Hypertensive Cases Quiz Flashcards
Which of the following medications are most likely to be effective for initial BP lowering in patients with low renin?
A) Hydrochlorothiazide
B) Lisinopril
C) Amlodipine
D) A and B
E) A and C
E - HCTZ is a thiazide diuretic and amlodipine is a DHP calcium channel blocker - both are considered first line agents for patients with HTN and low renin (African american patients). Lisinopril is an ACE inhibitor which is not considered a first line BP med for low renin patients unless there is an additional compelling indication such as diabetes or chronic renal dysfunction
A 67 y/o man with asthma, BPH, and CKD is diagnosed with HTN. What initial therapy is best to prescribe for this particular patient?
A) Hydrochlorothiazide 12.5 mg daily
B) Losartan 50 mg daily
C) Amlodipine 5 mg
D) Hydralazine 25 mg daily
B - the first line therapy for HTN treatment would be either thiazide diuretic, CCB, or ACE/ARB. However, this patient has a compelling indication due to his CKD in which the first line therapy for all patients (no matter age, etc) with CKD is an ACEi or ARB.
Hydralazine is sued in combination for treatment of HF in some patients, however when treating HTN hydralazine should be reserved for patients whose HTN does not respond to first line agents.
JM a 58 year old man has a history of type 2 diabetes mellitus that is not well controlled. He has recently developed mild hypertension that has not been controlled by lifestyle changes. You prescribe lisinopril 20 mg daily and 2 months later you note that his serum creatinine level has increased from 1.25 mg/dL to 1.5 mg/dL (baseline 0.64-1.27) and his BP has decreased from 142/88 mmHg to 128/78 mmHg.
Which one of the following should you do now?
A) Continue the current dosage of lisinopril
B) Decrease the dosage of lisinopril to 10 mg
C) Increase the dosage of lisinopril to 40 mg
D) Discontinue lisinopril and initiate chlorthalidone
E) Discontinue lisinopril and initiate losartan
A - your patient is currently at his goal BP of <130/80 so no medication changes are needed unless he is experiencing adverse effects. A rise in serum creatinine is a known side effect of ACE inhibitors such as lisinopril. These medications do not need to be discontinued unless baseline creatinine increases by >30% (this patient’s creatinine increased by 20%)
PD is a 55 year old man and has New York Heart Association class III chronic systolic heart failure due to hypertensive cardiomyopathy.
Which one medication is contraindicated in this patient?
A) Carvedilol
B) Digoxin
C) Ramipril
D) Spironolactone
E) Verapamil
E - ACE inhibitors and beta blockers improve mortality in HF. Digoxin and furosemide improve symptoms and reduce hospitalizations in systolic HF. Spironolactone, an aldosterone antagonist, reduces all cause mortality and improves ejection fractions in systolic HF. Verapamil, due to its negative inotropic effect, is associated with worsening HF and an increased risk of adverse cardiovascular events.
AS is a 55 year old man with a 4 year history of type 2 diabetes mellitus who was noted to have microalbuminuria 6 months ago, and returns for a follow up visit. He has been on an ACE inhibitor and his blood pressure is 140/90 mm Hg.
The addition of which one of the following medications is unnecessary and might increase the likelihood that dialysis would become required?
A) Hydrochlorothiazide
B) Amlodipine
C) Atenolol
D) Clonidine
E) Losartan
E - patients with diabetes mellitus, atherosclerosis, and end organ damage benefit from ACEs and ARBS equally when they are used to prevent progression of diabetic nephropathy. Combining an ACE inhibitor with an ARB is not recommended, as it provides no additional benefit and leads to higher creatinine levels, along with an increased likelihood that dialysis will becoming necessary.
RR is a 54 year old man who 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. All laboratory tests have been WNL. His medications include chlorthalidone 12.5 mg daily, carvedilol 25 mg twice daily, amlodipine 10 mg daily, and lisinopril 40 mg daily. He has been intolerant to clonidine in the past.
Which one of the following medication changes would be most reasonable?
A) Adding isosorbide mononitrate
B) Adding spironolactone
C) Substituting furosemide for chlorthalidone
D) Substituting losartan for lisinopril
B - spironolactone is recommended for treating resistant hypertension, even when hyperaldosteronism is not present. A longer acting diuretic such as chlorthalidone is also recommended for treating HTN, 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.
Your patient with recently diagnosed hypertension has very stable blood pressure at the high end of guideline values (133/85 down from 150/92 pre-treatment) while taking amlodipine 5 mg per day. Recently she noticed edema in her lower extremities and is very concerned about this adverse effect. Her other labs are stable, your examination has not found other significant findings, and her cardiac and her renal function is at healthy values and has not changed during treatment, Since she has improved her blood pressure values with amlodipine, and has no other adverse effects you would like to continue this medication. You decide to add a medication to offset the edema caused by amlodipine. You choose:
A) Hydrochlorothiazide 25 mg PO daily
B) Chlorthalidone 12.5 mg PO daily
C) Furosemide 40 mg PO BID
D) Losartan 50 mg PO daily
D - calcium channel antagonist related edema is due to elevated capillary pressures, NOT elevated sodium and fluid (so thiazide and loop diuretics would not help.) An ACE or an ARB will act to reduce the elevated capillary pressure for this patient.
