A 67-year-old woman is brought to your office by her daughters.

They report that she has not seen a doctor in many years. The patient states that she feels "fine" and specifically denies dyspnea, leg swelling, chest pain, abdominal pain, headache, or change in mental status. Her blood pressure is 172/104 mm Hg bilaterally. Her physical exam is notable only for an S4 gallop and grade 2 systolic ejection murmur. In considering your initial evaluation of this patient, which of the following is most appropriate?

A. Immediate referral to the emergency department B. Performance of exercise stress echocardiography C. Measurement of urinary catecholamines and metabolites D. Initiation of two-drug therapy with lisinopril 10 mg and hydrochlorothiazide 12.5 mg daily with follow-up in 1 week E. Initiation of therapy with hydrochlorothiazide 12.5 mg daily with follow-up in 3 months
Correct Answer: Initiation of two-drug therapy with lisinopril 10 mg and hydrochlorothiazide 12.5 mg daily with follow-up in 1 week This patient presents with stage 2 hypertension with no evidence of rapidly progressive end-organ damage. Appropriate initial management would include evaluation of serum electrolytes and creatinine, initiation of two-drug therapy (including a diuretic), and follow-up in a relatively short period of time.

A 62-year-old man with a 20-year history of type 2 diabetes presents to your office to establish care. He denies a history of retinopathy or nephropathy. At the first visit, you find his blood pressure to be 134/84 mm Hg. You draw labs and find his hemoglobin A1c to be 6.5% and his urine albumin/creatinine ratio to be 12 mg/g. After implementing dietary and lifestyle changes, his blood pressures on the second and third visits are 138/82 mm Hg and 132/78 mm Hg. What is the most appropriate action to take regarding his blood pressure? A. Ask him to return in 3 months for a repeat blood pressure measurement B. No action is necessary because his blood pressure is below 140/90 mm Hg C. Start an angiotensin-converting enzyme (ACE) inhibitor to lower blood pressure D. Start a diuretic to lower blood pressure E. No action is necessary because he has no history of nephropathy and his albumin excretion is normal
Correct Answer: Start an angiotensin-converting enzyme (ACE) inhibitor to lower blood pressure For a patient with diabetes, the blood pressure goal is less than 130/80 mm Hg. This patient's blood pressure is above that target and an agent should be started (despite no evidence of nephropathy or microalbuminuria). Taking no action or repeating the blood pressure measurement for a fourth time is inappropriate. In diabetics, an ACE

inhibitor or angiotensin receptor blocker is preferred to a diuretic, both to prevent nephropathy and to avoid the dysglycemic effects of diuretics.

In which of the following patients is a secondary cause of hypertension unlikely? A. An 18-year-old woman with newly diagnosed hypertension B. A 55-year-old man with previously well-controlled hypertension on a diuretic and ACE inhibitor (130/80 mm Hg at last month's visit) who presents with a blood pressure of 185/95 mm Hg despite adherence to medications C. A 37-year-old woman with new-onset hypertension, weight loss, and tachycardia D. A 66-year-old woman with poorly controlled hypertension despite excellent adherence to maximal doses of a thiazide diuretic, lisinopril, and nifedipine E. A 35-year-old overweight patient with newly diagnosed hypertension but no family history of the disease
Correct Answer: A 35-year-old overweight patient with newly diagnosed hypertension but no family history of the disease The 35-year-old overweight patient with newly diagnosed hypertension is the right age to have essential hypertension. There is no obvious reason to suspect a secondary cause. Clinicians should have a high suspicion for a secondary cause when the onset of hypertension is at a very young age (Answer A), when there is sudden recurrence of hypertension in a previously well-controlled patient (Answer B), or when the hypertension is very resistant, defined as continued elevation on three or more drugs, including a diuretic (Answer D). The patient in Answer C has other concerning symptoms (weight loss and tachycardia) that would make one consider a secondary cause, such as thyrotoxicosis.

A 47-year-old male with diabetes presents as a new patient to your clinic. He does not recall any abnormal blood pressure readings. You find his blood pressure to be 138/86 mm Hg on two readings during this visit. You should A. Start hydrochlorothiazide (HCTZ) 12.5 mg every day B. Provide lifestyle counseling and start HCTZ 12.5 mg every day C. Provide lifestyle counseling and recheck blood pressure within a few months

D. Do nothing now and recheck blood pressure within 1 year E. Do nothing now and recheck blood pressure within a few months

Correct Answer: Provide lifestyle counseling and recheck blood pressure within a few months Although drug therapy is indicated for diabetics with blood pressure greater than 130/80 mm Hg, it is first necessary to establish the diagnosis of hypertension, which requires elevated readings on at least two separate office visits. Lifestyle modification counseling, however, should begin immediately.

A 48-year-old woman presents to the emergency room with headache and a blood pressure of 192/104 mm Hg. She has a long history of hypertension, for which she has been treated in the past with benazepril, hydrochlorothiazide, and sustained-release metoprolol. She does not have a history of coronary artery disease. After careful interviewing, you determine that she stopped taking her antihypertensive medications approximately 2 months ago because she was feeling well and "did not want to be dependent on medications." She reports no other symptoms. On examination, she appears comfortable and is fully alert and oriented. Funduscopic examination reveals arteriovenous crossing changes but no papilledema. The cardiac examination is notable for a fourth heart sound and a grade 2 systolic ejection murmur at the left lower sternal border. The chest x-ray shows a mildly increased cardiothoracic ratio and aortic calcifications. The electrocardiogram shows increased QRS voltage consistent with left ventricular hypertrophy. Urinalysis reveals 1+ proteinuria with no cells or casts. Blood urea nitrogen, creatinine, and electrolytes are all within normal limits. Head computed tomography scan is unremarkable. Appropriate management of this patient would include A. Admission to the intensive care unit and administration of intravenous nitroprusside B. Admission to the intensive care unit and administration of intravenous esmolol C. Admission to the hospital ward and resumption of her usual medications D. Administration of oral clonidine 0.3 mg, observation in the clinic for 2 hours, and resumption of her usual medications E. Resumption of her usual medications and follow-up in the outpatient clinic within 1 week

Correct Answer: Resumption of her usual medications and follow-up in the outpatient clinic within 1 week Although this patient presents with stage 2 hypertension and evidence of end-organ damage (i.e., proteinuria and left ventricular hypertrophy), she has no evidence of acutely progressive organ damage. Additionally, there is a good explanation for her hypertension: nonadherence. She should respond well to resumption of her usual medications. The primary focus of management of this patient should be maintaining adherence to her medication regimen. The use of clonidine to lower her blood pressure rapidly has not been shown to decrease her risk of acute complications and may lead to symptomatic hypotension.

A 72-year-old white female, previously well controlled on chlorthalidone 25 mg daily, presents with a rise in her blood pressure to 170/110 mm Hg. You add 5 mg of lisinopril, and her creatinine rises from 1.1 to 1.9. What do you suspect? A. Nonadherence B. Hypertensive nephrosclerosis C. Hyperaldosteronism D. Atherosclerotic renal artery stenosis E. Pheochromocytoma

Correct Answer: Atherosclerotic renal artery stenosis The recurrence of hypertension in a previously well-controlled patient should prompt the clinician to consider nonadherence to the medication, as well as a secondary cause of hypertension. The rise in creatinine after addition of an angiotensinconverting enzyme inhibitor, however, is most suggestive of renal artery stenosis.

A 47-year-old male with type 2 diabetes returns for follow-up. You find his blood pressure to be 162/74 mm Hg in the right arm. One month ago, his blood pressures were 156/78 mm Hg in the left arm and 160/72 mm Hg in the right. He has attempted to modify his diet and to exercise. Urinalysis shows microalbuminuria. The most appropriate management for this patient's blood pressure would be

A. Lisinopril 5 mg daily B. Amlodipine/benazepril 5/10 mg daily C. Hydrochlorothiazide 12.5 mg daily D. Continue lifestyle modification and recheck blood pressure in 2 months E. Do nothing now and recheck blood pressure in 2 months

Correct Answer: Amlodipine/benazepril 5/10 mg daily The diagnosis of stage 2 hypertension is established in this patient. The presence of diabetes places him at high risk of complications from hypertension and warrants the initiation of drug therapy. Although hydrochlorothiazide is appropriate in most patients with hypertension, the use of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker is preferred in diabetics. Furthermore, initial therapy with two drugs is appropriate in a patient with stage 2 hypertension, whose blood pressure would not likely be controlled on a low dose of a single agent.

A 42-year-old obese male returns for follow-up. His last visit with you was 3 years ago, and since that time his weight has increased by 15 kg, such that his body mass index is now 32 kg/m2. He reports feeling tired during the day, and has increased his coffee consumption to 4 cups per day and his tobacco use to one pack of cigarettes per day. His blood pressure has increased from 136/86 mm Hg at last visit to 152/90 mm Hg today. He states that he has not drunk coffee or smoked in the last 6 hours. Which of the following is most likely to be contributing to his elevated blood pressure at this visit? A. Type 2 diabetes B. Excessive licorice consumption C. Obstructive sleep apnea D. Increased coffee intake E. Tobacco use

Correct Answer: Obstructive sleep apnea Type 2 diabetes is an important comorbidity in patients with hypertension, but not a cause of hypertension. Excessive licorice intake is a very rare cause of hypertension. Obstructive sleep apnea is a common identifiable cause of hypertension. Coffee and tobacco use can raise blood pressure acutely, but do not substantially increase the risk of development of sustained hypertension.

A 67-year-old woman is brought to the emergency room by her son. He states that she has been "acting strangely" for the last day or so. According to her records, her usual antihypertensive regimen consists of lisinopril/hydrochlorothiazide 20/25 mg daily, extended-release nifedipine 90 mg daily, and sustained-release metoprolol 50 mg every day. Her son indicates that she ran out of her medication 1 week ago. On examination, the patient is confused, somnolent, and complaining of headache. Her blood pressure is 230/114 mm Hg bilaterally. Funduscopic examination shows arteriolar narrowing and indistinct optic disk margins. The lung examination reveals no crackles; the cardiac examination is significant for an S4 gallop and a grade 2 mid-systolic ejection murmur. The abdomen is soft and nontender with no bruits. No peripheral edema is present. Appropriate management would include each of the following except A. Administration of clonidine 0.3 mg by mouth every 6 hours B. Admission to the intensive care unit (ICU) C. Computed tomography (CT) scan of the brain D. Measurement of serum creatinine, sodium, and potassium E. Placement of an arterial line

Correct Answer: Administration of clonidine 0.3 mg by mouth every 6 hours This patient is presenting with signs and symptoms of hypertensive encephalopathy a hypertensive emergency. Appropriate initial management includes admission to the ICU, placement of an arterial line to monitor blood pressure (BP), and administration of intravenous agents to lower BP. A noncontrast head CT scan is appropriate to exclude other causes of altered mental status, including intracerebral hemorrhage. Administration of oral agents may result in unpredictable rates of BP lowering and is not recommended.

A 37-year-old man presents to the outpatient clinic for a routine health maintenance examination. His height is 180 cm and his weight is 102 kg. Blood pressure (BP) in both arms is 148/86 mm Hg. He reports no chest pain, dyspnea, abdominal pain, or headache. He is asked to return in 1 month for follow-up, and at that time his BP is 146/90 mm Hg. Laboratory studies performed at the previous visit showed no abnormalities in the serum glucose, electrolytes, and creatinine, normal urinalysis, and normal resting electrocardiogram. The patient states that he wishes to avoid taking medication if possible. Currently, he smokes 10 cigarettes per day, drinks 3 cups of coffee per day, consumes 1 glass of wine per day, and exercises infrequently. Which of the following is most likely to result in significant improvement in his blood pressure? A. Discontinuation of all alcohol use B. Discontinuation of all tobacco use C. Relaxation therapy and stress management techniques D. Reduction of coffee intake to fewer than 2 cups per day E. Loss of 5 kg through diet and exercise

Correct Answer: Loss of 5 kg through diet and exercise Limitation of alcohol use to 1 ounce (of ethanol) or less in men, limitation of sodium intake to 2.4 g, and weight loss of 10 pounds or more are established means of controlling BP. Relaxation therapy, discontinuation of tobacco, and discontinuation of caffeine have not been shown to consistently lower BP.

A 49-year-old female with established hypertension returns to the clinic for follow-up. She has been monitoring her blood pressure (BP) at home using an automated device with an arm cuff. She states that she takes several measurements every morning, and provides you with a list of blood pressures. She asks you if you think her measurements are accurate. Which of the following is not a potential cause of inaccurate BP readings? A. Use of a cuff that is smaller than recommended B. Taking of two blood pressure measurements in succession in the same arm C. Measurement of blood pressure in the right arm only D. Measurement of blood pressure with the arm held in front of the body at shoulder height E.

Consumption of caffeine 15 minutes prior to measurement

Correct Answer: Taking of two blood pressure measurements in succession in the same arm It is not necessary to wait more than about 1 minute in between measurements, even in the same arm. Use of a cuff that is too small may falsely elevate BP readings. BP should be measured in both arms and the higher of the two measurements used for management. The arm should be relaxed and at the level of the heart. Caffeine and tobacco should not be consumed in the 30 minutes prior to measurement.

A 62-year-old man with a history of hypertension and type 2 diabetes mellitus presents to the emergency department with headache and confusion for the past 5 hours. His son states that he ran out of his blood pressure medications last week. Prior to that, his blood pressure had been well controlled on lisinopril and nifedipine. In the emergency department, the patient's vital signs are blood pressure 210/120 mm Hg, pulse 96 beats/min, respirations 14 breaths/min, and temperature is 97.8F. Physical examination is notable for a left ventricular heave and an S4 gallop. His lungs are clear. He is oriented to name but his neurologic examination is otherwise nonfocal. Initial labs reveal a hematocrit of 40.1% and a creatinine of 2.3 mg/dL. Urinalysis shows 10 to 15 red blood cells (RBCs) per high-power field. The most appropriate management is A. Admission to the hospital and administration of intravenous nitroprusside with a goal of lowering blood pressure by 25% in the first 2 hours B. Resumption of antihypertensive medications and outpatient follow-up within 1 week C. Admission to the hospital for observation and reinstitution of his outpatient medications D. Admission to the hospital and administration of nitroglycerin with the goal of lowering his blood pressure to 130/80 within the first 2 hours E. Admission to the hospital and administration of intravenous enalaprilat, with the goal of lowering his blood pressure to 130/80 within the first 2 hours

Correct Answer: Admission to the hospital and administration of intravenous nitroprusside with a goal of lowering blood pressure by 25% in the first 2 hours This patient has a hypertensive emergency as evidenced by acute organ dysfunction

in the brain and kidneys. Hypertensive emergency is differentiated from hypertensive urgency by the presence of acute target organ damage. Urgency may be treated on an outpatient basis with close follow-up within 24 hours. The appropriate management of hypertensive emergency requires admission to the hospital and intravenous medication to lower blood pressure by roughly 25% in the first 2 hours. Care should be taken to avoid a precipitous decline in blood pressure to normal, which might result in cerebral watershed infarct (from impaired cerebrovascular autoregulation). A reasonable first-line choice is nitroprusside, as it is easily titrated and causes both arterial and venous dilation. Enalaprilat is more useful in emergencies associated with congestive heart failure and results in a more unpredictable fall in blood pressure.

You have been treating a 75-year-old man for hypertension for the last 20 years. He frequently misses medication doses, and his blood pressure is rarely well controlled. In the office today, his blood pressure is 165/90 mm Hg. He states that he feels well. Which of the following would you expect on his physical exam? A. Basilar crackles in the lung fields B. S4 gallop and a left ventricular heave C. S4 gallop and a right ventricular heave D. S3 gallop and a left ventricular heave E. Papilledema

Correct Answer: S4 gallop and a left ventricular heave This patient has long-standing, poorly controlled hypertension and will probably manifest evidence of chronic target organ damage. This probably includes an S4 gallop and a left ventricular heave (both associated with left ventricular hypertrophy). He shows no evidence of acute symptomatic organ dysfunction, and is therefore unlikely to have papilledema or evidence of acute congestive heart failure.

A 48-year-old man comes to your office for a routine visit. He feels well. He has had hypertension for 10 years that was previously well controlled on sustained-release metoprolol, 100 mg daily. He last saw you 3 months ago, at which time his blood pressure was 142/88 mm Hg. You did not increase his medication at the time. Today, his blood pressure is 185/95 mm Hg. His exam is

unremarkable, apart from abdominal obesity. You draw routine labs and find the following: Sodium: 139 mEq/L Potassium: 3.0 mEq/L Serum bicarbonate: 19 mEq/L Hematocrit: 40.2% Creatinine: 1.1 mg/dL Urinalysis: negative for protein Which of the following is most likely to provide a diagnosis? A. Magnetic resonance angiography (MRA) of the renal arteries B. Plasma renin and serum aldosterone levels C. 24-hour urinary free cortisol D. Thyroid-stimulating hormone level E. Renal artery duplex ultrasound

Correct Answer: Plasma renin and serum aldosterone levels This patient has worsening blood pressure control but is otherwise asymptomatic. Given his hypokalemia and mild metabolic acidosis, hyperaldosteronism must be considered. A good initial screening test would be a plasma aldosterone-to-renin ratio, which should be greater than 20 in hyperaldosteronism. An MRA of the renal arteries or renal artery duplex ultrasound would be more useful in diagnosing renovascular atherosclerosis, which is uncommon at this age. The patient does not have signs or symptoms of hypercortisolism or hypothyroidism.

Which of the following scenarios illustrates the most appropriate first-line selection of antihypertensive agent in the hypertensive patient described? A. A 72-year-old man with tophaceous gout is prescribed a diuretic B. A 35-year-old woman, pregnant with her first child, is prescribed lisinopril C. A 32-year-old with chronic migraines is prescribed metoprolol D. A 76-year-old woman with a history of chronic obstructive pulmonary disease (COPD) is prescribed propranolol E.

A 42-year-old woman with newly diagnosed Graves disease is prescribed a diuretic

Correct Answer: A 32-year-old with chronic migraines is prescribed metoprolol Although diuretics should always be considered as first-line agents in uncomplicated patients with hypertension, the presence of comorbidities may dictate choice of a different agent. Use of a -blocker in a patient with chronic migraines may serve to both control blood pressure and prevent migraines. Use of a diuretic is relatively contraindicated in a patient with poorly controlled gout. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are absolutely contraindicated in pregnancy. Nonselective -blockers are relatively contraindicated in COPD or asthma. -Blockers would be preferred in a patient with symptomatic hyperthyroidism.

A 67-year-old African American woman with a history of diabetes and stage IV chronic kidney disease (CKD) returns for management of hypertension. Her regimen consists of sustained-release verapamil 180 mg daily, furosemide 40 mg daily, and lisinopril 20 mg daily. Her blood pressure is 162/74 mm Hg. Which of the following statements regarding her drug regimen is true? A. Sustained-release nifedipine is a more effective antihypertensive than verapamil and should be substituted B. Hydrochlorothiazide is preferred to furosemide in patients with renal insufficiency C. Angiotensin-converting enzyme (ACE) inhibitors are contraindicated in patients with stage IV CKD D. The dosing frequency of furosemide should be increased to twice daily E. Calcium channel blockers are considered less effective in patients of African descent

Correct Answer: The dosing frequency of furosemide should be increased to twice daily Furosemide has a short duration of action (approximately 6 hours) and should be dosed twice daily when used for hypertension. Regarding the other choices, all calcium channel blockers that are Food and Drug Administration approved for the treatment of hypertension are approximately equally efficacious when used in standard doses. Hydrochlorothiazide is considered less effective in patients with stage

IVV CKD, so loop diuretics are preferred in this population. ACE inhibitors are not contraindicated in patients with advanced CKD, but they must be used with caution to avoid hyperkalemia or worsening uremia. Calcium channel blockers are considered especially effective in patients of African ethnicity.

Which of the following blood pressure goals is incorrect? A. A 72-year-old man with diabetes: 130/80 mm Hg B. A 35-year-old woman with hypercholesterolemia: 140/90 mm Hg C. A 60-year-old woman with a history of percutaneous transluminal coronary angioplasty with stent: 135/85 mm Hg D. A 51-year-old man with a creatinine of 1.8 mg/dL and microalbuminuria: 130/80 mm Hg E. An 87-year-old woman with glaucoma: 140/90 mm Hg

Correct Answer: A 60-year-old woman with a history of percutaneous transluminal coronary angioplasty with stent: 135/85 mm Hg Patients with diabetes, chronic kidney disease, or coronary artery disease should be treated to a goal of 130/80 mm Hg. Hypercholesterolemia and glaucoma do not modify the treatment goal for uncomplicated hypertension, which is 140/90 mm Hg.