ABFM HYPERTENSION EXAM QUESTIONS AND
CORRECT ANSWERS GRADED A 2024
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 - Correct 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 - Correct 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. 1 / 4
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 - Correct 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 - Correct 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 2 / 4
Hydralazine Hydrochlorothiazide - Correct 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) - Correct Answer A 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- 3 / 4
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. Laboratory evaluation reveals normal serum electrolytes, a serum creatinine level of 3.8 mg/dL (N 0.7-1.3), and a BUN level of 60 mg/dL (N 6-20). A urinalysis shows gross hematuria and 3+ proteinuria.Which one of the following will rapidly lower his blood pressure and increase renal blood flow?Diazoxide (Proglycem) Enalaprilat (Vasotec) Esmolol (Brevibloc) Fenoldopam (Corlopam) Nitroprusside (Nitropress) - Correct Answer D Fenoldopam is a selective peripheral dopamine-receptor agonist used for the treatment of severe hypertension. In studies investigating fenoldopam use in severe hypertension, its efficacy in lowering blood pressure was found to be comparable to that of nitroprusside. It is FDA-approved for the in- hospital management of severe hypertension when rapid but quickly reversible reduction of blood pressure is required, such as in a patient with malignant hypertension who has deteriorating end- organ function. By virtue of its actions on peripheral dopamine receptors, fenoldopam produces renal arterial vasodilation and natriuresis, and thus can provide a renal protective effect in clinical situations associated with impaired renal function. In addition, there is evidence that it may improve creatinine clearance and urine flow rates in severely hypertensive patients with either normal or impaired renal function. The 2017 American College of Cardiology/American Heart Association (ACC/AHA) hypertension guidelines include fenoldopam as a preferred agent for treating hypertensive emergencies associated with acute renal failure. Other options include nicardipine and clevidipine.Compared to the typical American diet, the Dietary Approaches to Stop Hypertension (DASH) diet includes reduced consumption of which one of the following?Dietary fiber Dietary protein Low-fat dairy products Nuts and whole grains Fats and sweets - Correct Answer E
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