Hypertension

Question 1

What are the main risk factors for hypertension?

Answer 1

Family history

Black

High salt intake

Alcohol

Obesity

Inactivity

Question 2

What is the normal blood pressure?

Answer 2

Normal: SBP <120 mmHg and DBP <80 mmHg

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

When do patients with stage 1 HTN obtain medication?

Answer 7

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

Question 8

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

Answer 8

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

Question 9

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

Answer 9

lifestyle changes with 1-2 anti-hypertensive medications.

Question 10

At what blood pressure is a patient in hypertensive crisis?

Answer 10

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 11

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

Answer 11

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 12

At what BP do patients get pharmacological intervention for their hypertension?

Answer 12

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 13

What are the symptoms of hypertensive urgency versus emergency?

Answer 13

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 14

What condition may convolute the diagnosis of hypertension?

Answer 14

White Coat Syndrome

Elevated BP 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.

Question 16

What initial workup is recommended for newly diagnosed hypertension?

Answer 16

Labs: Renal function (BUN/Cr), urinalysis, electrolytes, glucose, lipid profile, TSH.

ECG: To assess for left ventricular hypertrophy or ischemic changes.

Question 17

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

Answer 17

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 18

What heart condition is due to chronic hypertension?

Answer 18

Left ventricular hypertrophy on ECG indicates chronic hypertension and an increased risk for cardiovascular complications like heart failure.

Question 19

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

Answer 19

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 20

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

Answer 20

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 21

What is a major side effect of CCBs?

How can this be mitigated?

Answer 21

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 22

What is the treatment approach for hypertension?

Answer 22

1) Start an appropriate antihypertensive

2) Maximize the dose

3) Add an additional antihypertensive

4) Add a third antihypertensive

5) if still hypertensive, evaluate for a secondary cause of hypertension.

Question 23

What SHOULD occur prior to initiation of a third anti-hypertensive medication?

Answer 23

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

Question 24

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

Answer 24

more than 40% of cases.

Question 25

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

Answer 25

secondary causes for hypertension.

particularly fibromuscular dysplasia or pheochromocytoma.

Question 26

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

Answer 26

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).

Question 27

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

Answer 27

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

Question 28

When should ACEi be avoided?

Answer 28

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

Question 29

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

Answer 29

OCPs

Question 30

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

Answer 30

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 31

What complications are associated with untreated hypertension?

Answer 31

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 32

What retinal changes occur secondary to hypertensive states?

Answer 32

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

Question 33

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

Answer 33

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 34

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 34

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 35

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 35

less than 160/100 mmHg

Question 36

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 36

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.

Clonidine (b) is another option but may cause rebound hypertension if not continued.
Follow-up alone (c) is inadequate without an initial intervention.
IV labetalol (a) and hospital admission (e) are unnecessary in the absence of end-organ damage.

Question 37

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

Answer 37

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 38

What are the first line antihypertensives and when are they used?

Answer 38

oral antihypertensive agents (e.g., clonidine, captopril) are used in hypertensive urgency

IV agents like nitroglycerin, labetalol, hydralazine, nicardipine, esmolol, or nitroprusside.