SECTION 1: CARDIOLOGY CHAPTER 2: HYPERTENSION Q.1. 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 on two readings during this visit. You should A. Start 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 one year E. Do nothing now and recheck blood pressure within a few months Answer: C. Although drug therapy is indicated for diabetics with high normal blood pressure (i.e., 130–139/85–89), it is first necessary to establish the diagnosis of hypertension, which requires elevated readings on at least two office visits, not just two readings during one office visit. Lifestyle counseling, however, should begin immediately. Q.2. A 48-year-old woman presents to the emergency room with headache and a blood pressure of 192/104. She has a long history of hypertension, for which she has been treated in the past with benazepril, hydrochlorothiazide, and metoprolol. She does not have a history of coronary artery disease. After careful interviewing, you determine that she stopped taking her antihypertensive medications approximately two 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 CT 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 short-acting nifedipine 30 mg po, observation in the emergency room for six hours, and resumption of her usual medications E. Resumption of her usual medications and follow-up in the outpatient clinic within one week Answer: E. 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 short-acting nifedipine to lower her blood pressure rapidly does not decrease her risk of acute complications and may, in fact, be hazardous. Q.3. A 72-year-old white female, previously well controlled on a once-daily combination pill containing atenolol 50 mg and hydrochlorothiazide 25 mg, presents with a rise in her blood pressure to 170/110. 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 Answer: D. 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 decline in renal function after addition of an angiotensin-converting enzyme inhibitor, however, is most suggestive of bilateral renal artery stenosis. Q.4. A 47-year-old male with type 2 diabetes returns for follow-up. You find his blood pressure to be 138/72 in the left arm and 142/74 in the right arm. One month ago, his blood pressures were 136/68 in the left arm and 140/72 in the right, and on the visit before that the readings were 138/70 in the left arm and 142/68 in the right arm. He has attempted to modify his diet and exercise. Urinalysis shows microalbuminuria. You recommend A. Start lisinopril 5 mg po every day B. Start amlodipine 5 mg po every day C. Start hydrochlorothiazide 12.5 mg every day D. Continue lifestyle modification and recheck blood pressure in two months E. Do nothing now and recheck blood pressure in two months Answer: A. The diagnosis of stage 1 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 a very reasonable option in most patients with hypertension, the use of an angiotensin- converting enzyme inhibitor is more appropriate in this patient because it has been shown to decrease the incidence of diabetic nephropathy in patients with microalbuminuria. Q.5. A 42-year-old obese male returns for follow-up. His last visit with you was three years ago, and since that time his weight has increased by 15 kg, such that his BMI is now 32. He reports feeling tired during the day, and has increased his coffee consumption to four cups per day and his tobacco use to one pack of cigarettes per day. His blood pressure has increased from 136/86 at last visit to 152/90 today. He states that he has not drunk coffee or smoked in the last six 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 Answer: C. 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 increase the risk of development of hypertension. Q.6. 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/HCTZ 20/25 mg po every day, nifedipine extended release 90 mg po every day, and atenolol 50 mg every day. Her son indicates that she ran out of her medication a week ago. On examination, the patient is confused, somnolent, and complaining of headache. Her blood pressure is 230/114 bilaterally. Funduscopic examination shows arteriolar narrowing and indistinct optic disc margins. The lung examination reveals no rales; the cardiac examination is significant for an S4 gallop and a grade 2 midsystolic 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 po every six hours B. Admission to the intensive care unit C. CT imaging of the brain D. Measurement of serum creatinine, sodium, and potassium E. Placement of an arterial line Answer: A. This patient is presenting with signs and symptoms of hypertensive encephalopathy, a hypertensive emergency. Appropriate initial management includes admission to ICU, placement of an arterial line to monitor BP, and administration of intravenous agents to lower BP. A noncontrast head CT is appropriate to exclude other causes of altered mental status, including intracerebral hemorrhage. Administration of oral agents may result in unpredicable rates of BP lowering and is not recommended. Q.7. 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. BP in both arms is 148/86. He reports no chest pain, dyspnea, abdominal pain, or headache. He is asked to return in one month for follow-up, and at that time his BP is 146/90. 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 three cups of coffee per day, consumes one 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 two cups per day E. Loss of 5 kg through diet and exercise Answer: E. Limitation of alcohol use to 1 ounce (of ethanol) or less in men, limitation of sodium intake to 2.4 gm, 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. Q.8. A 49-year-old female with established hypertension returns to the clinic for follow-up. She has been monitoring her blood pressure 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.