Exam (elaborations)
ABFM HYPERTENSION – QUESTIONS & ANSWERS
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- ABFM HYPERTENSION – QUESTIONS & ANSWERS
ABFM HYPERTENSION – QUESTIONS & ANSWERS
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ABFM HYPERTENSION – QUESTIONS &ANSWERS
A 39-year-old male sees you for evaluation of high blood pressure. His past
medical history is unremarkable. On examination he has a BMI of 32 kg/m2
and you note that he has a round face and a plethoric complexion. His blood
pressure is 150/98 mm Hg, his pulse rate is 88 beats/min, and his respiratory
rate is 16/min. Other notable findings include a prominent dorsal cervical fat
pad and supraclavicular fat pads, as well as violaceous striae on his trunk.
Laboratory findings are notable only for a fasting glucose level of 114
mg/dL.Which one of the following is the most likely cause of his
hypertension?
Addison's disease
Cushing syndrome
Hemochromatosis
Pheochromocytoma
Primary hyperaldosteronism - -B
This patient's clinical findings are consistent with Cushing syndrome, or
hyperadrenocorticism. This is a clinical syndrome and metabolic disorder
resulting from chronic excess of glucocorticoids. The most common cause is
corticosteroid use, but adrenal neoplasms account for 20%-25% of cases.
Findings include general weakness, osteoporosis, moon facies, facial
plethora, ecchymoses, truncal obesity, violaceous striae of the abdomen,
deposition of adipose tissue in the interscapular area ("buffalo hump"), and
glucose intolerance.
-You diagnose stage 2 hypertension in a 54-year-old male. His past medical
history is otherwise unremarkable and a physical examination is notable for
mild AV nicking on funduscopic examination. A baseline EKG reveals
evidence of left ventricular hypertrophy.Which one of the following classes of
antihypertensive agents has NOT been shown to produce a regression of left
ventricular hypertrophy?
ACE inhibitors
β-Blockers
Calcium channel blockers
Direct vasodilators
Thiazide diuretics - -D
In patients with left ventricular hypertrophy, studies have shown a reduction
in left ventricular mass in those treated with ACE inhibitors, diuretics,
calcium channel blockers, and β-blockers, with the most consistent reduction
achieved with ACE inhibitors and the least with β-blockers. Regression of left
ventricular hypertrophy has not been demonstrated with direct vasodilators
such as hydralazine and minoxidil.
, -According to currently accepted criteria, hypertension in children is defined
as repeated blood pressure measurements at or above a threshold of which
one of the following percentiles for age, sex, and height?
80th
85th
90th
95th
99th - -D
In children and adolescents, hypertension is defined as blood pressure at or
above the 95th percentile for age, sex, and height, on repeated
measurements.
-Which one of the following conditions is associated with isolated systolic
hypertension?
Aortic stenosis
Hypothyroidism
Paget's disease
Renovascular hypertension
Severe osteoporosis - -C
Isolated elevation of systolic blood pressure can be secondary to conditions
associated with elevated cardiac output, such as anemia, Paget's disease,
hyperthyroidism, arteriovenous fistula, and aortic insufficiency.
-A 59-year-old African-American male with a history of hypercholesterolemia
and gout sees you for a health maintenance visit. A physical examination is
notable only for a blood pressure of 144/85 mm Hg.Laboratory FindingsLDL-
cholesterol............82 mg/dLHDL-cholesterol............47 mg/dLSerum
triglycerides............134 mg/dLLiver panel............normalSerum
creatinine............1.7 mg/dL (N 0.7-1.3)Estimated glomerular filtration
rate............56 mL/min/1.73 m2Which one of the following does the JNC 8
panel recommend as initial management of this patient's blood pressure
elevation?
Lifestyle measures only
An ACE inhibitor
A calcium channel blocker
Hydralazine
Hydrochlorothiazide - -B
The JNC 8 panel recommends the initiation of pharmacologic treatment to
lower blood pressure in patients ≥18 years of age with a systolic blood
pressure ≥140 mm Hg or a diastolic blood pressure ≥90 mm Hg if they have
chronic kidney disease (CKD), defined as an estimated or measured
,glomerular filtration rate (GFR) <60 mL/min/1.73 m2. Treatment is
recommended for patients of any age with these blood pressure values who
also have albuminuria, defined as >30 mg of albumin/g of creatinine
regardless of GFR (SOR C).Although a thiazide diuretic or a calcium channel
blocker is generally recommended as first-line antihypertensive therapy in
African-Americans, for patients ≥18 years of age who have CKD, the JNC 8
panel recommends initial (or add-on) antihypertensive treatment with an
ACE inhibitor or angiotensin receptor blocker to improve kidney outcomes,
regardless of ethnicity or diabetes status (SOR B).The 2017 American College
of Cardiology/American Heart Association hypertension guidelines similarly
recommend use of an ACE inhibitor in patients with stage 3 CKD, as well as
in patients who have stages 1 or 2 CKD with albuminuria >300 mg/day.
-A 67-year-old male with a history of hypertension and type 2 diabetes has
inadequately controlled blood pressure. His current medications are lisinopril
(Prinivil, Zestril), 40 mg daily; hydrochlorothiazide, 25 mg daily; and
extended-release metformin (Glucophage XR), 1500 mg daily. Laboratory
testing reveals a hemoglobin A1c of 6.8%, normal serum electrolytes, a
serum creatinine level of 1.0 mg/dL (N 0.6-1.5), and a urinary
albumin/creatinine ratio of 80 mg/g (N <30).Which one of the following
agents should be AVOIDED in this patient?
Aliskiren (Tekturna)
Atenolol (Tenormin)
Diltiazem (Cardizem)
Doxazosin (Cardura)
Felodipine (Plendil) - -A
The ALTITUDE study (Aliskiren Trial in Type 2 Diabetes Using Cardiorenal
Endpoints) was a randomized, double-blind, placebo-controlled international
multicenter trial undertaken to determine whether the addition of the direct
renin inhibitor aliskiren to standard therapy with renin-angiotensin system
blockade would be beneficial for patients with type 2 diabetes who are at
high risk for cardiovascular and renal events. The study was terminated
prematurely after a median follow-up of 27 months when no benefit was
apparent, and a higher risk of hyperkalemia and hypotension was seen in
patients receiving aliskiren. Based on this study, the FDA issued a drug
safety warning in 2012 that announced two additions to the drug labeling of
aliskiren-containing products. The first addition was a contraindication to the
use of aliskiren in patients with diabetes mellitus who are taking angiotensin
receptor blockers (ARBs) or ACE inhibitors, because of an increased risk of
renal impairment, hypotension, and hyperkalemia. The second addition was
a warning to avoid the use of aliskiren with ARBs or ACE inhibitors in patients
with moderate to severe renal impairment (glomerular filtration rate <60
mL/min/1.73 m2).The use of ACE inhibitors, ARBs, β-blockers, diuretics, and
calcium channel blockers has been shown to be effective in reducing
cardiovascular events in patients with diabetes mellitus. Although no such
, benefit has been seen with doxazosin, there is no contraindication to its use
in patients with diabetes.
-A 44-year-old male has a 1-week history of generalized headaches and
nonspecific dizziness. His past medical history is notable only for a 3-year
history of hypertension, which has been poorly controlled because of a lack
of adherence to his drug regimen. His renal status was normal 1 month ago.
On examination his blood pressure is 250/150 mm Hg, and you note cotton-
wool exudates on funduscopic examination. Laboratory evaluation reveals
normal serum electrolytes, a serum creatinine level of 3.8 mg/dL (N 0.7-1.3),
and a BUN level of 60 mg/dL (N 6-20). A urinalysis shows gross hematuria
and 3+ proteinuria.Which one of the following will rapidly lower his blood
pressure and increase renal blood flow?
Diazoxide (Proglycem)
Enalaprilat (Vasotec)
Esmolol (Brevibloc)
Fenoldopam (Corlopam)
Nitroprusside (Nitropress) - -D
Fenoldopam is a selective peripheral dopamine-receptor agonist used for the
treatment of severe hypertension. In studies investigating fenoldopam use in
severe hypertension, its efficacy in lowering blood pressure was found to be
comparable to that of nitroprusside. It is FDA-approved for the in-hospital
management of severe hypertension when rapid but quickly reversible
reduction of blood pressure is required, such as in a patient with malignant
hypertension who has deteriorating end-organ function. By virtue of its
actions on peripheral dopamine receptors, fenoldopam produces renal
arterial vasodilation and natriuresis, and thus can provide a renal protective
effect in clinical situations associated with impaired renal function. In
addition, there is evidence that it may improve creatinine clearance and
urine flow rates in severely hypertensive patients with either normal or
impaired renal function. The 2017 American College of Cardiology/American
Heart Association (ACC/AHA) hypertension guidelines include fenoldopam as
a preferred agent for treating hypertensive emergencies associated with
acute renal failure. Other options include nicardipine and clevidipine.
-Compared to the typical American diet, the Dietary Approaches to Stop
Hypertension (DASH) diet includes reduced consumption of which one of the
following?
Dietary fiber
Dietary protein
Low-fat dairy products
Nuts and whole grains
Fats and sweets - -E
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