Transcript Hypertension

HYPERTENSION
Llewellyn F Mensah, MD
Classification (Adults)
BP Classification
Systolic BP (mmHg)
Diastolic BP (mmHg)
Normal
< 120
and < 80
Prehypertension
120 – 139
or 80 - 89
Stage 1 hypertension
140 – 159
or 90 – 99
Stage 2 hypertension
≥ 160
or ≥ 100
Measuring BP
• Seated quietly for 5 minutes in chair
• Feet on floor, arm supported at heart level
• No caffeine, exercise or smoking for 30 minutes
• Cuff bladder should encircle at least 80% arm circumference
• Inflate 20 – 30 mmHg above pulse examination
• Deflate at rate of 2 mmHg/sec
• Take at least 2 measurements separated by > 2 mins and average
Etiologies
• Essential
 onset 25 to 55 years
 Positive family history
 Unclear mechanism but ?additive microvascular renal injury over time with
contribution of hyperactive sympathetics
 Older age leads to decreased arterial compliance and systolic HTN
• Secondary
 Consider if patient < 20 or > 50 y or if sudden onset, severe, refractory HTN
Standard Workup
• Goals:
 Identify CV risk factors or other diseases that would modify prognosis or
treatment
Reveal secondary causes of hypertension
Assess for target organ damage
• History:
 CAD, HF, TIA/CVA, PAD, DM, Renal insufficiency, sleep apnea, preeclampsia, Fhx
of HTN, diet, Na intake, smoking, alcohol, prescription and OTC meds, OCP
• Physical exam:
 Check BP in both arms, fundoscopy, CV exam, abdominal, neuro
• Testing:
 K, BUN, Cr, Ca, glc, Hct, U/A, Lipids, TSH, urinary albumin:creatinine (if  Cr, DM,
peripheral edema), ?renin, ECG (for LVH), CXR, TTE (eval for valve abnormalities,
LVH)
Complications of HTN
• Each 20 mmHg increase in SBP or 10 mmHg increase in DBP leads to
a 2 fold increase in CV complications
• Neurologic: TIA/CVA, ruptured aneurysms, vascular dementia
• Retinopathy: stage I - arteriolar narrowing; II – copper wiring, AV
nicking; III – hemorrhages and exudates; IV – papilledema
• Cardiac: CAD, LVH, HF, AF
• Vascular: aortic dissection, aortic aneurysm (HTN is key risk factor
for aneurysms)
• Renal: proteinuria, renal failure
BP and cardiovascular risk
• The relationship between BP and risk of CVD events is continuous,
consistent and independent of other risk factors
• Death from IHD and stroke increase progressively and exponentially
from a normal pressure of 115/75 mmHg
• For every 20 mmHg systolic or 10 mmHg diastolic increase in BP,
there is a doubling of mortality from both IHD and stroke
Management
• Goal: < 140/90 mmHg; if DM or CKD goal is < 140/90 mmHg (in DM,
target of < 120 systolic does not decrease CV risk and increases
adverse events)
• Treatment results in 50% decrease in HF, 40% decrease in stroke, 20
– 25% decrease in MI
Lifestyle modifications
Modification
Recommendation
Approx. SBP reduction
Weight reduction
Maintain normal body weight (BMI
18.5 – 24.9)
5 – 20 mmHg/10 kg
DASH eating plan
Fruits, vegetables, low fat dairy
products
8 – 14 mmHg
Dietary Na reduction
No more than 100 mmol per day (2.4
g Na/6 g NaCl)
2 – 8 mmHg
Physical activity
Regular aerobics e.g. brisk walking
(at least 30 mins/d, most days of the
week)
4 – 9 mmHg
Moderation of alcohol No more than 2 drinks (e.g. 24 oz
consumption
beer, 10 oz wine, or 3 oz 80 – proof
whiskey) per day in most men, and
to no more than 1 drink per day in
women and lighter weight persons
2 – 4 mmHg
JNC 8 summary
• 60 years or older, treat to SBP < 150 mmHg and a DBP < 90 mmHg
• Younger than 60 years, treat to a SBP of < 140 mmHg and a diastolic
BP of < 90 mmHg
• CKD (eGFR < 60) and in patients with albuminuria (> 30 mg of
albumin per gram of creatinine), treat to SBP < 140 and a DBP < 90
mmHg
• In DM, treat to a SBP < 140 and DBP < 90 mmHg
• If minimal or no response to monotherapy, optimize drug dosing
before attempting to add a second drug
JNC 8 summary
• In the general black population, including those with diabetes, the
appropriate initial choice is a thiazide diuretic or CCB.
• In the general nonblack population, including patients with
diabetes, the appropriate initial choice is a thiazide diuretic, CCB,
ACE-I, or ARB
• Initial Rx with a thiazide diuretic is most effective in improving heart
failure outcomes
• βB and alpha blockers are not recommended for initial treatment
• Do not use an ACE-I and an ARB together
Evidence based summary
• The AHA and European Society of Hypertension/European Society
of Cardiology, as well as various meta analyses all concluded that
the amount of BP reduction is the major determinant of reduction
in CV risk and not the choice of antihypertensive drug
• This conclusion also applies to patients at increased CV risk
(ALLHAT, VALUE, CAMELOT trials)
• ACCOMPLISH trial however demonstrated that with combination
drug therapy, choice may be important (20% lower rate of CV events
with amlodipine plus benazepril vs hctz plus benazepril)
Evidence based summary
• Monotherapy: for patients who are less than 20/10 mmHg above goal
• Consider ACE/ARB for monotherapy in younger patients and
dihydropyridine CCB for elderly/black patients
• If a thiazide diuretic is chosen evidence is stronger for use of
chlorthalidone rather than HCTZ.
• Patients who have minimal or no response to the initial antihypertensive
drug should be treated with sequential monotherapy c.f. JNC 8 guidelines
(50% will respond after a change Materson et al 1995). If monotherapy is
with a thiazide switch to a long acting ACE/ARB plus a long acting CCB
Evidence based summary
• Combination therapy recommended for patients with initial BP > 20/10
mmHg above goal
• Start off with long acting ACEI/ARB plus long acting dihydropyridine CCB
• Among nonobese patients who are already being treated with an
ACEI/ARB plus a thiazide, d/c the thiazide and use long acting
dihydropyridine CCB
• Among obese patients can continue this regimen
• Continue any other combination regimens if they are working
• At least one antihypertensive should be taken at bedtime if on multiple
medicines (not the diuretic)
Evidence based summary
• UKPDS – United Kingdom Prospective Diabetes Study (BMJ 1998)
• VALUE – Valsartan Antihypertensive Long Term Use Evaluation
(Lancet, 2004)
• ACCOMPLISH - Avoiding Cardiovascular Events through
Combination Therapy in Patients living with Systolic Hypertension
(NEJM, 2008)
• ALLHAT - Antihypertensive and Lipid Lowering Treatment to
Prevent Heart Attack Trial (JAMA 2002)
• CAMELOT – Comparison of Amlodipine vs Enalapril to Limit
Occurrences of Thrombosis (JAMA 2004)
Antihypertensives in diabetes
• 20 – 60% of diabetics have concomitant HTN
• Diabetics with HTN have twice the risk of cardiovascular disease as
non diabetics with HTN
• In the UKPDS, each 10 mmHg decrease in mean SBP was associated
with reductions in risk of:
 12% for any complication related to diabetes
 15% for deaths related to diabetes
 11% for MI
13% for microvascular complications
Antihypertensives in diabetes
• Reduction in CV events and microvascular complications in diabetics
is seen with multiple drug classes including ACE-Is, ARBs, diuretics,
β blockers
• Dihydropyridine CCBs appear inferior to ACE-Is and β – blockers in
reducing MI and heart failure
• Non dihydropyridine CCBs have been shown to reduce albumin
excretion
• The α2 blocker arm of the ALLHAT study was terminated due to an
increase in cases of new onset heart failure in patients assigned to
the α2 blocker.
HTN and erectile dysfunction
• ARBs, ACEIs and CCBs have a neutral effect on erectile function.
• Centrally acting α1 agonists, β blockers and diuretics have a negative
effect on erectile function
• Nitrates are contraindicated with PDE-5 inhibitor use; combination may
trigger severe hypotension/circulatory collapse
 Allow 48 h after last tadalafil dose
 Allow 24 h after last sildenafil or vardenafil dose
• α2 blockers should be used with caution; combination may trigger
hypotension
 Initiate PDE – 5 inhibitor at lowest dose
HTN in minority populations
• African American patients exhibit somewhat reduced BP responses
to monotherapy with ACEIs, ARBs, β – blockers when compared
with diuretics or CCBs
• These differential responses are largely eliminated by drug
combinations that include adequate doses of a diuretic
• Thiazide diuretics should be used in drug treatment for most
patients with uncomplicated hypertension either alone or combined
with drugs from other classes
• ACEI induced angioedema occurs 2 – 4 times more frequently in
African American patients than in other groups
Treatment induced decline in renal function
• A 20 – 30% increase in creatinine, which then stabilizes, represents a
hemodynamic change, and not a structural change
• Slight rise in creatinine serves as an indirect indicator that
intraglomerular pressure has been reduced
• ACEI/ARBs also dilate efferent arteriole, exaggerating decline in
intraglomerular pressure
• If creatinine increases by more than 30%, agent should be
discontinued and other causes of renal dysfunction should be
evaluated
Thiazide diuretics in HTN
• Should be used in drug treatment for most, either alone or
combined with drugs from other classes
• Reduce excretion of
 Calcium (slow demineralization in osteoporosis)
Uric acid (increasing likelihood of gout)
 Lithium
• Increase excretion of
 Potassium (average decrease of 0.3 – 0.4 mmol/L; dietary salt restriction can
minimize thiazide induced K loss)
Magnesium (complicates correction of hypokalemia)
Thiazide diuretics in HTN
• Average increase in glucose attributed to thiazide use: 3 – 5 mg/dL
• Presence of diabetes is not a contraindication to use of thiazides
• Typically considered ineffective when GFR < 30 – 40 mL/min
(exception is metolazone)
• Substitute furosemide or torsemide
Systolic hypertension in the elderly
• Approx 2/3 of those over 60 have HTN
• Most cases of isolated systolic HTN are caused by reduced elasticity and
compliance of large arteries resulting from age and atherosclerosis
• In the systolic hypertension in the elderly program (SHEP study),
treatment with chlorthalidone resulted in reduction of:
 Stroke incidence (36%)
 Coronary heart disease (27%)
 CHF (55%)
• The therapeutic approach and goals for isolated systolic HTN are similar to
those for other types of HTN: target < 140/90; 140/90 mmHg in diabetics
and those with CKD
Secondary causes of hypertension
DISEASES
Renal
Endocrine
SUGGESTIVE FINDINGS
INITIAL WORKUP
Renal parenchyma DM, Polycystic kidneys, GN
(2 – 3%)
CrCl, albuminuria
Renovascular (1 –
2 %)
ARF induced by ACE-I/ARB,
Recurrent flash pulmonary
edema, renal bruit
MRA, CTA, Duplex
U/S, angio, plasma
renin (low Sp)
Conn’s / Cushings
(1 – 5%)
Hypokalemia
Metabolic alkalosis
Pheo (< 1%)
Paroxysmal HTN, H/A, Palp
Myxedema (< 1%)
 Ca2+ (< 1%)
TFTs
Polyuria, dehydration, AMS
iCa
Obstructive sleep apnea
Other
Medications: OCP, Steroids, licorice, NSAIDs (esp COX-2), Epo,
cyclosporine
Aortic coarctation:  LE pulses, systolic murmur, radial – femoral artery
delay, abnormal TTE, CXR
Polycythemia vera:  Hct
Secondary causes
• Renovascular:
 control BP with diuretic + ACE-I/ARB or CCB
Atherosclerosis risk – factor modification: quit smoking, decrease
cholesterol
If refractory HTN, recurrent flash pulmonary edema, worse CKD, consider
revascularisation
 For atherosclerosis: stenting decreases restenosis compared with PTA
alone, but no clear improvement in BP or renal function compared with
medical therapy
 For FMD (usually more distal lesions): PTA +/- bailout stenting
• Renal parenchymal disease: salt and fluid restriction, +/- diuretics
• Pregnancy: methyldopa, labetalol, nifedipine, hydralazine; avoid
diuretics; no ACE-I/ARB
Resistant HTN
• Failure to reach goal BP taking at least 3 drugs, one of which is a
diuretic
 Identify and treat secondary causes
 Centrally acting alpha agonists
 Direct vasodilators
 Aldosterone antagonists
Renal artery denervation
Hypertensive crises
• Hypertensive urgency: SBP > 180 or DBP > 120 (?110) with minimum
or no target organ damage
• Hypertensive emergency:
 neurologic ischemia: encephalopathy, stroke, papilledema
 cardiac ischemia: ACS, HF/Pulmonary edema, aortic dissection
 renal ischemia: proteinuria, hematuria, AKI, scleroderma renal crisis,
microangiopathic hemolytic anemia, pre-eclampsia/eclampsia
Precipitants
• Progression of essential HTN +/- medical noncompliance (esp.
clonidine) or change in diet
• Progression of renovascular disease; acute GN, scleroderma,
preeclampsia
• Endocrine: pheochromocytoma, Cushing’s
• Sympathomimetics: cocaine, amphetamines, MAOIs + foods rich in
tyramine
• Cerebral injury (do not treat HTN in acute ischemic stroke unless
patient is getting lysed, extreme BP > 220/120, aortic dissection,
active ischemia or HF)
Treatment
• Tailor goals to clinical context (e.g. more rapid lowering for aortic
dissection)
• Emergency: Decrease MAP by ~ 25% in minutes to 2 hours with IV
agents (may need arterial line for monitoring); goal DBP < 110 within
2 – 6 h, as tolerated
• Urgency: decrease BP in hours using oral agents; goal normal BP in
~ 1 – 2 days
• Watch urine output, creatinine, mental status: may indicate a lower
BP is not tolerated
• Drugs for hypertensive crises
 IV – nitroprusside, nitroglycerin, labetalol, esmolol, fenoldopam, hydralazine,
nicardipine, clevidipine, phentolamine, enalaprilat
 PO – captopril, labetalol, clonidine, hydralazine
Summary of pharmacologic options
• Pre – HTN: ARB prevents onset of HTN
• HTN:
 uncomplicated: thiazide if likely salt sensitive (e.g. elderly, black, obese),
otherwise start with ACE-I or CCB. βB not first line.
 + high risk CAD: ACE-I or ARB; ACE-I + CCB superior to ACE-I + thiazide or βB +
diuretic
 + angina: βB, CCB, nitrates
 + post – MI: ACE-I, βB +/- aldosterone antagonist
 + HF: ACE-I/ARB, βB, diuretics, aldosterone antagonist, hydralazine, isosorbide
 + secondary stroke prevention: ACE-I, ?ARB
 + diabetes mellitus: ACE-I or ARB; can also consider diuretic, βB or CCB
 + CKD: ACE-I/ARB
Indications for individual drug classes
Indication
Diuretics
Heart failure
✓
ΒB
ACEI
ARB
✓
✓
Post - MI
✓
✓
High coronary disease risk ✓
✓
✓
✓
✓
✓
✓
✓
✓
Diabetes
CKD
Recurrent stroke
prevention
✓
✓
CCB
✓
Aldost
antagonis
t
✓
✓
✓
✓
ABFM Questions
• A postmenopausal female who has recently been diagnosed with
hypertension returns for follow-up 3 months after the initiation of
therapeutic lifestyle changes. Her blood pressure has improved but
remains higher than goal at 142/90 mm Hg, and pharmacologic
treatment is indicated. The patient has a family history of
osteoporosis. Which one of the following may slow the
demineralization of bone in this patient?
• A) An ACE inhibitor
• B) An -blocker
• C) A -blocker
• D) A calcium channel blocker
• E) A thiazide diuretic
• ANSWER: E
• Thiazide-type diuretics are useful in slowing demineralization from
osteoporosis.
• A 58-year-old male has a history of type 2 diabetes mellitus that is
not well controlled. He has recently developed mild hypertension
that has not been controlled by lifestyle changes. You prescribe
lisinopril (Prinivil, Zestril), 20 mg daily, for the hypertension and 2
months later you note that his serum creatinine level has increased
from 1.25 mg/dL to 1.5 mg/dL (N 0.64–1.27) and his blood pressure
has decreased from 142/88 mm Hg to 128/78 mm Hg. Which one of
the following should you do now?
• A) Continue the current dosage of lisinopril
• B) Decrease the dosage of lisinopril to 10 mg
• C) Increase the dosage of lisinopril to 40 mg
• D) Discontinue lisinopril and initiate chlorthalidone
• E) Discontinue lisinopril and initiate losartan (Cozaar)
• ANSWER: A
• ACE inhibitors such as lisinopril do not need to be discontinued
unless baseline creatinine increases by >30%. (This patient’s
creatinine increased by 20%.) The current dosage of lisinopril is
appropriate, as the blood pressure meets the diabetic goal of
<130/80 mm Hg. Small increases in creatinine have been associated
with long-term preservation of renal function, and may be a marker
of changes in intraglomerular pressure.
• A 62-year-old male underwent percutaneous coronary intervention
and placement of two stents for a myocardial infarction yesterday.
He is currently taking simvastatin (Zocor), aspirin, lisinopril (Prinivil,
Zestril), and hydrochlorothiazide. His last LDL-cholesterol level was
70 mg/dL and his blood pressure is 130/80 mm Hg. Which one of the
following additions to his current regimen would be most
appropriate at this time?
• A) Amlodipine (Norvasc)
• B) Diltiazem (Cardizem)
• C) Verapamil (Calan, Verelan)
• D) Metoprolol (Lopressor, Toprol-XL)
• E) No changes
• ANSWER: D
• β-Blockers are first-line antihypertensive medications for patients
with coronary artery disease (CAD) and have been shown to reduce
the risk of death by 23% at 2 years. They should also be given to
normotensive patients with CAD if tolerated. Cardioselective (1) blockers such as metoprolol and atenolol are preferred, as they
cause fewer adverse effects.
• A 55-year-old male with a 4-year history of type 2 diabetes mellitus
was noted to have microalbuminuria 6 months ago, and returns for
a follow-up visit. He has been on an ACE inhibitor and his blood
pressure is 140/90 mm Hg. The addition of which one of the
following medications would INCREASE the likelihood that dialysis
would become necessary?
• A) Hydrochlorothiazide
• B) Amlodipine (Norvasc)
• C) Atenolol (Tenormin)
• D) Clonidine (Catapres)
• E) Losartan (Cozaar)
• Answer: E
• Do not use an ACE and ARB together
• A 48-year-old female presents as a new patient to your office. She has not
seen a physician for several years and her medical history is unknown. Her
BMI is 24.4 kg/m2 and she is not taking any medication. Her blood
pressure is 172/110 mm Hg in the left arm sitting and 176/114 mmHg in the
right arm sitting; her cardiovascular examination is otherwise
unremarkable. A baseline metabolic panel reveals a creatinine level of
0.68 mg/dL (N 0.6–1.1) and a potassium level of 3.3 mEq/L (N 3.5–5.5). If
the patient’s hypertension should prove refractory to treatment, which
one of the following tests is most likely to reveal the cause of her
secondary hypertension?
• A) A 24-hour urine catecholamine level
• B) A plasma aldosterone/renin ratio
• C) MRA of the renal arteries
• D) Echocardiography
• E) A sleep study (polysomnography)
• ANSWER: B
• Primary hyperaldosteronism is the most common cause of
secondary hypertension in the middle-aged population, and can be
diagnosed from a renin/aldosterone ratio. This diagnosis is further
suggested by the finding of hypokalemia, which suggests
hyperaldosteronism even though it is not present in the majority of
cases.
• Which one of the following is a preferred first-line agent for
managing hypertension in patients with stable coronary artery
disease?
• A) A thiazide diuretic
• B) An angiotensin receptor blocker
• C) A β-blocker
• D) A long-acting calcium channel blocker
• E) A long-acting nitrate
• ANSWER: C
• American Heart Association guidelines recommend treating
hypertension in patients with stable heart failure with ACE
inhibitors and/or β-blockers. Other agents, such as thiazide diuretics
or calcium channel blockers, can be added if needed to achieve
blood pressure goals (SOR B).
• An 11-year-old male is brought to your clinic for follow-up after a recent
well child visit revealed elevated blood pressure. The parents have
restricted his intake of sodium and fatty foods during the last several
weeks. His blood pressure today is 140/92 mm Hg, which is similar to the
reading at his last visit. The parents checked the child’s blood pressure
with a home unit several times and found it consistently to be in the 130s
systolic and low 80s diastolic. The child had a normal birth history and has
no known chronic medical conditions. Both of his parents and his two
younger siblings are healthy. He is at the 75th percentile for both height
and weight with a BMI in the normal range. He eats a balanced diet and is
active. What should be the next step for this patient?
• A) Reassurance that this is likely white-coat hypertension
• B) A goal weight loss of at least 5 lb
• C) Evaluation for causes of secondary hypertension
• D) Hydrochlorothiazide
• E) Lisinopril (Prinivil, Zestril)
• ANSWER: C
• Hypertension in a patient this young should prompt a search for
secondary causes, which are more common in young hypertensive
patients than in adults with hypertension. The recommended
workup includes blood and urine testing, as well as renal
ultrasonography. An evaluation for end-organ damage is also
recommended, including retinal evaluation and echocardiography.
• A 54-year-old male sees you for a 6-month follow-up visit for
hypertension. He feels well, but despite the fact that he takes his
medications faithfully, his blood pressure averages 150/90 mmHg.
He has had an intensive workup for hypertension in the recent past,
with normal repeat laboratory results, including a CBC, serum
creatinine, an electrolyte panel, and a urinalysis. His medications
include chlorthalidone, 12.5 mg daily; carvedilol (Coreg), 25 mg
twice daily; amlodipine (Norvasc), 10 mg daily; and lisinopril (Prinivil,
Zestril), 40 mg daily. He has been intolerant to clonidine (Catapres)
in the past. Which one of the following medication changes would
be most reasonable?
• A) Adding isosorbide mononitrate (Imdur)
• B) Adding spironolactone (Aldactone)
• C) Substituting furosemide (Lasix) for chlorthalidone
• D) Substituting losartan (Cozaar) for lisinopril
• ANSWER: B
• Spironolactone is now recommended for treating resistant
hypertension, even when hyperaldosteronism is not present. A
longer-acting diuretic such as chlorthalidone is also recommended
for treating hypertension, particularly in resistant cases with normal
renal function.
• A 62-year-old African-American male is admitted to the hospital for
the third time in 6 months with heart failure. He has dyspnea with
minimal activity. Echocardiography reveals an ejection fraction of
40%. Which one of the following combinations of medications is
most appropriate for long-term management of this patient?
• A) Enalapril (Vasotec) plus digoxin
• B) Hydralazine plus isosorbide dinitrate
• C) Losartan (Cozaar) plus amlodipine (Norvasc)
• D) Spironolactone (Aldactone) plus bisoprolol (Zebeta)
• ANSWER: B
• The combination of the vasodilators hydralazine and isosorbide
dinitrate has been shown to be effective in the treatment of heart
failure when standard treatment with diuretics, β-blockers, and an
ACE inhibitor (or ARB) is insufficient to control symptoms or cannot
be tolerated. This combination is particularly effective in AfricanAmericans with NYHA class III or IV heart failure, with advantages
including reduced mortality rates and improvement in quality-of-life
measures.
• Treatment with which one of the following antihypertensive
medications may mimic the effects of primary hyperparathyroidism?
• A) Amlodipine (Norvasc)
• B) Doxazosin (Cardura)
• C) Hydrochlorothiazide
• D) Lisinopril (Prinivil, Zestril)
• E) Metoprolol (Lopressor, Toprol-XL)
• ANSWER: C
• These laboratory findings may occur with lithium or thiazide use.
• A 32-year-old gravida 2 para 1 with long-standing untreated
hypertension presents at 8 weeks gestation for prenatal care. Her
physical examination is normal except for a blood pressure of
156/114 mm Hg. Which one of the following would be most
appropriate as initial treatment?
• A) Labetalol (Trandate)
• B) Lisinopril (Prinivil, Zestril)
• C) Losartan (Cozaar)
• D) Metoprolol (Lopressor, Toprol-XL)
• E) Nifedipine, immediate release (Procardia)
• Answer: A
• The drug most often recommended as first-line therapy for
hypertension in pregnancy is labetalol. Immediate-release
nifedipine is not recommended due to the risk of hypotension.
• A 60-year-old male is referred to you by his employer for management of
his hypertension. He has been without primary care for several years due
to a lapse in insurance coverage. During a recent employee health
evaluation, he was noted to have a blood pressure of 170/95 mm Hg. He
has a 20-year history of hypertension and suffered a small lacunar stroke
10 years ago. He has no other health problems and does not smoke or
drink alcohol. A review of systems is negative except for minor residual
weakness in his right upper extremity resulting from his remote stroke.
His blood pressure is 168/98 mm Hg when initially measured by your
nurse, and you obtain a similar reading during your examination. In
addition to counseling him regarding lifestyle modifications, which one of
the following is the most appropriate treatment for his hypertension?
• A) An angiotensin receptor blocker
• B) A -blocker
• C) A calcium channel blocker
• D) A thiazide diuretic/ACE inhibitor combination
• E) No medication
• Answer: D
• This patient has stage 2 hypertension, and his history of stroke is a
compelling indication to use combination therapy with a diuretic
and an ACE inhibitor.
• A 45-year-old male has diabetes mellitus and hypertension. He has
no other medical problems. Which one of the following classes of
medications is the preferred first-line therapy for the treatment of
hypertension in this patient?
• A) Potassium-sparing diuretics
• B) ACE inhibitors
• C) -Receptor blockers
• D) Calcium channel blockers
• E) -Blockers
• ANSWER: B
• ACE inhibitors and angiotensin receptor blockers (ARBs) are the
preferred first-line agents for the management of patients with
hypertension and diabetes.