ABFM HYPERTENSION|| 77 QUESTIONS
AND ANSWERS 100% ACCURATE
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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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) - ANSWER-A
An obese 64-year-old female with a history of hypercholesterolemia has a blood
pressure of 168/102 mm Hg and is started on hydrochlorothiazide and lisinopril. For
patients such as this, the 2017 treatment guidelines jointly developed by the American
Academy of Family Physicians and the American College of Physicians recommend a
target systolic blood pressure of less than
160 mm Hg
150 mm Hg
140 mm Hg
135 mm Hg
130 mm Hg - ANSWER-B
Although a target blood pressure of <140/90 mm Hg was generally favored in the past,
the JNC 8 panel found insufficient evidence to conclude that a goal SBP of <140 mm Hg
in patients age 60 or older provided additional benefit compared to a goal SBP of <140-
160 mm Hg or <140-149 mm Hg. Accordingly, the JNC 8 panel recommends a goal
SBP of <150 mm Hg and a goal diastolic blood pressure of <90 mm Hg in those age 60
or older (SOR A). The higher target blood pressure recommended by the JNC 8 panel
has generated controversy, as reflected in a special article published in the Annals of
Internal Medicine, written by five members of the original 18-member JNC 8 panel who
disagreed with raising the target blood pressure in subjects older than 60.Support for
lowering the target blood pressure can be found in the SPRINT findings, which were
published after the JNC 8 panel recommendations and reported a significant reduction
in major cardiovascular events among hypertensive patients over age 50 at high
cardiovascular risk if a target SBP of <120 mm Hg was used, when compared to a
target of <140 mm Hg. Although the 2017 American College of Cardiology/American
Heart Association (ACC/AHA) hypertension guidelines generally support a target blood
pressure of <130/80 mm Hg in ambulatory community-dwelling adults over 65 years of
, age, they also urge caution in older adults with a high burden of comorbidity and a
limited life expectancy. Earlier the same year, the American College of Physicians
(ACP) and the American Academy of Family Physicians (AAFP) issued a joint clinical
practice guideline that was in general agreement with JNC 8, favoring an SBP treatment
threshold of 150 mm Hg for average-risk adults older than 60, with consideration of
treatment to lower targets for some patients in the context of shared decision-making.
A 47-year-old African-American female with a 5-year history of type 2 diabetes is
diagnosed with hypertension. A physical examination is notable only for a blood
pressure of 144/88 mm Hg. Laboratory findings include a hemoglobin A1c of 6.7%, a
normal serum creatinine level, and the absence of albuminuria.Both the JNC 8 panel
and the 2017 American College of Cardiology/American Heart Association guidelines
recommend which one of the following drug classes as initial therapy for patients such
as this?
ACE inhibitors
Angiotensin receptor blockers
β-Blockers
Calcium channel blockers
Loop diuretics - ANSWER-D
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.
AND ANSWERS 100% ACCURATE
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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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) - ANSWER-A
An obese 64-year-old female with a history of hypercholesterolemia has a blood
pressure of 168/102 mm Hg and is started on hydrochlorothiazide and lisinopril. For
patients such as this, the 2017 treatment guidelines jointly developed by the American
Academy of Family Physicians and the American College of Physicians recommend a
target systolic blood pressure of less than
160 mm Hg
150 mm Hg
140 mm Hg
135 mm Hg
130 mm Hg - ANSWER-B
Although a target blood pressure of <140/90 mm Hg was generally favored in the past,
the JNC 8 panel found insufficient evidence to conclude that a goal SBP of <140 mm Hg
in patients age 60 or older provided additional benefit compared to a goal SBP of <140-
160 mm Hg or <140-149 mm Hg. Accordingly, the JNC 8 panel recommends a goal
SBP of <150 mm Hg and a goal diastolic blood pressure of <90 mm Hg in those age 60
or older (SOR A). The higher target blood pressure recommended by the JNC 8 panel
has generated controversy, as reflected in a special article published in the Annals of
Internal Medicine, written by five members of the original 18-member JNC 8 panel who
disagreed with raising the target blood pressure in subjects older than 60.Support for
lowering the target blood pressure can be found in the SPRINT findings, which were
published after the JNC 8 panel recommendations and reported a significant reduction
in major cardiovascular events among hypertensive patients over age 50 at high
cardiovascular risk if a target SBP of <120 mm Hg was used, when compared to a
target of <140 mm Hg. Although the 2017 American College of Cardiology/American
Heart Association (ACC/AHA) hypertension guidelines generally support a target blood
pressure of <130/80 mm Hg in ambulatory community-dwelling adults over 65 years of
, age, they also urge caution in older adults with a high burden of comorbidity and a
limited life expectancy. Earlier the same year, the American College of Physicians
(ACP) and the American Academy of Family Physicians (AAFP) issued a joint clinical
practice guideline that was in general agreement with JNC 8, favoring an SBP treatment
threshold of 150 mm Hg for average-risk adults older than 60, with consideration of
treatment to lower targets for some patients in the context of shared decision-making.
A 47-year-old African-American female with a 5-year history of type 2 diabetes is
diagnosed with hypertension. A physical examination is notable only for a blood
pressure of 144/88 mm Hg. Laboratory findings include a hemoglobin A1c of 6.7%, a
normal serum creatinine level, and the absence of albuminuria.Both the JNC 8 panel
and the 2017 American College of Cardiology/American Heart Association guidelines
recommend which one of the following drug classes as initial therapy for patients such
as this?
ACE inhibitors
Angiotensin receptor blockers
β-Blockers
Calcium channel blockers
Loop diuretics - ANSWER-D
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.
