CARDIOLOG

Y
DIAN PARAMITA KARTIKASARI
MAY, 17TH
1

Which of the following patients performing an exercise stress test would be identified as a moderate risk for
cardiovascular death or nonfatal myocardial infarction over 5 years follow-up?
A 45-year-old male performs 7 minutes on EST, limited by chest pain with 2 mm ST depressions during exercise in
the inferior leads
B. A 55-year-old female performs 7 minutes on EST, and she stops due to fatigue with 1 mm of horizontal ST
depressions into recovery in the anterior precordial leads
C. A 64-year-old female performs 8 minutes on EST, and she stops as a result of leg pain with 0.5 mm ST
depressions in the inferior leads during exercise only
D. A 55-year-old female performs 4 minutes on EST, and she stops due to dyspnea, with 3 mm of horizontal ST
depressions in the anterior precordial leads during exercise
E. A 70-year-old male performs 7 minutes on EST, limited by leg cramping, with no ST deviation
This patient’s Duke Treadmill score is 2, which falls into the moderate risk category.
Duke Treadmill Score (DTS) =
Exercise time in minutes on the standard Bruce protocol – 5 × ST deviation (depression or elevation measured in mm
in the lead with the greatest degree of ST deviation) − 4 × exercise angina index,
0 = no angina on the treadmill,
1 = angina occurred,
2 = angina caused termination of exercise.
A DTS of +5 or greater constitutes the lowest risk;
a DTS of +4 to −10 constitutes a moderate risk;
and a DTS of −11 or lower constitutes the highest risk.
Option A has a DTS of −11 (high risk).
Option C has a DTS of 5.5 (low risk).
Option D has a DTS of −11 (high risk).
Option E has a DTS of 7 (low risk).
2

Select the false statement about EST:

A. Digoxin can produce ST segment depression during exercise even if the effect is not evident on the resting ECG
B. Exercise-induced ST segment elevation is nonspecific for the territory of myocardial ischemia and the coronary
artery involved
C. The expected lower sensitivity and specificity traditionally observed in women may be explained by differing CAD
prevalence and severity
D. Submaximal exercise testing in which exercise is stopped at a predetermined end point, such as a peak heart rate of
120 beats/min, 70% of MPHR, or a peak MET level of 5, can be used as a class I indication 4 to 7-plus days post-MI for
evaluation of medical therapy, prognostic assessment, or development of an activity prescription
E. Exercise-induced ST segment depression does not localize the site of myocardial ischemia, nor does it indicate which
coronary artery is involved
• Unlike ST segment depression, ST segment elevation during exercise
in contiguous leads with an R wave localizes to the coronary artery
involved.
• Although ST depression is consistent with subendocardial ischemia, ST
elevation is most consistent with transmural ischemia. Options A and
C through E are true.
3

A 65-year-old man is referred to you from his family physician for the management of
hypertension. On history, he admits to snoring when sleeping and describes daytime fatigue. On
exam, BP in both arms is 164/98, HR 86 O2 sat 96% on RA. Normal heart sounds are present,
and lungs are clear to auscultation. Which of the following statements is false?
A. The most common curable form of hypertension is sleep apnea
B. Treatment with a CPAP mask is most likely indicated
C. Both sleep apnea and hypertension are closely linked to obesity
D. Approximately 60% of sleep apnea patients are hypertensive
E. Approximately 25% of hypertensive patients have sleep apnea
• The most common curable form of hypertension is renal artery stenosis (not sleep
apnea).
• Sleep apnea is emerging as one of the major causes of hypertension that is of
epidemiologic significance. Support for a causal association between sleep-
disordered breathing and hypertension includes physiological mechanisms involving
vascular dysfunction secondary to altered sympathovagal balance and insulin
resistance (option B). Both sleep apnea and hypertension are common, and
unsurprisingly there are many people with both conditions. Furthermore, both are
closely linked to obesity (particularly central obesity, as seen in the metabolic
syndrome), so there is a cluster of related syndromes: hypertension, sleep apnea,
diabetes, and the metabolic syndrome (option C). Option D: Approximately 60% of
sleep apnea patients are hypertensive7, and, conversely, approximately 25% of
hypertensive patients have sleep apnea8,9 (option E)
4
There is a fundamental difference between the genesis of hypertension in younger and older patients.
Which of the following does not represent a true difference?
A. In general, the systolic and diastolic BPs are increased in younger patients, whereas in people aged 60
years and older, the diastolic BP starts to fall, but there is a marked increase in systolic BP
B. Younger patients will have an increased peripheral resistance with a normal cardiac output, whereas
older patients will have a selective increase of systolic BP as a result of increased arterial stiffness
C. In younger patients, the increased peripheral resistance is a result of active vasoconstriction that is
mediated hormonally, particularly by the sympathetic nervous system and the renin-angiotensin system
D. The benefits of treatment in older patients with systolic pressures below 160 mm Hg remain unproven
E. There is some evidence for BP treatment of the very old (age 85 years or older) to improve mortality
• There is evidence that in the very old (age 85 years or older), mortality may be higher in those with the lowest
blood pressures, the benefit or harm of treating this patient population is currently being evaluated. In younger
patients, whatever the underlying etiology of the hypertension (with a few exceptions), both systolic and diastolic
BPs are raised, whereas in people aged 60 years and older, the diastolic BP starts to fall, but there is a marked
increase of systolic BP (option A). The underlying hemodynamics are also different: in younger patients, the
characteristic changes are an increased peripheral resistance with a normal cardiac output, whereas in older
patients, the reason for the selective increase of systolic BP is increased arterial stiffness11 (option B).
• In younger patients, the increased peripheral resistance is a result of active vasoconstriction that is mediated
hormonally, particularly by the sympathetic nervous system and the renin-angiotensin system. In older patients
with systolic hypertension, hormonal mediation is less important, and the changes are mostly mechanical (eg, loss
of elastin fibers in
• the media of the arterial wall11 (option C). In younger patients, it is clearly established that starting drug
treatment when the pressure exceeds 140/90 mm Hg is beneficial. This may also be true in older patients, but the
clinical trials that have investigated the benefits of treatment have almost all used an initial systolic BP of 160 mm
Hg or greater as an entry criterion and have not lowered the pressure to below 140 or 150 mm Hg12 (option D).
5
You are going to counsel your 55-year-old female patient on her risk factors for
hypertension. Which of the following statements is false?
A. The diastolic pressure will typically increase up to the age of 50, will plateau, and then
will decrease throughout the remainder of the life span
B. Increasing body mass index correlates with an increased risk of hypertension
C. The incidence of hypertension is increased in those who smoke 15 or more cigarettes per
day
D. There is a strong positive relation between sodium intake and blood pressure
E. Mexican Americans have prevalences that are similar to that of African Americans
 
African Americans have among the highest prevalences of hypertension compared to other major ethnic
groups, and Mexican Americans have prevalences that are similar to that of whites. Age is the factor most
strongly associated with hypertension. Systolic BP rises monotonically with age, whereas diastolic BP
increases to about age 50, plateaus, and then decreases throughout the remainder of the life span
(option A). More than 42% of those with a body mass index of 30 kg/m2 or greater have hypertension,
compared to 28%
in those who are overweight (body mass index 25 to less than 30 kg/m2)13,14 (option B). Cigarette
smoking has an acute effect on increasing blood pressure, primarily through stimulation of the
sympathetic nervous system, with adverse effects on arterial stiffness and wave reflection (option C).
Dietary sodium is implicated by many genetic,
epidemiological, migrational, and intervention studies to contribute to increasing BP in the population,
and higher salt intake is likely to contribute to coronary vascular disease mainly through its effects on BP
but also independently by
increasing arterial stiffness and albuminuria15 (option D). The INTERSALT study involved 10,079 persons
and found a strong positive relation between sodium intake and BP, with an increase of 6 g/d in salt
intake estimated to elevate systolic BP 9 mm Hg over 30 years
6
The principal complications of hypertension include all of the following
except:
A. Left ventricular hypertrophy
B. Peripheral arterial disease
C. Hypothyroidism
D. Stroke
E. Heart failure
The principal complications of hypertension include coronary heart
disease, left ventricular hypertrophy (option A), peripheral arterial
disease (option B), stroke (option D), heart failure (option E), and
chronic kidney disease.
The 36-year follow-up data from the Framingham Heart Study show
that while the relative impact of hypertension is greatest for stroke and
heart failure (RRs, 2.6–4.0), because the overall incidence of CHD is
greater than that for stroke or heart failure, the absolute impact of
hypertension on CHD is greatest, even though the RR is lower
7
A 58-year-old woman with a history of untreated hypertension presents
to your office to discuss the results of her cardiac echocardiogram.
Which of the following would be the least likely to be found on her
echocardiogram report?
A. Diastolic dysfunction
B. Tricuspid valve regurgitation
C. Increased left atrial size
D. Systolic dysfunction
E. Left ventricular hypertrophy
There is no direct association between tricuspid regurgitation and systemic
hypertension (option A). Approximately half of the patients who present with
classic signs and symptoms of heart failure appear to have a normal ejection
fraction of more than 50% on echocardiography, termed “diastolic dysfunction,”
diastolic heart failure,” or “heart failure with preserved ejection fraction.”
Diastolic heart failure is thought to be responsible for as many as 74% of cases of
heart failure in hypertensive patients.

Hypertrophy (option E) and systolic dysfunction and heart failure (option D) are
known complications of hypertension. Increased left atrial size (option C)
associated with left ventricular hypertrophy can result with systemic
hypertension.
8
Which of the following statements regarding stroke and hypertension is incorrect?
A. The linear relationship between stroke and hypertension is stronger for
diastolic than for systolic pressure
B. BP typically rises acutely after a stroke, and it is postulated that this helps to
maintain cerebral perfusion in the infarct’s penumbra zone
C. Of all the risk factors for stroke, hypertension has the highest relative risk
D. Hypertension indirectly raises the risk of stroke through its role in atrial
fibrillation and left atrial enlargement
E. Treatment of hypertension reduces stroke rates by approximately 35% to 45%
 
• As with coronary events, there is a strong log-linear relationship between both systolic and
diastolic pressure and stroke, although the relationship is steeper for strokes than for CHD
events and much stronger for systolic than diastolic pressure.
• BP typically rises acutely after a stroke, and it is postulated that this helps to maintain
cerebral perfusion in the infarct’s penumbra zone (option B). This forms therationale for
avoiding excessive reduction of BP immediately after a stroke. Of all the risk factors for
stroke, hypertension has the highest relative risk (4.0 at 40 to 50 years, falling to 2.0 at ages
70 to 80 years), and the highest population attributable risk (40% at ages 40 to 50 years and
30% at ages 70 to 80 years) (option C). Hypertension also indirectly raises the risk of stroke
through its role as an important risk factor for atrial fibrillation and left atrial enlargement,
which both relate directly to stroke risk (option D). Treatment of hypertension reduces
stroke rates by 35% to 44%; this has been shown in both younger patients with systolic and
diastolic hypertension and in older patients with isolated systolic HT
9
Your 65-year-old female patient presents to the office to discuss the results of her blood
work. You have been treating her for hypertension over the last 10 years. Her creatinine
has risen slightly, and you are concerned. Which of the following statements is true?
A. There is a twofold greater risk for end-stage renal disease with a systolic BP of > 140
mm Hg compared to a systolic BP of < 117 mm Hg
B. Chronic kidney disease causes remodeling of the arteries and increased stiffness
C. Hypertensive patients with mildly impaired renal function (estimated GFR < 60
mL/min) compared to normal renal
function have an equivalent prevalence of target organ damage
D. Diastolic BP is a stronger risk factor for renal death than systolic BP
E. In a patient with chronic kidney disease, it is obvious whether the hypertension or the
kidney disease came first
• There are two main effects of CKD on the arteries: (1) increased prevalence of atherosclerosis
and (2) remodeling of the arteries and increased stiffness, which has been related to increased
mortality. The Multiple Risk Factor Intervention Trial showed systolic BP of > 140 mm Hg to be
associated with a five- to sixfold (not twofold) greater risk for end-stage renal disease (ESRD)
compared to systolic BP of less than 117 mm Hg (option A). Hypertensive patients with mildly
impaired renal function (estimated GFR < 60 mL/min) have an increased prevalence of target
organ damage, such as left ventricular hypertrophy, increased carotid intima-media thickness,
and microalbuminuria (option C). In a large pooled cohort study of more than 500,000
individuals from the Asia-Pacific region followed for a median of 6.8 years, systolic BP was the
strongest risk factor for renal death, with each standard deviation increase in systolic BP (19 mm
Hg) associated with a more than 80% higher risk (HR, 1.84; 95%
• CI, 1.60–2.12)21 (option D). Although chronic kidney disease is certainly a major cause of
hypertension, it is often difficult to decide whether the hypertension or the kidney disease came
first because a vicious cycle can develop where one condition exacerbates the other (option E).
10
A 52-year-old man presents to your office for prevention of cardiovascular
disease. His examination is notable for a blood pressure (BP) of 153/98
mm Hg. He wants to know about factors that would predispose him to
hypertension. Which of the following is not associated with hypertension?
A. Excess sodium intake
B. Excess potassium intake
C. Obesity
D. Sedentary lifestyle
E. A and D
• Although primary hypertension is heterogeneous, some of the main
causes of high BP are known. For example, overweight and obesity
may account for 65% to 75% of the risk for primary hypertension
(option C). Sedentary lifestyle, excess intake of alcohol or salt, and low
potassium intake are also known to increase BP in some patients
(options A, B, D, and E
11
A 23-year-old man is involved in a car accident and is bleeding into his
abdomen. Which of the following systems do not regulate blood
pressure (BP) acutely?
A. Arterial baroreceptors
B. Chemoreceptors
C. Central nervous system (CNS)
D. Renin-angiotensin-aldosterone system (RAAS)
E. Increase in vasodilation
• with rapid blood loss, three important neural control systems begin to function powerfully
within seconds:
• (1) the arterial baroreceptors, which detect changes in BP and send appropriate autonomic
reflex signals back to the heart and blood vessels to return the BP toward normal (option A);
• (2) the chemoreceptors, which detect changes in oxygen or carbon dioxide in the blood and
initiate autonomic feedback responses that influence BP (option B); and
• (3) the central nervous system (CNS) (option C), which responds within a few seconds to
ischemia of the vasomotor centers in the medulla, especially when BP falls below about 50 mm
Hg.
• Within a few minutes or hours after a BP disturbance, additional controls react, including (1) a
shift of fluid from the interstitial spaces into the blood in response to decreased BP (or a shift of
fluid out of the blood into the interstitial spaces in response to increased BP); (2) the RAAS,
which is activated when BP falls too low and suppressed when BP increases above normal
(option D); and (3) multiple vasodilator systems that are suppressed when BP decreases and
stimulated when BP increases above normal (option E).
12
Which of the following alters pressure-natriuresis in chronic
hypertension?
A. Increased tubular resorption
B. Decreased anti-natriuretic hormones
C. Decreased activity of the sympathetic nervous system (SNS)
D. A and C
E. None of the above
• In all types of human or experimental hypertension studied thus far, there is a shift
of pressure natriuresis that appears to sustain the hypertension.
• In some cases, abnormal pressure natriuresis is caused by intrarenal disturbances
that alter renal hemodynamics or increased tubular reabsorption (option A).
• In other cases, altered kidney function is caused by extrarenal disturbances, such as
increased SNS activity or excessive formation of anti-natriuretic hormones that
reduce the kidney’s ability to excrete sodium and water and eventually increase BP
(options B and C).
• Consequently, effective treatment of patients with hypertension requires
interventions that reset pressure natriuresis toward normal BP either by directly
increasing renal excretory capability (eg, with diuretics), or by reducing
antinatriuretic influences (eg, with RAAS blockers) on the kidneys.
13
Which of the following is not true of the two-kidney, one-clip Goldblatt
model of hypertension?
A. The clipped kidney is at greater risk for nephron loss than the untouched
kidney
B. The clipped kidney produces more renin than the untouched kidney
C. Blood flow through the untouched kidney may be increased compared to
the flow before clipping of the contralateral kidney
D. Removal of clipping will restore blood pressure to normal levels, even
after the untouched kidney becomes dysfunctional
E. None of the above
• In the two-kidney, one-clip Goldblatt model of hypertension, the
clipped kidney has reduced blood flow, while the untouched kidney
has normal or increased blood flow (option C). This differential in
blood flow results in high levels of renin being made by the clipped
kidney but almost no renin from the untouched kidney (optionB).
• Overtime,the untouched kidney will develop injury from the increased
blood flow, leading to nephron loss (option A). Once damage has
occurred to the untouched kidney, reversal of clipping will no longer
be able to completely reverse hypertension (option D).
14
Which of the following are true regarding salt-sensitive hypertension?
A. Loss of functional nephrons contributes to salt-sensitive
hypertension
B. High levels of Ang II or mineralocorticoids contribute to salt-sensitive
hypertension by increasing renal tubular resorption
C. A and B
D. Increased sensitivity of the RAAS is associated with salt-sensitive
hypertension
E. None of the above
• After the loss of entire nephrons, the surviving nephrons must excrete
greater amounts of sodium and water to maintain balance. This is
achieved by increasing GFR and decreasing reabsorption in the
remaining nephrons, resulting in increased sodium chloride delivery
to the macula densa and suppression of renin release (option A). This,
in turn, impairs the kidney’s ability to further decrease renin secretion
during high sodium intake, and BP becomes salt sensitive. Factors that
increase renal tubular sodium reabsorption, such as excessive levels
of mineralocorticoids or Ang II, can also cause hypertension (option
B). Reduced sensitivity of the RAAS contributes to salt-sensitive
hypertension (option D).
15
A 45-year-old air traffic controller presents to your office for evaluation of
hypertension. Which of the following is not true about how the SNS contributes to
hypertension?
A. Activation of the renal sympathetic nerves causes increases in renin secretion
and sodium resorption
B. Radiofrequency renal denervation is an effective way to treat refractory
hypertension
C. Epidemiologic studies have suggested a relationship between chronic stress and
hypertension
D. Obesity results in increased renal sympathetic activity
E. Renal sympathetic activity is regulated by various regions of the brain
• It is widely believed that chronic stress may lead to long- term increases in blood pressure.
Support for this concept comes largely from a few epidemiologic studies showing that air
traffic controllers, lower socioeconomic groups, and other groups who are believed to lead
more stressful lives also have increased prevalence of hypertension (optionC)
• Even mild increases in renal sympathetic activity stimulate renin secretion and sodium
reabsorption in multiple segments of the nephron, including the proximal tubule, the loop of
Henle, and distal segments (option A). Obese persons have elevated SNS activity in various
tissues, including the kidneys and skeletal muscle, as assessed by microneurography, tissue
catecholamine spillover, and other methods (option D). The preganglionic neurons that
synapse with the renal sympathetic postganglionic fibers are located in the lower thoracic
and upper lumbar segments of the spinal cord and receive multiple inputs from various
regions of the brain, including the brainstem, forebrain, and cerebral cortex (option E).
Whether renal denervation will prove to be an effective therapy for patients who are
resistant to the usual pharmacological treatments remains to be determined (option B).
16
A 58-year-old man with hypertension presents to your office to establish care. His
blood pressure is well controlled with lisinopril. Which of the following is true
about renin-angiotensin-aldosterone system (RAAS) blockade and hypertension?
A. Blood pressure is very salt-sensitive in the setting of RAAS blockade
B. Angiotensin II (Ang II) elevation promotes sodium and water retention
C. ACE inhibitors can reduce GFR by inhibition of the constrictor effect of Ang II
on efferent arterioles
D. RAAS blockade can prevent glomerular injury when the nephrons are
hyperfiltering
E. All of the above are true
• Ang II causes salt and water retention by increasing renal sodium reabsorption
through the stimulation of aldosterone secretion, by direct effects on epithelial
transport, and by hemodynamic effects (option B). Blockade of the RAAS, with Ang
II–receptor blockers (ARBs) or angiotensin- converting enzyme (ACE) inhibitors,
increases renal excretory capability so that sodium balance can be maintained at
reduced BP. However, blockade of the RAAS also makes BP salt sensitive (option A).
The impairment of GFR after RAAS blockade is caused, in part, by inhibition of the
constrictor effects of Ang II on efferent arterioles as well as reduced BP (option C).
RAAS blockade is often beneficial when nephrons are hyperfiltering, especially if
Ang II is not appropriately suppressed (option D). For example, in diabetes mellitus
and certain forms of hypertension associated with glomerulosclerosis and nephron
loss, Ang II blockade decreases BP, efferent arteriolar resistance, and glomerular
Hydrostatic pressure, and it attenuates glomerular hyperfiltration
17
A 55-year-old man is being treated with bevacizumab for his lung cancer. He is
seeing you for management of his hypertension. Which of the following is not
true about hypertension associated with VEGF inhibitors?
A. VEGF-inhibitor-induced hypertension is likely to result from decreased NO
B. VEGF inhibition is likely to result from increased endothelin-1
C. VEGF-induced hypertension is solely to be mediated by its effects on the
vasculature and is less likely to involve a direct effect on the kidney
D. All of the above are false
E. All of the above are true
 
• VEGF and VEGF receptors are highly expressed in the kidney. VEGF is
expressed in glomerular podocytes, and VEGF receptors are present on
endothelial, mesangial, and peritubular capillary cells. Signaling between
endothelial cells and podocytes is thought to be important for maintenance
of the filtration function of the glomerulus, and inhibitors of VEGF signaling
have been shown to alter glomerular structure and function (option C).
Because the endothelium is a major target for VEGF actions, it is likely that
decreases in the production of endothelium-derived relaxing factors such as
NO and PGs or enhanced production of vasoconstricting factors such as
thromboxane and ET-1 play a role in the hypertensive response to drugs
that block the VEGF pathway (options A and B)
18
A 53-year-old woman presents with hypertension. Her serum
laboratory tests are notable for hypokalemia and metabolic alkalosis.
Examination is notable for the absence of acne, adiposity, or hair loss.
Which is the next best diagnostic test?
A. Dexamethasone suppression test
B. Plasma renin and aldosterone
C. Serum metanephrines
D. Genetic testing
E. None of the above
• This patient is most likely to have Conn syndrome or primary
aldosteronism. Conn syndrome is manifest by expansion of
extracellular fluid volume, hypertension, suppression of renin
secretion, hypokalemia, and metabolic alkalosis. Therefore, testing of
renin and aldosterone levels can be useful to establish a diagnosis
(option B). A dexamethasone suppression test can be useful to
differentiate ACTH- dependent and ACTH-independent Cushing
syndrome (option A). Serum metanephrines can be useful for
diagnosing pheochromocytoma (option C). Genetic testing is unlikely
to be of high yield at this stage of diagnostics (option D).
19
A 35-year-old obese woman presents to you for evaluation of hypertension.
She wants to know whether her hypertension would resolve if she were to
lose weight. Which of the following is true about obesity and
hypertension?
A. Central adiposity is more strongly associated with hypertension than
subcutaneous fat
B. Obesity results in increased activity of the SNS
C. Obesity results in activation of the RAAS
D. Obesity results in physical compression of the kidneys
E. All of the above are true
• Adipose tissue distribution is important to the risk for obesity-related hypertension.
Most population studies that have investigated the relationship between obesity
and BP have measured BMI rather than visceral or retroperitoneal fat, which
appear to be better predictors of increased BP than subcutaneousfat(optionA)
• Additionally, three mechanisms appear to be especially important in increasing
sodium reabsorption and impairing renal-pressure natriuresis in obesity
hypertension:
• (1) increased SNS activity (option B),
• (2) activation of the RAAS (option C), and
• (3) physical compression of the kidneys by fat accumulation within and around the
kidneys and by increased abdominal pressure (option D).
20
Which of the following statements about hypertension is false?
A. Hypertension is a public health problem worldwide
B. Treating hypertension with antihypertensive drugs is effective for the long-
term prevention of cardiovascular disease
C. Normal (optimal) pressure is classified as blood pressure < 120/80 mm Hg
D. Blood pressure measurements outside the office or clinic are always
identical to office or clinic pressure measurement
E. The prevalence of hypertension is increasing in relation to increased
overweight
 
• By current guidelines, normal (optimal) pressure is classified as blood
pressure < 120/80 mm Hg (option C). Hypertension is highly prevalent
in adult populations throughout the world and is increasing in relation
to increased overweight and reduced daily exercise (option E), and it
is a growning cause of fatal and nonfatal cardiovascular and renal
disease worldwide (option A
21
During a routine checkup, a 55-year-old male factory worker’s recorded
blood pressure is 150/90 mm Hg. What is the goal for the initial
evaluation of hypertensive patients?
A. Estimate the average blood pressure
B. Consider the overall cardiovascular risk status
C. Determine the presence or absence of target organ pathology
D. Educate the patient on long-term cardiovascular risk reduction
E. All of the above
• Most hypertensive patients are initially identified during office or clinic visits
when seen for check-ups or nonemergent symptoms. Initial evaluation and
classification of these patients is crucial because hypertension is mostly a
silent disorder, and patients are often asymptomatic for long periods of
time. The goals for the initial evaluation of hypertensive patients include:
estimating the average blood pressure (option A), considering the overall
cardiovascular risk status (option B), determining the presence or absence of
target organ pathology (option C), and beginning the process of education
that will lead the patient to recognize and collaborate in long-term risk
reduction (option D). It is also an opportune moment to assess the patient
for identifiable (secondary) hypertension. Therefore, all of the above are
correct (option E).
22
Which of the following is considered correct blood pressure
measurement in the clinic?
A. Using the same cuff size for all patients
B. Taking blood pressures in both arms, in the seated and standing
positions
C. Taking the blood pressure in one arm with the patient standing
D. Taking the blood pressure in one arm with the patient seated
E. Using the brachial artery pressure as a substitute for central aortic
pressure
• Blood pressure measurement in the clinic requires careful and consistent practices
• Choosing an appropriate cuff size is essential for accurate pressure readings;
therefore,larger adult cuffs are mandatory for most large or obese patients (option
A).
• In general, a cuff that is too large will underestimate blood pressure. During
measurement, the patient should be seated comfortably, and pressures should be
taken in both arms due to possible variability. Blood pressures can also be
measured in the standing position (option B) to assess for orthostatic hypotension,
particularly in the elderly and in those with dizziness

• Brachial artery pressure may fail to reflect central aortic pressures (option E), the
latter of which is measured directly by invasive catheterization.
23
A 36-year-old woman patient has a blood pressure of 140/90 mm Hg in the clinic. An out-
of-office ambulatory blood pressure monitor is requested for the next 24 hours. Which of
the following is not an advantage of this monitoring device?
A. It predicts the risk of morbid events better than clinic blood pressure
B. It can diagnose white coat hypertension
C. It can diagnose masked hypertension
D. It eliminates the need for medical history and physical examination in determining
cardiovascular disease risk
E. It can measure systolic and diastolic pressures while the patient sleeps
Ambulatory blood pressure measurement is a non-invasive, fully automated technique in
which multiple blood pressure measurements are recorded over an extended period
(typically 24 hours). It can thus measure blood pressure when a patient is awake during the
day, as well as when the patient is sleeping during the night (option E).
Studies suggest that the average level of ambulatory blood pressure predicts risk of morbid
events better than clinic blood pressure (option A).

Ambulatory blood pressure monitoring is valuable for determining whether the patient’s
usual pressure, in “real life,” is either higher or lower than the clinic pressure, thereby
enabling the diagnosis of both white coat (option B) and masked hypertension (option C).
Nevertheless, a careful and well-focused medical history and physical examination are the
foundation for the initial appraisal of a hypertensive patient and his or her risk for
cardiovascular disease, and these cannot be substituted by the use of this device (option D).
24
After initial assessment in clinic followed by a 24-hour ambulatory pressure monitoring, a
50-year-old male banker is diagnosed with hypertension. Which of the following is not an
appropriate course of action?
A. Recommendation of the DASH diet
B. Recommendation of an exercise routine
C. Recommendation of smoking cessation and scheduled follow-up in 1 year
D. Prescription of antihypertensive medications
E. Performance of laboratory biochemical testing and imaging to define cardiovascular risk
 
• After the initial assessment of hypertensive patients, appropriate follow-up reassessment is
crucial.
• Studies have shown that increased cardiovascular event rates were related to failure to
intensify treatment, delays of more than 1.4 months for intensification, and delays in follow-
up of more than 2.7 months after intensification in general, the higher the BP, the greater
need for shorter interval between revisits.
• Therefore, while smoking cessation is important for cardiovascular prevention, 1 year is too
long an interval for follow-up (option C). There is general agreement that in the absence of
clues to identifiable hypertension, efficient use and appropriate selection of laboratory
resources can be confined to those needed to define cardiovascular risk, to target organ
pathology, and to establish a baseline for treatment (option E). Subsequently, appropriate
treatment should focus on lifestyle improvement such as adherence to an adequate diet
(option A) and increased exercise (option B), as well as prescription of antihypertensive drugs
(option D).
25

Which of the following diuretics used as an antihypertensive drug does not

cause hypokalemia as a side effect?
A. Spironolactone
B. Thiazides
C. Loop-active diuretics
D. All of the above
E. None of the above
• Thiazides have been the mainstay of antihypertensive drug treatment
since the 1960s as single agents or in effective two-drug combinations.
• The most frequent adverse reaction to these drugs is hypokalemia, due to
their effect on potassium excretion by the kidneys (option B). Loop-active
diuretics are preferred over thiazides when renal function is impaired or in
the presence of congestive heart failure, but they share similar adverse
reactions, including hypokalemia (option C). Potassium-sparing diuretics,
on the other hand, reduce potassium excretion by the kidneys and
therefore do not cause hypokalemia (option A). They are valuable for
treating primary aldosteronism or thiazide-related hypokalemia.