HYPERTENSION MASTER CLASS
Twice this month you will be meeting with Dr. Msaouel and me for the Hypertension Master Class. The goals of the sessions are to solidify our knowledge of the basics of hypertension treatment and to challenge us to become experts in this most common of conditions. To attain these goals, we will have to delve deeply into the details of the JNC 8 report, improving our familiarity with the large clinical trials that constitute the basis of the report. We will become expert practitioners of evidence-based medicine, using the guidelines promulgated by the experts where they best apply and using our own knowledge of the limitations of the guidelines and the specifics of each patient to individually tailor treatment.
Everyone should complete the test below prior to the class. You are encouraged, indeed required, to do the test in an “open book” fashion. Read the guidelines summary and recommendations in detail. Look into the huge full report of the JNC. Google and PubMed. Work together. Ask anyone you like. Please turn in a copy of your answers at the beginning of the class.
In addition to completing the test, each of you will be assigned one of the questions. You will lead a discussion of the question. You may prepare a powerpoint or a handout if you’d like. The more detailed your answer in terms of referencing original studies, the happier I will be.
Many of the questions below, though in multiple choice format, are not standard multiple choice. There are often multiple correct choices. For example the question may ask “Which of the following is true?” and B and C may both be true while A,D, and E are not. Try to get them all right.
0. Regarding the usage of guidelines in clinical practice, which of the following describes your attitude:
A. The guidelines are compiled by the experts working with many resources over long periods of time. They are the experts. I do not have the time or skills to review all the studies as they do, so I should just follow the guidelines.
B. I am not a statistician or an epidemiologist, I am a physician. It’s not for me to say whether a particular study has limitations or the guidelines err in some way. What do I know?
C. Guidelines come and guidelines go. I know what works for my patients. I will look at the guidelines, but still keep my own council.
D. If they are strictly evidence-based, guidelines do not address the many permutations and combinations of patient, insurance, and local factors that characterize each patient, so they often do not apply well to the clinical situations I would use them in.
E. Familiarity with the clinical studies that underpin the guidelines and with the processes with which the guidelines are composed can enhance my clinical practice.
F. All of the above
1. According to JNC 8, initial treatment of blood pressure of 149/88 in a black diabetic 60 year old without evidence of CKD could consist of all of the following except:
A. ACE inhibitor
B. ARB
C. Thiazide type diuretic
D. CACB
E. Thiazide + CACB
F. Lifestyle modification
G. Vasodilating beta blocker such as labetalol
2. In which of the following population groups does JNC 8 recommend treatment of diastolic BP to lower than 80 mm Hg?
A. Adults > 60 years old
B. Adults < 60 years old with CKD
C. Adults < 60 years old with CKD and DM
D. Adults < 30
E. None of the above groups because the HYVET study shows no difference in outcomes with DBP of < 90 v. < 80
F. None, the evidence from the HOT trial, which was the only trial specifically designed to assess the difference in outcomes between DBP lowered < 90 and DBP lowered to <80, was deemed low quality and thus disregarded.
3. What is the approximate NNT over 2 years to prevent one of the following composite outcomes -CVD related mortality, MI, CHF, CVA – in an 80 year old patient with BP of 180/90.
4. What is the approximate NNT over a few years to prevent the composite outcome in a 50 year old with BP of 180/90?
5. Which of the following are cited as reasons for treating persons younger than 60 with SBP 140 or higher with antihypertensive medication?
A) It has been demonstrated in good quality RCTs to reduce the risk for cardiovascular events
B) In studies which demonstrate the benefit of lowering diastolic BP in this age group to less than 90 the subjects were also likely to have systolic BP lowered to <140.
C) Previous recommendations specify this threshold and it would be too much trouble to change it
D) The experts could agree on this
E) The recommendations for diabetics and patients with CKD in this age group specify the same threshold and in the absence of evidence to the contrary it is simpler to have all the hypertensives in this age group be treated similarly
6. The JNC recommended against the use of combination antihypertensive pills because?
A) The dosages of the different ingredient medicines cannot be independently adjusted
B) Their use increases the likelihood that patients will inaccurately report to doctors the medicines they are taking
C) Patients can not split the dosage times i.e. take one pill in the morning and the other at night to mitigate any side effects.
D) The JNC did not recommend against the use of combination pills
7. A middle aged man with DM and HTN presented to his PCP for regular visit. His BP was 183/115 mm Hg despite taking lisinopril 40 mg and verapamil 180 mg daily. He had previously taken HCTZ, which was discontinued due to hypokalemia 1 month ago, as well as atenolol, which was stopped 2 months earlier. As part of the workup for secondary HTN, plasma aldosterone concentration (PAC) and plasma renin activity (PRA) were measured as well as electrolytes. The K was 3.7, the Cr 0.88, the PAC was 22.8 and the PRA .32. The aldo/renin ratio was 71.25. How do you interpret these results:
A. Primary aldosteronism is confirmed
B. Primary aldosteronism is suggested. Imaging is required for confirmation.
C. Primary aldosteronism is suggested. Aldosterone suppression test is required for confirmation.
D. Results are unreliable; ARR should be measured 1 month after discontinuing lisinopril
8. The reason that ACE/ARB are not recommended as first line therapy in black patients
A. They are recommended
B. Blacks have lower renin levels than non blacks
C. A single large trial showed that ACE/ARB are not as effective in black patients
9. A 75-year-old woman is evaluated during a follow-up visit for escalating hypertension. She has a 54-pack-year history of smoking; she quit 5 years ago after she had a transient ischemic attack. She is adherent to her medication regimen, which consists of a β-blocker, a calcium channel blocker, and a diuretic. Six months ago her blood pressure was 148/82 mm Hg, and three months ago it was 158/90 mm Hg. On physical examination, temperature is normal, blood pressure is 174/96 mm Hg, and pulse rate is 60/min. BMI is 20. Cardiopulmonary examination reveals bilateral carotid bruits as well as midline and bilateral epigastric bruits. An S4 gallop is noted. There is trace pedal edema. Laboratory studies reveal a serum creatinine level of 1.7 mg/dL (150 µmol/L), an estimated glomerular filtration rate of 29 mL/min/1.73 m2, and a negative urine dipstick.
A. Add an ACE inhibitor
B. Increase the β-blocker dose
C. Obtain Doppler ultrasonography of the renal arteries
D. Obtain kidney angiography
10. A 54-year-old woman is evaluated for an abnormal electrocardiogram obtained at a local health screening fair. She has no cardiovascular symptoms or risk factors and takes no medications. On physical examination, blood pressure is 136/80 mm Hg; other vital signs are normal. The remainder of the examination is unremarkable. Laboratory studies, including complete blood count, serum creatinine, electrolytes, and lipids, are normal. The electrocardiogram demonstrates voltage criteria for left ventricular hypertrophy. A follow-up echocardiogram confirms the presence of symmetric left ventricular hypertrophy without evidence of aortic valve disease or resting outflow gradient.
A. 24-Hour ambulatory blood pressure monitoring
B. Cardiac MRI
C. Chlorthalidone
D. Coronary artery calcium score
11. A 25-year-old woman comes for a preconception evaluation. She has a history of hypertension that is well controlled with lisinopril. Medical history is otherwise unremarkable. On physical examination, blood pressure is 134/86 mm Hg in both upper extremities; other vital signs are normal. Results of the cardiovascular examination are unremarkable. There is no edema, cyanosis, digital clubbing, or radial artery-femoral artery pulse delay. Laboratory studies reveal normal electrolytes, complete blood count, thyroid-stimulating hormone level, kidney function, and urinalysis. An electrocardiogram is normal.
A. Discontinue lisinopril
B. Substitute labetalol for lisinopril
C. Substitute losartan for lisinopril
D. Substitute spironolactone for Lisinopril
12. A 40-year-old man is evaluated during a follow-up visit for high blood pressure. Three weeks ago, his blood pressure was 150/94 mm Hg. He has no knowledge of prior blood pressure measurements. He has no history of cardiovascular disease. He takes no medications. On physical examination, temperature is 37.1 °C (98.8 °F), blood pressure is 148/96 mm Hg seated and 156/100 mm Hg standing, pulse rate is 82/min, and respiration rate is 18/min. BMI is 27. Funduscopic examination shows arteriolar narrowing with two arteriovenous crossing defects (“nicking”). The remainder of the examination is unremarkable. Initial laboratory studies, including serum electrolyte levels, complete blood count, lipid profile, and urinalysis, are normal. Normal kidney function is noted.
A. Atenolol
B. Electrocardiography
C. Home blood pressure monitoring
D. Plasma aldosterone-plasma renin activity ratio
13. The patient is a 65 year-old man with a history of hypercholesterolemia (treated with Zocor) who has had BP of 150-160/90-100 on several measurements taken over the course of the year that you’ve seen him. Every time he comes he adds that he’s nervous, that he just had something salty to eat, that he’s under stress, or something else. Furthermore he says that he has his own blood pressure cuff and that his home BP’s are 120/70-80. He brought the cuff in once and you verified its accuracy. Exam is otherwise normal. Labs, UA and EKG are normal. Which of the following are true?
A. The patient has whitecoat hypertension which carries an increased risk of stroke and should be treated with antihypertensive medications.
B. The patient has masked hypertension which carries an increased risk of stroke and should be treated with antihypertensive medications
C. The patient has whitecoat hypertension which probably does not carry an increased risk of stroke so he should not be treated with antihypertensive medications
D. The patient has whitecoat hypertension which carries an increased risk of progression to sustained hypertension so he should be monitored closely
E. The patient has whitecoat hypertension and should be reassured that no adverse consequence is associated with this phenomenon. He should stay away from doctors as much as possible.
14. The patient is a 65 year-old Caucasian woman you’ve been following for hypertension. Blood pressures range from 170-200/100-110 despite escalating doses HCTZ (current dose 50 mg), Atenolol (100 mg), Monopril (40 mg) and nifedipine (120 mg). Does the patient warrant a workup for secondary causes of hypertension? What would this workup consist of? What is the yield of such a workup? Are there any validated clinical predictors which can help the clinician decide who should be evaluated for secondary hypertension?
15. The patient is a 45 year-old African-American man you’ve been following for hypertension. Blood pressures range from160-190/95-110 despite escalating doses of HCTZ (current dose 50mg), Atenolol (currently 100mg qd), Monopril (40Mg) and Nifedipine XL (90mg). On exam the HR is 55 and there is an S4. The patient insists that he takes his medicines consistently and his wife agrees that he is “religious about his pills.” Which of the following changes in medication is reasonable at this point?
A. Add spironolactone 25 mg daily
B. Taper off Atenolol, start instead on carvedilol
C. Taper off Atenolol, start instead on metoprolol
D. Increase nifedipine to 60mg bid
E. Stop monopril and switch to Losartan
F. Add doxazosin 1 mg qhs and then increase to 16 mg qhs
G. Stop HCTZ 50 and start chlorthalidone 25 qd
H. Start clonidine .1 mg bid
I. Start hydralazine 10 mg tid