ABFM HYPERTENSION EXAM QUESTIONS
AND CORRECT ANSWERS
Question 1
A nonthiazide diuretic should be considered for initial antihypertensive therapy in
patients with which one of the following?
Diabetes mellitus
Recurrent calcium kidney stones
Stage 3 chronic kidney disease, with an estimated glomerular filtration rate of 50
mL/min/1.73 m2
Bipolar disorder treated with lithium
A past history of stroke
Correct Answer
D
Diuretic-induced sodium loss can reduce the renal clearance of lithium, thereby
increasing serum lithium levels and the risk of lithium toxicity. In addition, by
reducing urine calcium excretion, thiazide-type diuretics have been shown to
significantly reduce recurrence rates of calcium stones by up to 50% over a 3-year
period. Thiazide diuretics are generally thought to be less effective in patients with
moderate to severe chronic kidney disease (CKD). The 2017 American College of
Cardiology/American Heart Association guidelines favor the use of loop diuretics
over thiazide diuretics in patients with stage 4 CKD with a glomerular filtration rate
<30 mL/min/1.73 m2. Thiazide-type diuretics have been shown to improve clinical
outcomes in patients with diabetes mellitus, as well as following a stroke.
Page 1 of 129
,Question 2
A 65-year-old male comes to your office for an initial visit. He has a 5-year history of
type 2 diabetes treated with glipizide (Glucotrol), 10 mg daily. A physical examination
is notable for a blood pressure of 142/92 mm Hg and nonproliferative diabetic
retinopathy with scattered microaneurysms and cotton-wool spots. Laboratory testing
reveals a hemoglobin A1c of 8.4%, a serum creatinine level of 1.3 mg/dL (N 0.7-1.3),
and modest persistent albuminuria (30-299 mg/24 hr).You consider prescribing an
antihypertensive agent. Which one of the following has been shown to slow the
progression of microalbuminuria to macroalbuminuria (≥300 mg/24 hr) in this
situation, independent of blood pressure reduction?
ACE inhibitors
α1-Blockers
β-Blockers
Dihydropyridine calcium channel blockers
Hydrochlorothiazide
Correct Answer
A
Once macroalbuminuria develops in a patient with nephropathy due to type 2
diabetes, creatinine clearance declines an average of 10-12 mL/min/year in
untreated patients. In patients with hypertension, type 2 diabetes, and
microalbuminuria, both ACE inhibitors and angiotensin receptor blockers have been
shown to delay the progression to macroalbuminuria, independent of a reduction in
blood pressure.
Page 2 of 129
,Question 3
A 32-year-old female who works as an administrative assistant is referred to you for
evaluation of high blood pressure. Her past medical history is unremarkable, and she
does not take any prescribed or over-the-counter medications. A review of systems
reveals only a chronic history of mild fatigue and episodic muscle cramping. A
physical examination is normal except for a blood pressure of 156/100 mm Hg in
both arms without significant orthostatic changes.Laboratory
FindingsCBC............normalSodium............145 mEq/L (N 135-145)Potassium............2.9
mEq/L (N 3.5-5.0)Chloride............100 mEq/L (N 100-108)Bicarbonate............25 mEq/L (N
22-26)Creatinine............0.7 mg/dL (N 0.6-1.5)BUN............10 mg/dL (N 8-
25)Glucose............90 mg/dLUrinalysis............normalWhich one of the following is the
most likely cause of her hypertension?
Addison's disease
Bartter syndrome
Chronic licorice ingestion
Primary hyperaldosteronism
Renovascular hypertension
Correct Answer
D
Primary hyperaldosteronism, also known as Conn's syndrome, is associated with
hypersecretion of aldosterone, a mineralocorticoid. It is twice as common in women
as in men, and usually occurs between 30 and 50 years of age. In the past, it was
estimated that approximately 1% of unselected hypertensive patients had
hyperaldosteronism, but more recent data indicates that the prevalence is around
6% in patients with uncomplicated hypertension and as high as 20% in those with
resistant hypertension. Symptoms are largely related to the associated
hypertension, hypokalemia, or alkalosis, and include headaches, polyuria, polydipsia,
muscle weakness and fatigue, and intermittent paresthesias.
Page 3 of 129
, Question 4
A 75-year-old male with a history of hypertension sees you for a follow-up visit. His
current medications are lisinopril (Prinivil, Zestril), 40 mg daily, and chlorthalidone, 25
mg daily. His blood pressure is 136/84 mm Hg. You tell him that this blood pressure is
acceptable and he says that he read about the SPRINT study on the internet and that
he thinks his blood pressure should be lower.Which one of the following would be
appropriate information to provide when discussing the SPRINT (Systolic Blood
Pressure Intervention Trial) findings?
Lowering blood pressure to a target of <120/80 mm Hg was beneficial only in
patients with type 2 diabetes
Lowering blood pressure to a target of <120/80 mm Hg was beneficial in patients
with type 2 diabetes, as well as patients who did not have diabetes
The SPRINT trial was limited to patients determined to be at high cardiovascular risk
Intensive blood pressure lowering was associated with an absolute cardiovascular risk
reduction of 15%
The number of patients who benefited from intensive blood pressure therapy was
higher than the number who experienced significant adverse events
Correct Answer
C
The Systolic Blood Pressure Intervention Trial (SPRINT) included 9361 adults age 50
or older who were at high risk for cardiovascular disease but did not have a
previous history of diabetes mellitus or stroke. Subjects were randomly assigned to
either intensive lowering of systolic blood pressure (SBP) to 120 mm Hg, or to a
goal of 140 mm Hg. High cardiovascular risk was defined as one of the following:
clinical or subclinical cardiovascular disease other than stroke; chronic kidney
disease (an estimated glomerular filtration rate of 20-59 mL/min/1.73 m2, excluding
those with polycystic kidney disease), a 10-year risk of cardiovascular disease of
15% or greater on the basis of the Framingham risk score, or an age of 75 years or
older.After a median follow-up of 3.26 years, a 25% relative risk reduction in primary
composite outcome (myocardial infarction, other acute coronary syndromes, stroke,
heart failure, or death from cardiovascular causes) was demonstrated in the
intensive SBP-lowering treatment group. The corresponding absolute risk reduction
was only 1.6%, resulting in a number needed to treat of 61. Rates of serious adverse
events such as hypotension, syncope, electrolyte abnormalities, and acute kidney
injury or failure were higher in the intensive treatment group than in the standard
treatment group. A total of 220 participants in the intensive treatment group (4.7%)
and 118 participants in the standard treatment group (2.5%) had serious adverse
events that were classified as possibly or definitely related to the intervention, which
corresponds to an absolute risk increase in adverse events of 2.2% in the intensive
therapy group. The number needed to harm in SPRINT was 45.Although the 2017
Page 4 of 129
AND CORRECT ANSWERS
Question 1
A nonthiazide diuretic should be considered for initial antihypertensive therapy in
patients with which one of the following?
Diabetes mellitus
Recurrent calcium kidney stones
Stage 3 chronic kidney disease, with an estimated glomerular filtration rate of 50
mL/min/1.73 m2
Bipolar disorder treated with lithium
A past history of stroke
Correct Answer
D
Diuretic-induced sodium loss can reduce the renal clearance of lithium, thereby
increasing serum lithium levels and the risk of lithium toxicity. In addition, by
reducing urine calcium excretion, thiazide-type diuretics have been shown to
significantly reduce recurrence rates of calcium stones by up to 50% over a 3-year
period. Thiazide diuretics are generally thought to be less effective in patients with
moderate to severe chronic kidney disease (CKD). The 2017 American College of
Cardiology/American Heart Association guidelines favor the use of loop diuretics
over thiazide diuretics in patients with stage 4 CKD with a glomerular filtration rate
<30 mL/min/1.73 m2. Thiazide-type diuretics have been shown to improve clinical
outcomes in patients with diabetes mellitus, as well as following a stroke.
Page 1 of 129
,Question 2
A 65-year-old male comes to your office for an initial visit. He has a 5-year history of
type 2 diabetes treated with glipizide (Glucotrol), 10 mg daily. A physical examination
is notable for a blood pressure of 142/92 mm Hg and nonproliferative diabetic
retinopathy with scattered microaneurysms and cotton-wool spots. Laboratory testing
reveals a hemoglobin A1c of 8.4%, a serum creatinine level of 1.3 mg/dL (N 0.7-1.3),
and modest persistent albuminuria (30-299 mg/24 hr).You consider prescribing an
antihypertensive agent. Which one of the following has been shown to slow the
progression of microalbuminuria to macroalbuminuria (≥300 mg/24 hr) in this
situation, independent of blood pressure reduction?
ACE inhibitors
α1-Blockers
β-Blockers
Dihydropyridine calcium channel blockers
Hydrochlorothiazide
Correct Answer
A
Once macroalbuminuria develops in a patient with nephropathy due to type 2
diabetes, creatinine clearance declines an average of 10-12 mL/min/year in
untreated patients. In patients with hypertension, type 2 diabetes, and
microalbuminuria, both ACE inhibitors and angiotensin receptor blockers have been
shown to delay the progression to macroalbuminuria, independent of a reduction in
blood pressure.
Page 2 of 129
,Question 3
A 32-year-old female who works as an administrative assistant is referred to you for
evaluation of high blood pressure. Her past medical history is unremarkable, and she
does not take any prescribed or over-the-counter medications. A review of systems
reveals only a chronic history of mild fatigue and episodic muscle cramping. A
physical examination is normal except for a blood pressure of 156/100 mm Hg in
both arms without significant orthostatic changes.Laboratory
FindingsCBC............normalSodium............145 mEq/L (N 135-145)Potassium............2.9
mEq/L (N 3.5-5.0)Chloride............100 mEq/L (N 100-108)Bicarbonate............25 mEq/L (N
22-26)Creatinine............0.7 mg/dL (N 0.6-1.5)BUN............10 mg/dL (N 8-
25)Glucose............90 mg/dLUrinalysis............normalWhich one of the following is the
most likely cause of her hypertension?
Addison's disease
Bartter syndrome
Chronic licorice ingestion
Primary hyperaldosteronism
Renovascular hypertension
Correct Answer
D
Primary hyperaldosteronism, also known as Conn's syndrome, is associated with
hypersecretion of aldosterone, a mineralocorticoid. It is twice as common in women
as in men, and usually occurs between 30 and 50 years of age. In the past, it was
estimated that approximately 1% of unselected hypertensive patients had
hyperaldosteronism, but more recent data indicates that the prevalence is around
6% in patients with uncomplicated hypertension and as high as 20% in those with
resistant hypertension. Symptoms are largely related to the associated
hypertension, hypokalemia, or alkalosis, and include headaches, polyuria, polydipsia,
muscle weakness and fatigue, and intermittent paresthesias.
Page 3 of 129
, Question 4
A 75-year-old male with a history of hypertension sees you for a follow-up visit. His
current medications are lisinopril (Prinivil, Zestril), 40 mg daily, and chlorthalidone, 25
mg daily. His blood pressure is 136/84 mm Hg. You tell him that this blood pressure is
acceptable and he says that he read about the SPRINT study on the internet and that
he thinks his blood pressure should be lower.Which one of the following would be
appropriate information to provide when discussing the SPRINT (Systolic Blood
Pressure Intervention Trial) findings?
Lowering blood pressure to a target of <120/80 mm Hg was beneficial only in
patients with type 2 diabetes
Lowering blood pressure to a target of <120/80 mm Hg was beneficial in patients
with type 2 diabetes, as well as patients who did not have diabetes
The SPRINT trial was limited to patients determined to be at high cardiovascular risk
Intensive blood pressure lowering was associated with an absolute cardiovascular risk
reduction of 15%
The number of patients who benefited from intensive blood pressure therapy was
higher than the number who experienced significant adverse events
Correct Answer
C
The Systolic Blood Pressure Intervention Trial (SPRINT) included 9361 adults age 50
or older who were at high risk for cardiovascular disease but did not have a
previous history of diabetes mellitus or stroke. Subjects were randomly assigned to
either intensive lowering of systolic blood pressure (SBP) to 120 mm Hg, or to a
goal of 140 mm Hg. High cardiovascular risk was defined as one of the following:
clinical or subclinical cardiovascular disease other than stroke; chronic kidney
disease (an estimated glomerular filtration rate of 20-59 mL/min/1.73 m2, excluding
those with polycystic kidney disease), a 10-year risk of cardiovascular disease of
15% or greater on the basis of the Framingham risk score, or an age of 75 years or
older.After a median follow-up of 3.26 years, a 25% relative risk reduction in primary
composite outcome (myocardial infarction, other acute coronary syndromes, stroke,
heart failure, or death from cardiovascular causes) was demonstrated in the
intensive SBP-lowering treatment group. The corresponding absolute risk reduction
was only 1.6%, resulting in a number needed to treat of 61. Rates of serious adverse
events such as hypotension, syncope, electrolyte abnormalities, and acute kidney
injury or failure were higher in the intensive treatment group than in the standard
treatment group. A total of 220 participants in the intensive treatment group (4.7%)
and 118 participants in the standard treatment group (2.5%) had serious adverse
events that were classified as possibly or definitely related to the intervention, which
corresponds to an absolute risk increase in adverse events of 2.2% in the intensive
therapy group. The number needed to harm in SPRINT was 45.Although the 2017
Page 4 of 129
