypertension. This patient with a history of coronary artery disease, smoking, and hypertension presents with symptoms of pulmonary edema and decreased renal function following the initiation of an angiotensin-converting enzyme (ACE) inhibitor. These findings strongly suggest renal artery stenosis (RAS). Renal artery stenosis (RAS) is narrowing of one or both renal arteries and can result in secondary hypertension due to activation of the renin-angiotensin-aldosterone system (RAAS). This process increases blood pressure and can lead to systemic hypertension. ACE inhibitors, which are often used for managing hypertension, can worsen renal insufficiency in these patients. They reduce angiotensin Il-mediated efferent arteriole vasoconstriction, which can reduce glomerular filtration, thereby raising serum creatinine levels. In addition, RAS may be associated with episodes of "flash" pulmonary edema, leading to acute respiratory distress. A significant physical exam finding that may be present is an abdominal bruit, typically heard in the upper abdomen or flanks, which suggests turbulent blood flow due to the narrowed renal artery. Patients with RAS often have other manifestations of atherosclerotic disease, such as coronary artery disease, peripheral artery disease, and cerebrovascular disease.

Question 39

Other than intermittent palpitations, diaphoresis, headache, and tachycardia, what other symptom tends to be associated with pheochromocytoma?

Answer 39

**Orthostatic hypotension** Pheochromocytomas typically present with episodic hypertension, headaches, palpitations, and diaphoresis.

Question 40

Other than Pheochromocytoma, what is the other endocrine cause for secondary hypertension that also involves diaphoresis and heart palpitations?

Answer 40

Hyperthyroidism.

Question 41

Other than Pheochromocytoma, what is the other endocrine cause for secondary hypertension that also involves low potassium levels and high bicarbonate levels?

Answer 41

Primary aldosteronism.

Question 42

Other than Pheochromocytoma, what is the other endocrine cause for secondary hypertension that also involves low mood and weight gain?

Answer 42

Cushing syndrome.

Question 43

What congenital heart condition, also associated with a bicuspid aortic valve, can lead to secondary hypertension?

Answer 43

Coarctation of the aorta.

Question 44

What assessment tool is used to determine if obstructive sleep apnea is the underlying cause for secondary hypertension?

Answer 44

POLYSOMNOGRAM

Question 45

What are the symptoms of hypertensive urgency versus emergency?

Answer 45

Both: Severely elevated BP (≥180/≥120 mmHg). Hypertensive Urgency: No evidence of end-organ damage. Symptoms (if present) may include mild headache, dizziness, or anxiety. Hypertensive Emergency: Evidence of end-organ damage. CNS: Stroke, encephalopathy, seizures, confusion. Renal: Acute kidney injury, hematuria, proteinuria, MAHA. Cardiovascular: Myocardial ischemia, heart failure, aortic dissection. Pulmonary: Pulmonary edema (shortness of breath, hypoxia, rales, crackles, tachypnea). Ophthalmic: Hypertensive retinopathy with papilledema.

Question 46

What are the first line antihypertensives for hypertensive urgency or emergency when are they used?

Answer 46

oral antihypertensive agents (e.g., clonidine, captopril) are used in hypertensive urgency IV agents like nitroglycerin, labetalol, hydralazine, nicardipine, esmolol, or nitroprusside.

Question 47

A 68-year-old man with a history of hypertension is brought to the emergency department for evaluation of altered mental status and shortness of breath. He stopped taking his antihypertensive medications due to side effects and has not seen his primary physician since then. Temperature is 37.0°C (98.6°F), pulse is 110/min, blood pressure is 220/120 mmg, respiratory rate is 20/min, and oxygen saturation is 96% on 5L nasal cannula. The patient has labored breathing. He is oriented to person only. Pulmonary examination reveals bilateral rales. Fundoscopic examination is significant for papilledema. The electrocardiogram shows evidence of left ventricular hypertrophy without ST elevations or depressions or T-wave abnormalities. Lab results show serum creatinine of 2.5 mg/dL (1.7 mg/dL baseline) and hematuria on urinalysis. Which of the following is the best next step in management?

Answer 47

This patient presents with a hypertensive emergency as evidenced by a severely elevated blood pressure (220/120 mmHg) and evidence of end-organ damage, including neurological (altered mental status, papilledema), cardiovascular (respiratory distress, bilateral rales), and renal impairment (serum creatinine of 2.5 mg/dL). Treatment with intravenous labetalol should be initiated immediately. A hypertensive emergency is characterized by severe hypertension (BP > 180/120 mmHg) with evidence of end-organ damage. In the case of a hypertensive emergency, it is crucial to lower blood pressure promptly to prevent further damage; however, it must be done in a controlled manner to avoid ischemic events. In general, the goal is to reduce the mean arterial pressure (MAP) by no more than 25% within the first hour, followed by a gradual reduction toward 160/100-110 mmHg over the next 2-6 hours. Intravenous antihypertensives (labetalol, esmolol, nicardipine, and hydralazine) should be administered based on the presence of specific comorbid conditions and the side effect profiles of the medications. Intravenous antihypertensive agents, like labetalol, are used for blood pressure control in patients with hypertensive emergencies. Blood pressure should be reduced by no more than 25% within the first hour to avoid potential complications related to rapid correction, such as cerebral hypoperfusion and cardiac ischemia.

Question 48

What short-acting alpha-2 agonist that is occasionally used for severe hypertensive episodes?

Answer 48

Clonidine vvvvvvvvvvvvv Abrupt discontinuation can lead to severe rebound hypertension.

Question 49

what is the MAX that a patient's BP should be decreased by when experiencing hypertensive emergency or urgency?

Answer 49

The MAP should be reduced by a maximum of 20% in the first hour but no more than 25% within the first 24 hours. Overaggressive reduction in the BP can lead to ischemic end organ damage due to the inability to auto-regulate appropriately.

Question 50

When the patient is in hypertensive emergency and their BP is being reduced, aside from reducing the BP by 25% from baseline, what marker of reduction can be used instead?

Answer 50

less than 160/100 mmHg

Question 51

What complications are associated with untreated hypertension?

Answer 51

Cerebrovascular: Stroke (80% thromboembolic). Hypertension is the most important risk factor for cerebral infarctions. BP control reduces the risk of stroke and heart failure more effectively than any other intervention. Cardiac: Left ventricular hypertrophy, heart failure, coronary artery disease. Renal: Chronic kidney disease, nephrosclerosis. Vascular: Aortic dissection, aneurysm. Ophthalmic: Hypertensive retinopathy.

Question 52

What retinal changes occur secondary to hypertensive states?

Answer 52

Hypertensive retinopathy presents with papilledema, flame hemorrhages, or cotton-wool spots on fundoscopic examination.

Question 53

What is the management strategy for hypertensive urgency versus hypertensive emergency?

Answer 53

Hypertensive Urgency: No evidence of end-organ damage; managed by gradually lowering BP over 24 hours with oral antihypertensive agents (e.g., clonidine, captopril). Hypertensive Emergency: Evidence of end-organ damage (e.g., stroke, encephalopathy, AKI, aortic dissection). BP should be lowered by 25% in the first hour, then gradually over 24–48 hours using IV agents like nicardipine, esmolol, or nitroprusside.

Question 54

A 55-year-old man with a history of untreated hypertension presents to the emergency department with severe headache, nausea, and confusion that began 6 hours ago. On examination, his blood pressure is 220/125 mmHg, heart rate is 90/min, and respiratory rate is 18/min. Neurological examination reveals mild disorientation and difficulty with attention but no focal deficits. Fundoscopic examination shows bilateral papilledema. Serum creatinine is 2.4 mg/dL (baseline 1.1 mg/dL), and urinalysis reveals proteinuria and hematuria. Head CT shows no evidence of intracranial hemorrhage. What is the most appropriate next step in management? a) Oral clonidine b) Intravenous nicardipine c) Intravenous furosemide d) Observation and repeat blood pressure in 2 hours e) Intravenous labetalol

Answer 54

This patient has hypertensive emergency characterized by severely elevated blood pressure and evidence of end-organ damage, including hypertensive encephalopathy (headache, confusion, papilledema) and acute kidney injury (elevated creatinine). The goal is to reduce mean arterial pressure (MAP) by no more than 20% in the first hour to avoid ischemia, then gradually normalize BP over 24–48 hours, ensuring that there is no more than a 25% reduction of BP in the first 24-hours. IV nicardipine, a calcium channel blocker, is ideal for controlled BP reduction in this scenario. Labetalol (e) is an alternative but not preferred in renal impairment due to its combined beta- and alpha-blocking effects. Clonidine (a) is used for hypertensive urgency but is too slow for hypertensive emergencies. Furosemide (c) is not first-line unless there is pulmonary edema. Observation (d) is inappropriate given the end-organ damage.

Question 55

A 48-year-old woman with a history of essential hypertension presents to her primary care clinic complaining of mild headache and lightheadedness for 2 days. Her home blood pressure readings have been consistently high over the last week, averaging 180–190/110–115 mmHg. She denies chest pain, shortness of breath, vision changes, or neurologic symptoms. On examination, her blood pressure is 185/115 mmHg, pulse is 88/min, and the remainder of her physical exam is unremarkable. Basic metabolic panel, urinalysis, and fundoscopic examination show no evidence of end-organ damage. What is the most appropriate next step in management? a) Initiate IV labetalol b) Administer oral clonidine in the office c) Schedule outpatient follow-up within 1 week d) Start oral captopril and reassess in 30 minutes e) Admit for observation and continuous BP monitoring

Answer 55

This patient has hypertensive urgency, defined as severely elevated blood pressure (≥180/≥110 mmHg) without end-organ damage. The goal is to lower BP gradually over 24–48 hours to prevent ischemia from overly aggressive BP reduction. Oral captopril, a short-acting ACE inhibitor, is an appropriate option for BP control and allows reassessment in the clinic before discharge. IV labetalol (a) and hospital admission (e) are unnecessary in the absence of end-organ damage. Clonidine (b) is another option but may cause rebound hypertension if not continued. Follow-up alone (c) is inadequate without an initial intervention.