Question 1: Initial Hypertension Management
Vignette: A 58-year-old male patient with a history of type 2 diabetes presents to the clinic with a blood pressure of 152/94 mmHg. The patient is currently not on any antihypertensive medication. His medical history is significant for hyperlipidemia and no known drug allergies. Which of the following would be the most appropriate initial antihypertensive medication to start?
A) Amlodipine
B) Losartan
C) Hydrochlorothiazide
D) Metoprolol
E) Lisinopril
Rationale: This drug is an ACE inhibitor, is particularly beneficial in patients with diabetes due to its protective effects on the kidneys. ACE inhibitors are recommended as first-line therapy in hypertensive patients with diabetes due to evidence showing they reduce diabetes-related complications. Amlodipine, a calcium channel blocker, and Losartan, an ARB, are also suitable options but lack the specific renal protection benefits for diabetics that ACE inhibitors offer. Hydrochlorothiazide and Metoprolol could be used in hypertension but are not the first choice in a diabetic patient due to less favorable effects on metabolic parameters.
Question 2: Hypertension with Heart Failure
Vignette: A 65-year-old female with a history of chronic heart failure with reduced ejection fraction (HFrEF) presents with blood pressure of 138/85 mmHg. She is currently taking Furosemide 40 mg daily. Which of the following medications would be most beneficial to add to her regimen for blood pressure management?
A) Atenolol
B) Clonidine
C) Losartan
D) Verapamil
E) Spironolactone
Rationale: This drug is an ARB, is preferred in patients with heart failure with reduced ejection fraction due to its ability to reduce mortality and morbidity. ARBs, like ACE inhibitors, have been shown to be beneficial in HFrEF by reducing afterload and improving heart failure symptoms. Atenolol and Verapamil are not typically preferred due to their potential negative inotropic effects, which can worsen heart failure. Spironolactone, while beneficial in heart failure, does not primarily address hypertension and Clonidine is not first-line due to its side effect profile.
Question 3: Secondary Hypertension
Vignette: A 45-year-old male patient is diagnosed with secondary hypertension due to renal artery stenosis. He complains of fluctuating blood pressures, often reaching as high as 180/110 mmHg. Which of the following medication classes is contraindicated in this patient?
A) Beta-blockers
B) Diuretics
C) Calcium channel blockers
D) ACE inhibitors
E) Alpha-blockers
Rationale: These drugs are contraindicated in patients with renal artery stenosis because they can lead to a further decrease in glomerular filtration rate by reducing the pressure in the glomeruli. This can worsen renal function and is particularly dangerous in the setting of renal artery stenosis. While the other medication classes listed can be used in hypertension, caution must be exercised with diuretics due to the risk of precipitating renal insufficiency in the setting of decreased renal blood flow. Beta-blockers, calcium channel blockers, and alpha-blockers do not have the same level of contraindication in renal artery stenosis.
Question 4: Resistant Hypertension
Vignette: A 60-year-old female with resistant hypertension is currently taking maximum tolerated doses of amlodipine, lisinopril, and hydrochlorothiazide. Her blood pressure remains uncontrolled at 145/90 mmHg. Which of the following is the best addition to her regimen?
A) Furosemide
B) Spironolactone
C) Clonidine
D) Losartan
E) Bisoprolol
Rationale: This drug is a mineralocorticoid receptor antagonist, is often effective in treating resistant hypertension, which is defined as uncontrolled blood pressure despite the use of three antihypertensive medications of different classes. Its mechanism of action targets aldosterone, which can be a driver of resistant hypertension. Adding another diuretic like Furosemide or another antihypertensive without addressing aldosterone may not be as effective. Clonidine, while a potent antihypertensive, is generally reserved for use in specific situations due to its side effect profile.
Question 5: Hypertension in Pregnancy
Vignette: A 32-year-old pregnant woman at 20 weeks’ gestation is diagnosed with gestational hypertension, with blood pressures consistently reading 150/95 mmHg. She has no other medical issues. Which of the following medications is safest to initiate in this patient?
A) Enalapril
B) Atenolol
C) Labetalol
D) Losartan
E) Hydrochlorothiazide
Rationale: This drug is considered safe and effective for managing hypertension in pregnancy. It is a mixed alpha and beta-blocker that can reduce blood pressure without significantly reducing blood flow to the fetus. ACE inhibitors like Enalapril and ARBs like Losartan are contraindicated in pregnancy due to their association with fetal abnormalities. Atenolol, a beta-blocker, is not preferred due to concerns about fetal growth restriction. Hydrochlorothiazide is less commonly used due to potential effects on plasma volume in pregnancy.
Question 6: Hypertension and African American Patients
Vignette: A 50-year-old African American male with hypertension and no other comorbidities presents for a routine check-up. His blood pressure is currently 142/88 mmHg on no medication. Which of the following would be the most appropriate initial therapy for this patient?
A) Lisinopril
B) Amlodipine
C) Hydrochlorothiazide
D) Propranolol
E) Losartan
Rationale: This drug is calcium channel blocker, is often more effective as a first-line treatment for hypertension in African American patients compared to ACE inhibitors like Lisinopril. This population tends to have a better response to calcium channel blockers and thiazide diuretics, such as Hydrochlorothiazide, in terms of blood pressure reduction. Propranolol, a beta-blocker, is not the first choice due to less favorable effects on blood pressure and higher incidence of adverse effects. Losartan, an ARB, could be considered but may not be as effective as Amlodipine in this specific population.
Question 7: Diuretic-Induced Electrolyte Imbalance
Vignette: A 70-year-old female with hypertension is taking Hydrochlorothiazide 25 mg daily. Recently, she complains of fatigue and muscle weakness. Lab tests reveal a potassium level of 3.2 mmol/L. Which of the following is the best approach to address her condition?
A) Increase Hydrochlorothiazide dose
B) Add Spironolactone
C) Switch to Lisinopril
D) Add Potassium supplements
E) Switch to Amlodipine
Rationale: This drug is a potassium-sparing diuretic, can help address the hypokalemia induced by Hydrochlorothiazide, a thiazide diuretic, without losing the antihypertensive effect. This approach helps balance potassium levels while continuing to manage blood pressure. Increasing the dose of Hydrochlorothiazide could exacerbate potassium loss. While potassium supplements could directly address the hypokalemia, adding Spironolactone offers a more comprehensive approach to both manage blood pressure and correct electrolyte imbalance. Switching to Lisinopril or Amlodipine does not directly address the hypokalemia.
Question 8: Renovascular Hypertension
Vignette: A 55-year-old male with a history of smoking and peripheral arterial disease is diagnosed with renovascular hypertension. His current medications include simvastatin and aspirin. Which of the following is the most appropriate medication to add for his hypertension?
A) Ramipril
B) Atenolol
C) Amlodipine
D) Sildenafil
E) Furosemide
Rationale: This drug is an ACE inhibitor, is generally effective in managing renovascular hypertension by reducing angiotensin II levels, leading to vasodilation and a reduction in blood pressure. Although ACE inhibitors are contraindicated in bilateral renal artery stenosis, they are beneficial in unilateral disease and in patients without known renal artery stenosis but with risk factors for cardiovascular disease. Atenolol, a beta-blocker, and Amlodipine, a calcium channel blocker, are alternative options but do not offer the same renal protective effects. Sildenafil is not indicated for hypertension, and Furosemide is a diuretic that might be used adjunctively but not as a first choice.
Question 9: Hypertensive Urgency
Vignette: A 68-year-old male with a history of hypertension presents to the clinic with a blood pressure of 220/118 mmHg. He reports headache and dizziness but no chest pain, dyspnea, or neurological deficits. His current medications include lisinopril and amlodipine. Which of the following medications should be administered first?
A) Oral clonidine
B) Intravenous nitroglycerin
C) Oral captopril
D) Intravenous labetalol
E) Oral hydrochlorothiazide
Rationale: This drug is an appropriate choice for managing hypertensive urgency, which is characterized by severe hypertension without acute end-organ damage. It acts quickly to lower blood pressure without the need for intravenous administration, making it suitable for outpatient settings. Intravenous medications like nitroglycerin and labetalol are more suitable for hypertensive emergencies with acute end-organ damage. Captopril is an alternative oral option, but clonidine’s rapid action is particularly useful in urgent situations. Hydrochlorothiazide would not act quickly enough to address the immediate need for blood pressure reduction.
Question 10: Chronic Kidney Disease and Hypertension
Vignette: A 72-year-old male with chronic kidney disease (CKD) stage 3 and hypertension is being evaluated for medication optimization. His current blood pressure is 150/90 mmHg, and he is currently on amlodipine. Which of the following medications should be added to provide the best outcomes in this patient?
A) Telmisartan
B) Carvedilol
C) Furosemide
D) Terazosin
E) Atenolol
Rationale: This drug is anARB, is recommended for patients with CKD and hypertension due to its ability to provide renal protection by reducing proteinuria and slowing the progression of kidney disease. ARBs and ACE inhibitors are preferred in CKD patients for their protective effects on the kidneys. Carvedilol and Atenolol are beta-blockers that may be used in hypertension but do not offer the same renal protective benefits. Furosemide, a loop diuretic, may be necessary for fluid management in CKD but does not provide direct renal protection. Terazosin, an alpha-blocker, is primarily used for urinary symptoms associated with benign prostatic hyperplasia and is not the first choice for hypertension in CKD.