A 59-year-old African-American male with a history of hypercholesterolemia and gout sees you for an annual visit. The physical examination is notable only for a blood pressure of 144/85 mm Hg.
Laboratory Findings:
Serum triglycerides............134 mg/dL
LDL-cholesterol............82 mg/dL...
a 59 year old african american male with a history
appropriate diagnostic tests for suspected renovas
in a hypertensive patient with atrial fibrillation
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MFBA HYPERTENSION: QUESTIONS AND ANSWERS
A 59-year-old African-American male with a history of hypercholesterolemia and gout
sees you for an annual visit. The physical examination is notable only for a blood
pressure of 144/85 mm Hg.
According to JNC 8, which one of the following would be recommended as initial
management of this patient’s blood pressure elevation?
Losartan (Cozaar)
A calcium channel blocker
Hydralazine
Hydrochlorothiazide
No drug treatment
Critique:
JNC 8 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 (defined as an
estimated or measured glomerular filtration rate <60 mL/min/1.73 m2). Treatment is
recommended for patients of any age with these blood pressure values who have
albuminuria (defined as >30 mg of albumin/g of creatinine at any level of GFR) (SOR
C). Although a thiazide diuretic or a calcium channel blocker is recommended as first-
line antihypertensive therapy in the general African-American population, in patients ≥18
years of age who have chronic kidney disease, JNC 8 recommends initial (or add-on)
antihypertensive treatment with an ACE inhibitor or angiotensin receptor blocker (ARB)
,to improve kidney outcomes, regardless of ethnicity or diabetes status (SOR B).
Losartan has been shown to consistently lower serum uric acid, which is not true of
other ARBs, which may actually increase gout attacks. ACE inhibitors increase uric acid
levels and the likelihood of gout attacks.
Appropriate diagnostic tests for suspected renovascular hypertension include which of
the following? (Mark all that are true.)
Duplex Doppler flow studies of the renal arteries
Rapid sequence intravenous pyelography
CT angiography of the renal artery
Captopril renography
Magnetic resonance renal angiography
Critique:
In the hypertensive patient with suspected renovascular hypertension, appropriate
diagnostic tests include duplex Doppler flow studies, CT angiography, and magnetic
resonance angiography (MRA). Although it was a standard screening test for
renovascular hypertension in the past, intravenous pyelography is no longer favored
because of a false-positive rate of 11% and a false-negative rate of 12%. The diagnostic
accuracy of captopril renography is felt to be inferior to MRA and duplex Doppler flow
studies, particularly in patients with chronic kidney disease and bilateral atherosclerotic
renal artery stenosis.
In a hypertensive patient with atrial fibrillation, which of the following antihypertensive
agents will also help control the ventricular rate? (Mark all that are true.)
Metoprolol tartrate (Lopressor)
Verapamil (Calan)
Amlodipine (Norvasc)
Diltiazem (Cardizem)
Nifedipine (Adalat, Procardia)
,Critique:
Both β-blockers (e.g., metoprolol) and non-dihydropyridine calcium channel blockers
(e.g., verapamil, diltiazem) slow sinus and AV node conduction and can aid in
controlling the ventricular rate in patients with atrial fibrillation. Amlodipine and nifedipine
are dihydropyridine calcium channel blockers and do not have a significant effect on
cardiac conduction.
A 55-year-old male sees you for a follow-up visit for resistant hypertension. His blood
pressure has remained elevated despite treatment with hydrochlorothiazide, 25 mg/day;
lisinopril (Prinivil, Zestril), 40 mg twice daily; and amlodipine (Norvasc), 7.5 mg/day. His
past medical history is notable for a history of chronic hypertension, impaired fasting
glucose, and hypercholesterolemia. His only medication other than antihypertensive
drugs is simvastatin (Zocor), 40 mg/day. He drinks 1 or 2 beers per day and does not
smoke.On examination his blood pressure is 155/95 mm Hg, his BMI is 29.5 kg/m2, and
he has trace to 1+ ankle edema. Laboratory tests are unremarkable other than a serum
aldosterone/plasma renin activity ratio of 31 ng/dL:ng/mL/hr.
Which one of the following interventions is most likely to be beneficial in this patient?
Candesartan (Atacand)
Diltiazem (Cardizem)
Spironolactone (Aldactone)
Abstinence from alcohol
Critique:
Resistant hypertension is defined as blood pressure that remains above the target level
despite treatment with a combination of three or more antihypertensive agents of
different classes (one of which is usually a diuretic). The initial evaluation should assess
the patient for drug-related hypertension, pseudoresistance due to inaccurate blood
pressure measurement and the “white coat” effect, inadequate adherence to lifestyle
measures (e.g., weight loss, sodium intake, excessive alcohol consumption), and
nonadherence to the antihypertensive drug regimen. The differential diagnosis of truly
drug-resistant hypertension includes obstructive sleep apnea, primary
hyperaldosteronism, pheochromocytoma, Cushing’s syndrome, chronic kidney disease,
renal artery stenosis, and thyroid disease.Recent studies indicate a significant
antihypertensive effect when an aldosterone antagonist is added in patients with
uncontrolled hypertension despite a multidrug regimen. An elevated plasma
aldosterone/plasma renin activity ratio supports the diagnosis of primary
hyperaldosteronism, and indicates that the patient is likely to respond to a
mineralocorticoid antagonist. There is insufficient evidence that using same-class
, combinations (if using maximal doses of either of the combined agents) provides
significant additional antihypertensive benefit compared to monotherapy with different
agents. Although heavy alcohol intake has been shown to increase blood pressure,
moderate alcohol intake (no more than 1–2 drinks/day in men and 1 drink/day in
women) has been associated with a reduction in blood pressure.
A 68-year-old white male is diagnosed with uncomplicated hypertension, with blood
pressures consistently in the range of 140–145/90–94 mm Hg. Based on the current
evidence, which one of the following agents would be LEAST preferred as first-line
therapy?
A thiazide diuretic
A β-blocker
A dihydropyridine calcium channel blocker
An ACE inhibitor
An angiotensin receptor blocker
Critique:
The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial
(ALLHAT) found that β-blockers were less effective than thiazide diuretics, and the
Losartan Intevention for Endpoint Reduction Trial (LIFE) found β-blockers to be less
effective than an angiotensin receptor blocker. Based on this and similar evidence, the
British Hypertension Society and the National Institute for Health and Clinical
Excellence in the United Kingdom modified their guidelines to remove β-blockers as
first-line therapy for uncomplicated hypertension. In addition, the members of the JNC 8
panel recommend that for the general nonblack population, including those with
diabetes mellitus, initial antihypertensive treatment should include a thiazide-type
diuretic, calcium channel blocker, ACE inhibitor, or angiotensin receptor blocker.
In hypertensive patients with urinary flow obstruction due to benign prostatic
hypertrophy, which one of the following agents used to lower blood pressure can also
improve bladder emptying?
Central α2-agonists
ACE inhibitors
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