Amanda R. Vest • Leslie S. Cho
1.A 35-year-old woman at 24 weeks of pregnancy is found to have several blood pressure readings in the range of 145 to 158 mmHg systolic, 80 to 92 mmHg diastolic. This is her first pregnancy and she has no prior history of hypertension. She reports bilateral mild ankle swelling and nausea, but no right upper quadrant pain, visual changes, headaches, or dyspnea. A 24-hour urine collection shows 360 g protein. The hemoglobin is 8.0 g/dL and the platelet count is 43,000 cells/mm3. Which of the following is the correct diagnosis?
2.A 42-year-old woman presents for post hospitalization follow-up. She was recently admitted to hospital for 3 days due to sudden-onset dyspnea. Her blood pressure on presentation was 164/98 mmHg. Her examination and chest radiograph were consistent with pulmonary edema. She responded well to intravenous diuretics and was discharged on lisinopril. She has no family history of hypertension. On examination during the clinic visit, her blood pressure is 158/90 mmHg. She is normal in weight and has a normal cardiovascular examination except for a right-sided carotid bruit. Her blood tests are notable for a rise in creatinine from 0.9 to 1.8 mg/dL since hospital discharge. What is the most appropriate follow-up investigation?
b.Duplex ultrasonography of the renal arteries
d.24-Hour urinary-free cortisol
3.An 83-year-old woman presents to cardiology clinic for follow-up of her hypertension and coronary artery disease. Her only current symptom is dizziness on standing from a sitting position. The dizziness caused her to lose balance and fall on two occasions. Her current resting blood pressure is 144/90 mmHg with pulse 60 beats per minute (bpm). Her medications include hydrochlorothiazide 25 mg daily, doxazosin 2 mg daily, metoprolol XL 50 mg daily, simvastatin 40 mg daily, and aspirin 81 mg daily. What changes in medication therapy would you recommend?
a.Discontinue hydrochlorothiazide and start lisinopril 20 mg daily.
b.Discontinue atenolol and increase hydrochlorothiazide to 50 mg daily.
c.Discontinue doxazosin and initiate clonidine 0.4 mg twice daily.
d.Discontinue doxazosin and start lisinopril 5 mg daily.
e.Discontinue doxazosin and increase metoprolol to 100 mg daily.
4.A 64-year-old woman with hypertension, stage III chronic kidney disease (CKD), and diabetes is not yet at blood pressure goal on the following antihypertensives: lisinopril 40 mg, hydrochlorothiazide 25 mg, and metoprolol XL150 mg. Which of the following additional agents is contraindicated?
5.A 57-year-old woman with multidrug-resistant hypertension presents to her primary care doctor with multiple complaints. Her antihypertensive regimen consists of valsartan, hydralazine, amlodipine, captopril, and hydrochlorothiazide. Which of the following pairings of medication and side effect are most likely to be correct?
a.Valsartan and cough
b.Hydralazine and ankle edema
c.Amlodipine and insomnia
d.Captopril and constipation
6.A 19-year-old young man presents with an aortic root diameter of 4.4 cm and a strong family history of aortic dissection. His father died of a type A dissection at age 42, and his older brother recently underwent aortic root repair for an aneurysm measuring 5.6 cm in diameter. Both brothers have the fibrillin-1 gene mutation. The patient currently receives metoprolol 50 mg daily, with a pulse of 55 bpm and blood pressure measurements in the range of 115 to 125/65 to 75 mmHg. Which additional medication should be added?
a.No additional medications
7.A 62-year-old man with type 1 diabetes mellitus receives intermittent hemodialysis for his end-stage renal disease. His blood pressure has become elevated over the past year and has not reached goal levels despite initiation of three antihypertensive medications. He takes several medications for comorbid conditions, several of which may be exacerbating his elevated blood pressure. Medications for which of the following conditions would not be expected to have a side effect of hypertension?
8.A 58-year-old man with resistant hypertension returns for outpatient follow-up. His blood pressure is 168/79 mmHg and pulse 70 bpm, despite 25 mg hydrochlorothiazide daily, 200 mg metoprolol XL daily, 320 mg valsartan daily, 10 mg amlodipine daily, and a 0.1 mg/24 hour clonidine patch. He is considering entering a sympathetic denervation trial and has some questions about the procedure. Which of the following is the most accurate brief description of the denervation procedure?
a.Access through a femoral vein, cryoablation of a unilateral renal artery
b.Access through a femoral artery, radiofrequency ablation of a unilateral renal artery
c.Access through a femoral vein, radiofrequency ablation of bilateral renal arteries
d.Access through a femoral artery, alcohol ablation of bilateral renal arteries
e.Access through a femoral artery, radiofrequency ablation of bilateral renal arteries
f.At this time renal denervation cannot be recommended for this patient population
9.Which of the following patient characteristics is a risk factor for development of angiotensin-converting enzyme inhibitor (ACEI)-induced angioedema?
c.Age <45 years
d.Age >65 years
10.A 76-year-old man with hypertension has inadequate blood pressure control on chlorthalidone 25 mg daily. His primary care doctor is choosing a second antihypertensive agent. Which of the following comorbidities would be an evidence-based indication for choosing ramipril over amlodipine as the second agent?
a.Heart failure with preserved ejection fraction (HFPEF)
b.Peripheral arterial disease
11.A 30-year-old man with no past medical history presents to his primary care physician complaining of new-onset morning headaches that have been ongoing for the past few weeks. His blood pressure is noted to be 220/100 mmHg with a gradient between his brachial and popliteal arteries. On auscultation, there is a II/VI systolic crescendo–decrescendo murmur heard across the precordium. His electrocardiogram is significant for left ventricular hypertrophy. A chest X-ray shows cardiomegaly with evidence of rib notching. The patient most likely has what valvular abnormality?
a.Bicuspid aortic valve
12.A 55-year-old man with diabetes mellitus presents to his cardiologist with a blood pressure of 165/95 mmHg. According to the JNC (Joint National Committee) 8 guidelines, what is his target blood pressure measurement?
a.Prehypertension, 140/90 mmHg
b.Stage 2, 130/80 mmHg
c.Stage 1, 140/90 mmHg
d.Stage 2, 110/70 mmHg
13.What is the mechanism of action of the antihypertensive medication aliskiren?
c.Angiotensin receptor blocker (ARB)
d.Direct renin inhibitor
14.A 35-year-old woman with no past medical history, not receiving oral contraceptives, and with a family history of hypertension presents with a gradual increase in blood pressure over the past few years. Today in clinic her blood pressure is 155/95 mmHg. What is the most appropriate next step?
a.Patient has essential hypertension; start thiazide diuretic
b.She is asymptomatic; therefore, observe patient and have her follow-up in 1 year
c.Have her follow-up in a few weeks for repeat blood pressure measurements
d.Renal magnetic resonance imaging (MRI)
15.A 68-year-old man with coronary artery disease, hypertension, diabetes mellitus, and stage II hypertension presents for routine follow-up in the cardiology clinic. His blood pressure is 180/100 mmHg. He is compliant with all his medications and is currently on hydrochlorothiazide, lisinopril, metoprolol, amlodipine, and isosorbide mononitrate. He recently has had two episodes of noncardiogenic pulmonary edema in the setting of an ejection fraction of 55% with no evidence of diastolic dysfunction. What is the most appropriate next step in the management of his hypertension?
a.Addition of minoxidil
c.Discussion of medical adherence
d.Addition of hydralazine
16.A 44-year-old woman had a blood pressure of 115/75 mmHg a few years ago. She now has a blood pressure of 155/75 mmHg, which was confirmed on a repeat visit. How much has her risk for cardiovascular disease increased?
17.Which of the following antihypertensive agents is a known cause of autoimmune hemolytic anemia?
18.A patient is initiated on an ACEI. What is the recommended cutoff for rise in creatinine before stopping the medication?
a.10% increase in creatinine
b.20% increase in creatinine
c.35% increase in creatinine
d.50% increase in creatinine
19.A 68-year-old man with hypertension and history of a stroke presents for further management of his hypertension. He is currently prescribed a thiazide diuretic; however, his blood pressure remains elevated. From the standpoint of decreasing his future risk of stroke, which of the following drug classes would be most beneficial?
a.Calcium channel blocker
20.A 56-year-old woman presents to your clinic for physical examination. She has no significant past medical history and is asymptomatic. Her vital signs are significant for a blood pressure of 145/95 mmHg. What are the next steps in her evaluation for hypertension?
a.She should return in 1 year for her yearly physical examination.
b.She should have a repeat blood pressure measurement at a later time point during her visit and return in a few weeks to obtain repeat testing if that measurement is elevated.
c.Start patient on thiazide diuretic at the initial clinic visit.
d.Begin evaluation for secondary causes of hypertension.
21.A 45-year-old woman with no significant past medical history is noted to have a blood pressure of 145/90 mmHg in the outpatient clinic. This is confirmed on repeat visits. Which of the following tests would not be indicated at this time?
22.A 26-year-old man with no significant history presents to his primary care physician with complaints of episodic palpitations, morning headaches, and diaphoresis. He denies any illicit drug use. His physical examination is notable for a blood pressure of 230/120 mmHg. His ophthalmologic examination is significant for AV nicking. What is the most appropriate next step?
d.Start thiazide diuretic with follow-up in 1 month
23.A 65-year-old man with a history of hypertension and dyslipidemia is admitted to the coronary care unit with a diagnosis of a myocardial infarction. He undergoes an emergent cardiac catheterization with insertion of a drug-eluting stent to his left circumflex coronary artery. His vital signs show a blood pressure of 170/90 mmHg with a heart rate of 85 bpm and no evidence of heart failure on examination. Which of the following medications would be most appropriate to treat this patient’s hypertension?
24.Which of the following antihypertensive drug classes is most effective at reducing carotid intimal thickness?
a.Calcium channel blocker
25.What is the long-term antihypertensive mechanism of action for thiazide diuretics?
a.Decreased plasma volume
c.Decreased cardiac output
d.Decreased peripheral resistance
26.A 46-year-old woman, status post orthotopic heart transplantation, is currently taking mycophenolate, prednisone, and tacrolimus as an immunosuppressive regimen. On routine laboratory evaluation, she is found to have leukopenia. Mycophenolate levels have not been elevated in the past few months. Which of the following antihypertensive agents is the most likely culprit?
27.A 34-year-old man with isolated essential hypertension presents to clinic and is found to have a blood pressure of 180/100 mmHg after intensive lifestyle modifications. What is the most appropriate next step?
b.Start hydrochlorothiazide and lisinopril.
c.Repeat blood pressure in 4 weeks.
28.A 62-year-old man with isolated essential hypertension, currently taking hydrochlorothiazide 25 mg PO daily, comes to you for his first clinic visit. He notes that his blood pressure at home is always less than 140/80 mmHg, but in clinic it is always at least 155/95 mmHg. What is the next step?
a.Increase dose of thiazide
b.Addition of second antihypertensive medication
c.Do nothing as he has white coat hypertension
d.Evaluate for secondary causes of hypertension
29.A 48-year-old man with diabetes mellitus, hypertension, and hyperlipidemia presents to the emergency room with hypertensive emergency. His mean arterial pressure is 150 mmHg, pulse 58 bpm. The electrocardiogram is notable for sinus bradycardia with PR prolongation (260 milliseconds) and no ST deviations or T-wave abnormalities. Which medications would be the most appropriate therapy for this patient?
30.A 48-year-old obese man with hypertension, dyslipidemia, and diabetes mellitus presents to the outpatient clinic for his yearly physical. He has refused medications in the past, but now is willing to consider treatment. His blood pressure is 145/95 mmHg with a heart rate of 80 bpm. His laboratory data are significant for a creatinine of 1.3 mg/dL with the presence of microalbuminuria. Which of the following mediations would be most appropriate?
31.A 34-year-old woman with essential hypertension is considering becoming pregnant. Which of the following medications would be absolutely contraindicated to control her blood pressure during pregnancy?
32.A 48-year-old Caucasian man with impaired fasting glucose presents to his physician for a follow-up visit after he was noted to have a blood pressure of 150/95 mmHg. On repeat evaluation his blood pressure is 155/95 mmHg. Which of the following medications would be the least favored?
a.Hydrochlorothiazide 25 mg PO daily
b.Lisinopril 10 mg PO daily
c.Atenolol 25 mg PO daily
d.Chlorthalidone 25 mg PO daily
33.A 65-year-old African American man with isolated hypertension presents to clinic for his yearly physical examination. He is noted to have a blood pressure of 170/95 mmHg. He is currently prescribed lisinopril and metoprolol. Which of the following medication changes would be most appropriate?
a.Continue current medications at increased doses
b.Conversion of patient to a calcium channel blocker and thiazide diuretic
c.Addition of clonidine
d.Stopping lisinopril because of concern for renal artery stenosis
34.A 42-year-old woman with a new diagnosis of diabetes mellitus presents for management of hypertension. She was previously an avid athlete, but over the past few years has noted increased weight gain, a radial fracture after a minor fall, and increasing hirsutism. She is currently on hydrochlorothiazide, amlodipine, and lisinopril. What is the most appropriate next step in the management of this patient’s hypertension?
a.Referral to nutrition specialist to assist her with weight loss
b.Addition of clonidine
c.24-Hour urine cortisol test
d.MRI of the brain
35.A 69-year-old woman with diabetes mellitus and hyperlipidemia and no history of hypertension is noted at her yearly clinic visit to have new-onset hypertension with a blood pressure of 180/110 mmHg. She undergoes screening for secondary causes of hypertension and is found to have a pheochromocytoma. What of the following medications is contraindicated as monotherapy?
36.A 42-year-old man presents for a routine physical examination. He is noted to have a body mass index of 30 kg/m2, impaired fasting glucose, and a blood pressure of 135/85 mmHg. What is the best treatment plan for this individual?
a.Aggressive lifestyle modification
b.Institute thiazide diuretic regimen
c.No treatment at this time
37.A 50-year-old man with CKD and hypertension has a blood pressure of 165/110 mmHg. What is this patient’s target blood pressure according to the JNC 8 guidelines?
38.A 36-year-old patient, status post heart transplantation, is found to have hypertension. He is currently taking prednisone, mycophenolate, and cyclosporine. Which of the following antihypertensive medications would increase cyclosporine levels?
39.A 56-year-old man with resistant hypertension begins to take a new antihypertensive agent. Within the next few weeks he is diagnosed with pericarditis. Which of the following agents is most likely responsible?
40.A 27-year-old woman presents to the cardiology clinic for evaluation of uncontrolled hypertension. She was diagnosed 2 years ago and is currently taking hydrochlorothiazide, lisinopril, and amlodipine. She denies nonadherence and has a blood pressure of 170/100 mmHg that is equal in both arms. On routine laboratory examination, she has a potassium level of 2.9 mEq/L with a sodium level of 148 mEq/L. What is the most appropriate diagnostic test?
a.Renal MRI/magnetic resonance angiography
b.Morning renin and aldosterone concentrations
c.Adrenal vein sampling
d.24-Hour urine cortisol concentration
41.A 58-year-old obese man with hypertension, diabetes mellitus, hyperlipidemia, and recent myocardial infarction presents for his annual physical examination. He is currently prescribed atenolol, hydrochlorothiazide, amlodipine, and quinapril. His blood pressure is at target values. His HbA1c is at goal. However, he has noted increasing lower extremity edema over the past few months and had a near-fatal car accident after falling asleep while driving. His echocardiogram reveals an ejection fraction of 65% with no evidence of diastolic dysfunction. Which of the following management decisions would be most appropriate at this time?
a.Discontinue calcium channel blocker
c.Addition of loop diuretic
d.Maintain current regimen with advisement that his symptoms are typical with aging
42.A 56-year-old man on hydralazine, hydrochlorothiazide, lisinopril, and metoprolol begins to develop a malar rash and arthralgias. Which of the above antihypertensive agents is known to cause drug-induced lupus?
43.A 47-year-old man with coronary artery disease, diabetes mellitus, and hypertension is currently taking clonidine. He is found to have a blood pressure of 170/90 mmHg after forgetting to take his medication for 48 hours. What is the best strategy to control his blood pressure?
d.Add thiazide diuretic.