2026 ASSURED EXCEL!!
Ac39-year-
oldcmalecseescyoucforcevaluationcofchighcbloodcpressure.cHiscpastcmedicalchistoryciscunremarkable.c
OncexaminationchechascacBMIcofc32ckg/m2candcyoucnotecthatchechascacroundcfacecandcacplethoriccc
omplexion.cHiscbloodcpressurecisc150/98cmmcHg,chiscpulsecratecisc88cbeats/min,candchiscrespirator
ycratecisc16/min.cOthercnotablecfindingscincludecacprominentcdorsalccervicalcfatcpadcandcsupraclavi
cularcfatcpads,cascwellcascviolaceouscstriaeconchisctrunk.cLaboratorycfindingscarecnotableconlycforcacf
astingcglucoseclevelcofc114cmg/dL.Whichconecofcthecfollowingciscthecmostclikelyccausecofchischypert
ension?
Addison'scdisease
Cushingcsyndrome
Hemochromatosis
Pheochromocytoma
Primarychyperaldosteronismc-ccCORRECTcANSWERSB
Thiscpatient'scclinicalcfindingscarecconsistentcwithcCushingcsyndrome,corchyperadrenocorticism.cTh
isciscacclinicalcsyndromecandcmetaboliccdisordercresultingcfromcchroniccexcesscofcglucocorticoids.cT
hecmostccommonccausecisccorticosteroidcuse,cbutcadrenalcneoplasmscaccountcforc20%-
25%cofccases.cFindingscincludecgeneralcweakness,costeoporosis,cmooncfacies,cfacialcplethora,cecch
ymoses,ctruncalcobesity,cviolaceouscstriaecofcthecabdomen,cdepositioncofcadiposectissuecincthecinte
rscapularcareac("buffalochump"),candcglucosecintolerance.
Youcdiagnosecstagec2chypertensioncincac54-year-
oldcmale.cHiscpastcmedicalchistoryciscotherwisecunremarkablecandcacphysicalcexaminationciscnotabl
ecforcmildcAVcnickingconcfunduscopiccexamination.cAcbaselinecEKGcrevealscevidencecofcleftcventricu
larchypertrophy.WhichconecofcthecfollowingcclassescofcantihypertensivecagentschascNOTcbeencsho
wnctocproducecacregressioncofcleftcventricularchypertrophy?
ACEcinhibitors
β-Blockers
,Calciumcchannelcblockers
Directcvasodilators
Thiazidecdiureticsc-ccCORRECTcANSWERSD
Incpatientscwithcleftcventricularchypertrophy,cstudieschavecshowncacreductioncincleftcventricularcma
sscincthosectreatedcwithcACEcinhibitors,cdiuretics,ccalciumcchannelcblockers,candcβ-
blockers,cwithcthecmostcconsistentcreductioncachievedcwithcACEcinhibitorscandcthecleastcwithcβ-
blockers.cRegressioncofcleftcventricularchypertrophychascnotcbeencdemonstratedcwithcdirectcvasodi
latorscsuchcaschydralazinecandcminoxidil.
Accordingctoccurrentlycacceptedccriteria,chypertensioncincchildrenciscdefinedcascrepeatedcbloodcpr
essurecmeasurementscatcorcabovecacthresholdcofcwhichconecofcthecfollowingcpercentilescforcage,cse
x,candcheight?
80th
85th
90th
95th
99thc-ccCORRECTcANSWERSD
Incchildrencandcadolescents,chypertensionciscdefinedcascbloodcpressurecatcorcabovecthec95thcperce
ntilecforcage,csex,candcheight,concrepeatedcmeasurements.
Whichconecofcthecfollowingcconditionsciscassociatedcwithcisolatedcsystolicchypertension?
Aorticcstenosis
Hypothyroidism
Paget'scdisease
Renovascularchypertension
Severecosteoporosisc-ccCORRECTcANSWERSC
,Isolatedcelevationcofcsystoliccbloodcpressureccancbecsecondaryctocconditionscassociatedcwithceleva
tedccardiaccoutput,csuchcascanemia,cPaget'scdisease,chyperthyroidism,carteriovenouscfistula,candca
orticcinsufficiency.
Ac59-year-oldcAfrican-
Americancmalecwithcachistorycofchypercholesterolemiacandcgoutcseescyoucforcachealthcmaintenanc
ecvisit.cAcphysicalcexaminationciscnotableconlycforcacbloodcpressurecofc144/85cmmcHg.LaboratorycFi
ndingsLDL-cholesterol............82cmg/dLHDL-
cholesterol............47cmg/dLSerumctriglycerides............134cmg/dLLivercpanel............normalSeru
mccreatinine............1.7cmg/dLc(Nc0.7-
1.3)Estimatedcglomerularcfiltrationcrate............56cmL/min/1.73cm2Whichconecofcthecfollowingcdo
escthecJNCc8cpanelcrecommendcascinitialcmanagementcofcthiscpatient'scbloodcpressurecelevation?
Lifestylecmeasuresconly
AncACEcinhibitor
Accalciumcchannelcblocker
Hydralazine
Hydrochlorothiazidec-ccCORRECTcANSWERSB
ThecJNCc8cpanelcrecommendscthecinitiationcofcpharmacologicctreatmentctoclowercbloodcpressureci
ncpatientsc≥18cyearscofcagecwithcacsystoliccbloodcpressurec≥140cmmcHgcorcacdiastoliccbloodcpressur
ec≥90cmmcHgcifctheychavecchronicckidneycdiseasec(CKD),cdefinedcascancestimatedcorcmeasuredcglo
merularcfiltrationcratec(GFR)c<60cmL/min/1.73cm2.cTreatmentciscrecommendedcforcpatientscofcanyc
agecwithcthesecbloodcpressurecvaluescwhocalsochavecalbuminuria,cdefinedcasc>30cmgcofcalbumin/gc
ofccreatininecregardlesscofcGFRc(SORcC).Althoughcacthiazidecdiureticcorcaccalciumcchannelcblockercis
cgenerallycrecommendedcascfirst-linecantihypertensivectherapycincAfrican-
Americans,cforcpatientsc≥18cyearscofcagecwhochavecCKD,cthecJNCc8cpanelcrecommendscinitialc(orcad
d-
on)cantihypertensivectreatmentcwithcancACEcinhibitorcorcangiotensincreceptorcblockerctocimprovec
kidneycoutcomes,cregardlesscofcethnicitycorcdiabetescstatusc(SORcB).Thec2017cAmericancCollegecofc
Cardiology/AmericancHeartcAssociationchypertensioncguidelinescsimilarlycrecommendcusecofcancA
, CEcinhibitorcincpatientscwithcstagec3cCKD,cascwellcascincpatientscwhochavecstagesc1corc2cCKDcwithcalb
uminuriac>300cmg/day.
Ac67-year-
oldcmalecwithcachistorycofchypertensioncandctypec2cdiabeteschascinadequatelyccontrolledcbloodcpr
essure.cHisccurrentcmedicationscareclisinoprilc(Prinivil,cZestril),c40cmgcdaily;chydrochlorothiazide,c2
5cmgcdaily;candcextended-
releasecmetforminc(GlucophagecXR),c1500cmgcdaily.cLaboratoryctestingcrevealscachemoglobincA1cc
ofc6.8%,cnormalcserumcelectrolytes,cacserumccreatinineclevelcofc1.0cmg/dLc(Nc0.6-
1.5),candcacurinarycalbumin/creatininecratiocofc80cmg/gc(Nc<30).Whichconecofcthecfollowingcagentsc
shouldcbecAVOIDEDcincthiscpatient?
Aliskirenc(Tekturna)
Atenololc(Tenormin)
Diltiazemc(Cardizem)
Doxazosinc(Cardura)
Felodipinec(Plendil)c-ccCORRECTcANSWERSA
ThecALTITUDEcstudyc(AliskirencTrialcincTypec2cDiabetescUsingcCardiorenalcEndpoints)cwascacrandom
ized,cdouble-blind,cplacebo-
controlledcinternationalcmulticenterctrialcundertakenctocdeterminecwhethercthecadditioncofcthecdi
rectcrenincinhibitorcaliskirenctocstandardctherapycwithcrenin-
angiotensincsystemcblockadecwouldcbecbeneficialcforcpatientscwithctypec2cdiabetescwhocarecatchigh
criskcforccardiovascularcandcrenalcevents.cThecstudycwascterminatedcprematurelycaftercacmediancfol
low-
upcofc27cmonthscwhencnocbenefitcwascapparent,candcachighercriskcofchyperkalemiacandchypotensio
ncwascseencincpatientscreceivingcaliskiren.cBasedconcthiscstudy,cthecFDAcissuedcacdrugcsafetycwarnin
gcinc2012cthatcannouncedctwocadditionsctocthecdrugclabelingcofcaliskiren-
containingcproducts.cThecfirstcadditioncwascaccontraindicationctocthecusecofcaliskirencincpatientscwit
hcdiabetescmellituscwhocarectakingcangiotensincreceptorcblockersc(ARBs)corcACEcinhibitors,cbecaus
ecofcancincreasedcriskcofcrenalcimpairment,chypotension,candchyperkalemia.cThecsecondcadditionc
wascacwarningctocavoidcthecusecofcaliskirencwithcARBscorcACEcinhibitorscincpatientscwithcmoderatect
ocseverecrenalcimpairmentc(glomerularcfiltrationcratec<60cmL/min/1.73cm2).ThecusecofcACEcinhibit
ors,cARBs,cβ-
blockers,cdiuretics,candccalciumcchannelcblockerschascbeencshownctocbeceffectivecincreducingccardi
Ac39-year-
oldcmalecseescyoucforcevaluationcofchighcbloodcpressure.cHiscpastcmedicalchistoryciscunremarkable.c
OncexaminationchechascacBMIcofc32ckg/m2candcyoucnotecthatchechascacroundcfacecandcacplethoriccc
omplexion.cHiscbloodcpressurecisc150/98cmmcHg,chiscpulsecratecisc88cbeats/min,candchiscrespirator
ycratecisc16/min.cOthercnotablecfindingscincludecacprominentcdorsalccervicalcfatcpadcandcsupraclavi
cularcfatcpads,cascwellcascviolaceouscstriaeconchisctrunk.cLaboratorycfindingscarecnotableconlycforcacf
astingcglucoseclevelcofc114cmg/dL.Whichconecofcthecfollowingciscthecmostclikelyccausecofchischypert
ension?
Addison'scdisease
Cushingcsyndrome
Hemochromatosis
Pheochromocytoma
Primarychyperaldosteronismc-ccCORRECTcANSWERSB
Thiscpatient'scclinicalcfindingscarecconsistentcwithcCushingcsyndrome,corchyperadrenocorticism.cTh
isciscacclinicalcsyndromecandcmetaboliccdisordercresultingcfromcchroniccexcesscofcglucocorticoids.cT
hecmostccommonccausecisccorticosteroidcuse,cbutcadrenalcneoplasmscaccountcforc20%-
25%cofccases.cFindingscincludecgeneralcweakness,costeoporosis,cmooncfacies,cfacialcplethora,cecch
ymoses,ctruncalcobesity,cviolaceouscstriaecofcthecabdomen,cdepositioncofcadiposectissuecincthecinte
rscapularcareac("buffalochump"),candcglucosecintolerance.
Youcdiagnosecstagec2chypertensioncincac54-year-
oldcmale.cHiscpastcmedicalchistoryciscotherwisecunremarkablecandcacphysicalcexaminationciscnotabl
ecforcmildcAVcnickingconcfunduscopiccexamination.cAcbaselinecEKGcrevealscevidencecofcleftcventricu
larchypertrophy.WhichconecofcthecfollowingcclassescofcantihypertensivecagentschascNOTcbeencsho
wnctocproducecacregressioncofcleftcventricularchypertrophy?
ACEcinhibitors
β-Blockers
,Calciumcchannelcblockers
Directcvasodilators
Thiazidecdiureticsc-ccCORRECTcANSWERSD
Incpatientscwithcleftcventricularchypertrophy,cstudieschavecshowncacreductioncincleftcventricularcma
sscincthosectreatedcwithcACEcinhibitors,cdiuretics,ccalciumcchannelcblockers,candcβ-
blockers,cwithcthecmostcconsistentcreductioncachievedcwithcACEcinhibitorscandcthecleastcwithcβ-
blockers.cRegressioncofcleftcventricularchypertrophychascnotcbeencdemonstratedcwithcdirectcvasodi
latorscsuchcaschydralazinecandcminoxidil.
Accordingctoccurrentlycacceptedccriteria,chypertensioncincchildrenciscdefinedcascrepeatedcbloodcpr
essurecmeasurementscatcorcabovecacthresholdcofcwhichconecofcthecfollowingcpercentilescforcage,cse
x,candcheight?
80th
85th
90th
95th
99thc-ccCORRECTcANSWERSD
Incchildrencandcadolescents,chypertensionciscdefinedcascbloodcpressurecatcorcabovecthec95thcperce
ntilecforcage,csex,candcheight,concrepeatedcmeasurements.
Whichconecofcthecfollowingcconditionsciscassociatedcwithcisolatedcsystolicchypertension?
Aorticcstenosis
Hypothyroidism
Paget'scdisease
Renovascularchypertension
Severecosteoporosisc-ccCORRECTcANSWERSC
,Isolatedcelevationcofcsystoliccbloodcpressureccancbecsecondaryctocconditionscassociatedcwithceleva
tedccardiaccoutput,csuchcascanemia,cPaget'scdisease,chyperthyroidism,carteriovenouscfistula,candca
orticcinsufficiency.
Ac59-year-oldcAfrican-
Americancmalecwithcachistorycofchypercholesterolemiacandcgoutcseescyoucforcachealthcmaintenanc
ecvisit.cAcphysicalcexaminationciscnotableconlycforcacbloodcpressurecofc144/85cmmcHg.LaboratorycFi
ndingsLDL-cholesterol............82cmg/dLHDL-
cholesterol............47cmg/dLSerumctriglycerides............134cmg/dLLivercpanel............normalSeru
mccreatinine............1.7cmg/dLc(Nc0.7-
1.3)Estimatedcglomerularcfiltrationcrate............56cmL/min/1.73cm2Whichconecofcthecfollowingcdo
escthecJNCc8cpanelcrecommendcascinitialcmanagementcofcthiscpatient'scbloodcpressurecelevation?
Lifestylecmeasuresconly
AncACEcinhibitor
Accalciumcchannelcblocker
Hydralazine
Hydrochlorothiazidec-ccCORRECTcANSWERSB
ThecJNCc8cpanelcrecommendscthecinitiationcofcpharmacologicctreatmentctoclowercbloodcpressureci
ncpatientsc≥18cyearscofcagecwithcacsystoliccbloodcpressurec≥140cmmcHgcorcacdiastoliccbloodcpressur
ec≥90cmmcHgcifctheychavecchronicckidneycdiseasec(CKD),cdefinedcascancestimatedcorcmeasuredcglo
merularcfiltrationcratec(GFR)c<60cmL/min/1.73cm2.cTreatmentciscrecommendedcforcpatientscofcanyc
agecwithcthesecbloodcpressurecvaluescwhocalsochavecalbuminuria,cdefinedcasc>30cmgcofcalbumin/gc
ofccreatininecregardlesscofcGFRc(SORcC).Althoughcacthiazidecdiureticcorcaccalciumcchannelcblockercis
cgenerallycrecommendedcascfirst-linecantihypertensivectherapycincAfrican-
Americans,cforcpatientsc≥18cyearscofcagecwhochavecCKD,cthecJNCc8cpanelcrecommendscinitialc(orcad
d-
on)cantihypertensivectreatmentcwithcancACEcinhibitorcorcangiotensincreceptorcblockerctocimprovec
kidneycoutcomes,cregardlesscofcethnicitycorcdiabetescstatusc(SORcB).Thec2017cAmericancCollegecofc
Cardiology/AmericancHeartcAssociationchypertensioncguidelinescsimilarlycrecommendcusecofcancA
, CEcinhibitorcincpatientscwithcstagec3cCKD,cascwellcascincpatientscwhochavecstagesc1corc2cCKDcwithcalb
uminuriac>300cmg/day.
Ac67-year-
oldcmalecwithcachistorycofchypertensioncandctypec2cdiabeteschascinadequatelyccontrolledcbloodcpr
essure.cHisccurrentcmedicationscareclisinoprilc(Prinivil,cZestril),c40cmgcdaily;chydrochlorothiazide,c2
5cmgcdaily;candcextended-
releasecmetforminc(GlucophagecXR),c1500cmgcdaily.cLaboratoryctestingcrevealscachemoglobincA1cc
ofc6.8%,cnormalcserumcelectrolytes,cacserumccreatinineclevelcofc1.0cmg/dLc(Nc0.6-
1.5),candcacurinarycalbumin/creatininecratiocofc80cmg/gc(Nc<30).Whichconecofcthecfollowingcagentsc
shouldcbecAVOIDEDcincthiscpatient?
Aliskirenc(Tekturna)
Atenololc(Tenormin)
Diltiazemc(Cardizem)
Doxazosinc(Cardura)
Felodipinec(Plendil)c-ccCORRECTcANSWERSA
ThecALTITUDEcstudyc(AliskirencTrialcincTypec2cDiabetescUsingcCardiorenalcEndpoints)cwascacrandom
ized,cdouble-blind,cplacebo-
controlledcinternationalcmulticenterctrialcundertakenctocdeterminecwhethercthecadditioncofcthecdi
rectcrenincinhibitorcaliskirenctocstandardctherapycwithcrenin-
angiotensincsystemcblockadecwouldcbecbeneficialcforcpatientscwithctypec2cdiabetescwhocarecatchigh
criskcforccardiovascularcandcrenalcevents.cThecstudycwascterminatedcprematurelycaftercacmediancfol
low-
upcofc27cmonthscwhencnocbenefitcwascapparent,candcachighercriskcofchyperkalemiacandchypotensio
ncwascseencincpatientscreceivingcaliskiren.cBasedconcthiscstudy,cthecFDAcissuedcacdrugcsafetycwarnin
gcinc2012cthatcannouncedctwocadditionsctocthecdrugclabelingcofcaliskiren-
containingcproducts.cThecfirstcadditioncwascaccontraindicationctocthecusecofcaliskirencincpatientscwit
hcdiabetescmellituscwhocarectakingcangiotensincreceptorcblockersc(ARBs)corcACEcinhibitors,cbecaus
ecofcancincreasedcriskcofcrenalcimpairment,chypotension,candchyperkalemia.cThecsecondcadditionc
wascacwarningctocavoidcthecusecofcaliskirencwithcARBscorcACEcinhibitorscincpatientscwithcmoderatect
ocseverecrenalcimpairmentc(glomerularcfiltrationcratec<60cmL/min/1.73cm2).ThecusecofcACEcinhibit
ors,cARBs,cβ-
blockers,cdiuretics,candccalciumcchannelcblockerschascbeencshownctocbeceffectivecincreducingccardi
