Hypertension

Fenoldopam (Corlopam)

-Antihypertensive with dopaminergic qual -Dec preload & afterload -Also improves renal perfusion- Diuresis -peripheral dopamine 1 agonist indicated for parenteral use in lowering BP. -produces effects by inducing arteriolar vasodilation mainly through stimulation f D1 receptors. Appears to be as effective as sodium nitroprusside for short-term treatment of severe hypertension and may have beneficial effects on renal function bc it increases renal blood flow. Acute hypertension, renal failure \\\ D1A -receptor agonist, SE: ↑HR, ↑ocular P., ↓ K+ The 2017 ACC/AHA hypertension guidelines include fenoldopam as a preferred agent for treating hypertensive emergencies associated with acute renal failure; o

A 58-year-old male with hypertension and type 2 diabetes mellitus has a baseline serum creatinine level of 1.7 mg/dL. His blood pressure is 147/92 mm Hg at this visit, and he is started on benazepril (Lotensin). Two weeks later he is found to have a blood pressure of 128/80 mm Hg with a serum creatinine level of 2.1 mg/dL. A repeat serum creatinine level 1 week later is unchanged. Which one of the following is the most appropriate course of action? xContinue the benazepril at the same dosage Reduce the benazepril dosage Discontinue benazepril Recommend increased sodium intake Evaluate the patient for bilateral renal artery stenosis

An initial decline in renal function is not uncommon in the hypertensive patient whose blood pressure is brought under control. This decline is generally thought to be functional and associated with long-term renal protection. In the patient who experiences good blood pressure control with antihypertensive therapy, stabilization of serum creatinine levels after an initial 20%-30% percent rise indicates that the intraglomerular pressure has been successfully reduced.

agents for htn emerg

Avoid: nifedipine, enalaprilat Short-acting nifedipine is no longer considered appropriate in the initial treatment of hypertensive emergencies or urgencies because of its association with excessive falls in blood pressure that may precipitate renal, cerebral, or coronary ischemia. JNC-7 specifically recommends that intravenous enalaprilat be avoided in the setting of acute myocardial infarction. In the Cooperative New Scandinavian Enalapril Survival Study II (Consensus II), the intravenous administration of enalaprilat was associated with an excessive risk of hypotension in patients presenting within 24 hours of acute myocardial infarction. The presence of coronary ischemia is regarded as a special indication for the use of intravenous nitroglycerin. Use: Other appropriate agents include esmolol, labetalol, clevidipine, and nicardipine.

In a hypertensive patient with atrial fibrillation, which of the following antihypertensive agents will also help control the ventricular rate? (Mark all that are true.) xMetoprolol tartrate (Lopressor) xVerapamil (Calan) Amlodipine (Norvasc) xDiltiazem (Cardizem) Nifedipine (Adalat, Procardia)

Both β-blockers (e.g., metoprolol) and non-dihydropyridine calcium channel blockers (e.g., verapamil, diltiazem) slow sinus and AV node conduction and can aid in controlling the ventricular rate in patients with atrial fibrillation. Amlodipine and nifedipine are dihydropyridine calcium channel blockers and do not have a significant effect on cardiac conduction.

A 58-year-old male with COPD is diagnosed with stage 1 hypertension. His blood pressure is 158/100 mm Hg, and his EKG is shown below. Which one of the following should be AVOIDED in this patient? Enalapril (Vasotec) Valsartan (Diovan) xVerapamil (Calan) Amlodipine (Norvasc) Clonidine (Catapres)

Both β-blockers such as metoprolol and nondihydropyridine calcium channel blockers such as verapamil and diltiazem slow sinus and AV node conduction. Consequently, these agents should not be used in patients who have heart block greater than first degree. Since the EKG demonstrates bifascicular heart block, verapamil should be avoided, as its use would increase the risk for development of complete heart block. Amlodipine is a dihydropyridine calcium channel blocker and thus can be safely used in patients with bifascicular block.

Which of the following antidepressant agents can increase the risk of hypotension by potentiating the action of agents with α -blocking activity, such as prazosin, 1 terazosin, doxazosin, and labetalol? (Mark all that are true.) ○ Fluoxetine (Prozac) x○ Amitriptyline x○ Nefazodone ○ Bupropion (Wellbutrin) x○ Amoxapine

By blocking α1-adrenergic receptors, amitriptyline, nefazodone, and amoxapine can potentiate the effects of agents that reduce blood pressure by α-blockade. Such agents include not only the α1-blockers (i.e., prazosin, terazosin, doxazosin) but also agents that block both α1- and β-receptors, such as labetalol and carvedilol.

A 65-year-old African-American male is diagnosed with hypertension. He has a history of coronary heart disease and heart failure, with a left ventricular ejection fraction of 38%. Which of the following blood pressure medications should be AVOIDED? (Mark all that are true.) x○ Diltiazem (Cardizem) x○ Clonidine (Catapres) ○ Metoprolol succinate (Toprol-XL) x○ Doxazosin (Cardura) ○ Hydralazine

Certain classes of drugs should be avoided in patients with ischemic systolic heart failure with hypertension. Nondihydropyridine calcium channel blockers should not be prescribed because of their negative inotropic properties and the increased likelihood of exacerbating heart failure symptoms. Since clonidine falls in the same class of agents as moxonidine, which has been associated with increased mortality in patients with heart failure, both of these drugs should be avoided as well. In the ALLHAT trial, doxazosin was associated with a doubled risk of developing heart failure compared to chlorthalidone; α-blockers should therefore be used with caution in patients with heart failure. Drugs that have been shown to improve outcomes and lower blood pressure include β-blockers, diuretics, ACE inhibitors, angiotensin receptor blockers, and aldosterone receptor antagonists. The combination of hydralazine and nitrates has been shown to confer benefit in African-American patients with advanced heart failure.

A 47-year-old African-American female with a 5-year history of type 2 diabetes is diagnosed with hypertension. The physical examination is notable only for a blood pressure of 144/88 mm Hg. Laboratory findings include a hemoglobin A1c of 6.7%, a normal serum creatinine level, and the absence of albuminuria. JNC 8 recommends which of the following drug classes as initial therapy for patients such as this? (Mark all that are true.) ACE inhibitors Angiotensin II antagonists β-Blockers Calcium channel blockers Thiazide diuretics

D, E. When used as monotherapy, thiazide diuretics and calcium channel blockers have been found to be more effective for reducing blood pressure in African-American patients than β-blockers, ACE inhibitors, or angiotensin receptor blockers. The ALLHAT trial found thiazide diuretics to be more effective than ACE inhibitors for improving heart failure and cardiovascular outcomes in African-American patients. Calcium channel blockers have been found to be more effective than ACE inhibitors for reducing stroke in African-American patients. JNC 8 recommends that for the general African-American population, including those with diabetes mellitus, initial antihypertensive treatment should include a thiazide-type diuretic or a calcium channel blocker (SOR B).

A patient with bipolar disorder that is well controlled by lithium is diagnosed with essential hypertension. Which of the following antihypertensive agents should be avoided because they can raise serum lithium levels? (Mark all that are true.) x○ Hydrochlorothiazide ○ Propranolol ○ Clonidine (Catapres) x○ Ramipril (Altace) ○ Doxazosin (Cardura)

Diuretic-induced sodium loss can reduce the renal clearance of lithium, thereby increasing serum lithium levels and the risk of lithium toxicity. There is also evidence that ACE inhibitors can substantially increase steady-state plasma lithium levels and sometimes result in lithium toxicity. In a population-based, nested, case-control study, a 7.6-fold increased risk for lithium toxicity was seen within 1 month of starting an ACE inhibitor.

A 44-year-old African-American 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? Nitroprusside Fenoldopam (Corlopam) Enalaprilat Diazoxide (Proglycem) Esmolol (Brevibloc)

Fenoldopam is a selective peripheral dopamine-receptor agonist used for the treatment of severe hypertension. In studies investigating its 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 the 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 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.

An obese 14-year-old female is diagnosed with stage 1 hypertension. Her previous medical history and family history are unremarkable. A physical examination is notable only for a blood pressure of 134/84 mm Hg. Which of the following studies should be routinely obtained in this situation? (Mark all that are true.) x○ A urinalysis x○ A fasting lipid profile x○ Serum creatinine x○ Hemoglobin A1c ○ An echocardiogram ○ Renal ultrasonography

For children >13 years of age, the American Academy of Pediatrics (AAP) defines stage 1 hypertension as a blood pressure of 130/80-139/89 mm Hg and stage 2 hypertension as a blood pressure ≥140/90 mm Hg. The AAP recommends that all pediatric patients with hypertension be evaluated with a urinalysis, a chemistry panel (including electrolytes, BUN, and creatinine), and a lipid profile. Renal ultrasonography is recommended for patients <6 years of age with hypertension, as well as those with abnormal findings on a urinalysis or renal function studies. For adolescents and obese pediatric patients with hypertension, recommended tests also include hemoglobin A1c, aspartate transaminase (AST) and alanine transaminase (ALT), and a fasting lipid panel. Echocardiography is recommended to assess for cardiac target organ damage if pharmacologic treatment of hypertension is being considered. An extensive evaluation for secondary causes of hypertension is not recommended for children older than 6 years if they have a family history of hypertension, or if they are overweight or obese, and the history and physical examination do not suggest a secondary cause for their hypertension.

True statements regarding lowering blood pressure in patients with a hypertensive emergency include which of the following? (Mark all that are true.) Blood pressure should be lowered by no more than 25% within the first hour Blood pressure should generally be lowered to 160/100 mm Hg within 2-6 hours Reduction of blood pressure has been shown to be beneficial in patients with acute ischemic stroke Sedation with a benzodiazepine is an important component of treatment in hypertensive emergency related to cocaine abuse The preferred antihypertensive agents are those with a rapid onset and short duration

In patients presenting with a hypertensive emergency, the goal is to lower mean arterial blood pressure by no more than 25% within minutes to 1 hour. If the patient remains stable, the goal is to further reduce the blood pressure to 160/100-110 mm Hg within the next 2-6 hours. To achieve this, antihypertensive agents with a rapid onset and short duration are preferred. In patients with an ischemic stroke, there is no clear evidence from clinical trials to support the use of immediate antihypertensive treatment. Sedation with a benzodiazepine is considered important in the treatment of hypertensive emergencies related to cocaine abuse, since benzodiazepines not only reduce heart rate and systemic arterial pressure, but also attenuate cocaine's toxic effects on the heart and the nervous system.

Which of the following classes of antihypertensive agents have been shown to produce a regression of left ventricular hypertrophy? (Mark all that are true.) xACE inhibitors Direct vasodilators xβ-Blockers xCalcium channel blockers xThiazide diuretics

In patients with left ventricular hypertrophy, studies have shown a reduction in left ventricular mass in those treated with ACE inhibitors, diuretics, calcium antagonists, 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.

Effective diagnostic tests for suspected renovascular hypertension include which of the following? (Mark all that are true.) xDuplex Doppler flow studies of the renal arteries Rapid-sequence intravenous pyelography Renal artery angiography Captopril renography xMagnetic resonance renal angiography

In the hypertensive patient with suspected renovascular hypertension, appropriate noninvasive screening tests include duplex Doppler flow studies, CT angiography, and magnetic resonance angiography (MRA). Although it was a standard screening test for renovascular hypertension in the past, intravenous pyelography is no longer favored because of a false-positive rate of 11% and a false-negative rate of 12%. The diagnostic accuracy of captopril renography is felt to be inferior to MRA and duplex Doppler flow studies, particularly in patients with chronic kidney disease and bilateral atherosclerotic renal artery stenosis. While renal artery angiography remains the gold standard for identifying the anatomy of the renal artery, it is an invasive procedure with some associated risk, and is not recommended for the sole purpose of diagnosing renovascular hypertension.

A 68-year-old hypertensive male with a serum creatinine level of 2.2 mg/dL (N 0.6-1.5) is found to have a blood pressure of 152/96 mm Hg despite being placed on benazepril (Lotensin), 40 mg daily. Which of the following diuretic agents can be used to lower his blood pressure further? (Mark all that are true.) Chlorthalidone Hydrochlorothiazide xMetolazone (Zaroxolyn) xFurosemide (Lasix) xBumetanide

Inadequate diuretic therapy is common in resistant hypertension. Volume overload, if present, can be managed by the use of appropriate diuretics. Thiazide diuretics, which include chlorthalidone, hydrochlorothiazide, and metolazone, work by interfering with renal sodium absorption in the early distal tubule. Although this class of agents is routinely used in the majority of hypertensive patients, only metolazone retains its diuretic properties despite the presence of renal impairment. Loop diuretics, which include furosemide, torsemide, bumetanide, and ethacrynic acid, work by interfering with sodium absorption at the loop of Henle and continue to be effective in patients with renal impairment.

Conditions associated with isolated systolic hypertension include which of the following? (Mark all that are true.) Hypothyroidism xAnemia xAortic insufficiency xPaget's disease Severe osteoporosis

Isolated elevation of systolic blood pressure can be secondary to conditions associated with elevated cardiac output. Such conditions include anemia, Paget's disease, hyperthyroidism, arteriovenous fistula, and aortic insufficiency.

An 81-year-old male sees you for a routine visit. His past medical history is notable only for an episode of pneumonia several years ago. He is overweight, but his physical examination is otherwise remarkable only for a blood pressure of 190/78 mm Hg. True statements regarding his blood pressure include which of the following? (Mark all that are true.) xTreatment of isolated systolic hypertension has been shown to reduce the risk of stroke and coronary heart disease xSystolic blood pressure is more important than diastolic pressure as a predictor of ischemic heart disease risk in patients over 60 years of age xCombination therapy with two or more drugs will likely be required to control his hypertension His target systolic blood pressure is <160 mm Hg xAttempts to lower his systolic blood pressure should cease if his diastolic blood pressure falls below 65 mm Hg

Isolated systolic hypertension (ISH) is the predominant form of hypertension after age 50. Before age 50, diastolic blood pressure is the major predictor of ischemic heart disease, whereas systolic blood pressure is more important after age 60. Treatment of ISH has been shown to reduce the risk of stroke, coronary heart disease, and heart failure. Weight loss and reduced salt intake are thought to be particularly beneficial in lowering blood pressure in older people. A systolic blood pressure ≥160 mm Hg is classified as stage 2 hypertension, and combination therapy with two or more drugs will likely be required. Although the 2017 ACC/AHA guidelines still generally favor a target systolic blood pressure of <130 mm Hg in noninstitutionalized ambulatory adults >65 years of age, JNC 8 guidelines recommend a target systolic blood pressure of <150 mm Hg in patients ≥60 years of age (SOR A) and <140 mm Hg in patients <60 years of age (SOR C). The 2011 American Heart Association consensus document on hypertension in the elderly recommends that efforts to lower systolic blood pressure to the target level in elderly patients should cease if the diastolic blood pressure is reduced to a potentially dangerous level of <65 mm Hg.

According to JNC-8, pharmacologic therapy is indicated for which of the following patients? (Mark all that are true.) A 61-year-old Asian male with a blood pressure of 150/72 mm Hg A 73-year-old African-American male with a blood pressure of 148/88 mm Hg A 58-year-old Hispanic female with type 2 diabetes and a blood pressure of 136/86 mm Hg A 69-year-old white female with type 2 diabetes and a blood pressure of 142/82 mm Hg A 40-year-old white male with chronic kidney disease and a blood pressure of 136/84 mm Hg A 65-year-old African-American male with chronic kidney disease and a blood pressure of 148/84 mm Hg

JNC 8 recommends the initiation of pharmacologic therapy for hypertension in the following groups of patients: Persons <60 years of age with a systolic blood pressure ≥140 mm Hg or a diastolic blood pressure ≥90 mm Hg Persons ≥60 years of age with a systolic blood pressure ≥150 mm Hg or a diastolic blood pressure ≥90 mm Hg Persons ≥18 years of age with chronic kidney disease who have a systolic blood pressure ≥140 mm Hg or a diastolic blood pressure ≥90 mm Hg Persons ≥18 years of age with diabetes mellitus who have a systolic blood pressure ≥140 mm Hg or a diastolic blood pressure ≥90 mm Hg

A 59-year-old African-American male with a history of hypercholesterolemia and gout sees you for an annual visit. The physical examination is notable only for a blood pressure of 144/85 mm Hg. Laboratory Findings Serum triglycerides............134 mg/dL LDL-cholesterol............82 mg/dL HDL-cholesterol............47 mg/dL Liver panel............normal Serum creatinine............1.7 mg/dL Estimated glomerular filtration rate............56 mL/min/1.73 m2 According to JNC 8, which one of the following would be recommended as initial management of this patient's blood pressure elevation? xAn ACE inhibitor A calcium channel blocker Hydralazine Hydrochlorothiazide No drug treatment

JNC 8 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 (defined as an estimated or measured glomerular filtration rate <60 mL/min/1.73 m2). Treatment is recommended for patients of any age with these blood pressure values who have albuminuria (defined as >30 mg of albumin/g of creatinine at any level of GFR) (SOR C). Although a thiazide diuretic or a calcium channel blocker is recommended as first-line antihypertensive therapy in the general African-American population, in patients ≥18 years of age who have chronic kidney disease, JNC 8 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).

A 62-year-old male has had consistently elevated blood pressure at three consecutive visits. His past medical history is notable only for a history of a single episode of gout 9 months ago. He does not take any medications. A physical examination is normal except for a blood pressure of 145/92 mm Hg. Laboratory findings are within the normal range except for a serum uric acid level of 8.9 mg/dL (N 4.5-8.0). Which one of the following antihypertensive agents would also help to prevent future gout attacks by reducing the patient's uric acid levels? Furosemide (Lasix) Hydrochlorothiazide Lisinopril (Prinivil, Zestril) xLosartan (Cozaar) Metoprolol succinate (Toprol-XL)

Losartan is the only angiotensin receptor blocker that has consistently been shown to lower serum uric acid levels, and there is evidence that it reduces the risk for incidents of gout as well. Calcium channel blockers also appear to have urate-lowering properties and may also reduce the risk of gout. Thiazide diuretics, loop diuretics, and β-blockers have all been shown to raise uric acid levels. Furthermore, a higher risk for incident gout has been reported for patients treated with diuretics, β-blockers, ACE inhibitors, and angiotensin II receptors other than losartan.

Which of the following antihypertensive agents has NOT been shown to lower the plasma aldosterone-renin ratio? xAliskiren (Tekturna) Amlodipine (Norvasc) Hydrochlorothiazide Lisinopril (Prinivil, Zestril) Losartan (Cozaar)

Primary aldosteronism is a major secondary cause of hypertension that occurs in 5%-10% of patients with hypertension and up to 20% of patients with resistant hypertension. The recommended screening test is calculation of the aldosterone:renin activity ratio (ARR), with the plasma aldosterone concentration reported in ng/dL and plasma renin activity in ng/mL/hr. Although there is no established threshold for an abnormal result, a commonly used cutoff is an ARR > 30, provided the plasma aldosterone is >10-15 ng/dL. Patients should have unrestricted salt intake and serum potassium in the normal range. Medications that can elevate the ARR include β-blockers, central α2-agonists, direct renin inhibitors, and NSAIDs. Medications that can lower the ARR include potassium-sparing diuretics, spironolactone, eplerenone, potassium-wasting diuretics, ACE inhibitors, angiotensin II receptor blockers, and dihydropyridine calcium channel blockers; antihypertensive medications with minimal effect on the ARR include verapamil, hydralazine, prazosin, doxazosin, and terazosin. Mineralocorticoid receptor antagonists have a particularly pronounced effect, and the American Heart Association recommends that agents such as spironolactone or eplerenone be withdrawn for at least 4 weeks before testing.

Which one of the following is the most sensitive laboratory test for detecting pheochromocytoma? xA plasma metanephrine level A plasma catecholamine level 24-hour urine for catecholamines 24-hour urine for metanephrines 24-hour urine for vanillylmandelic acid

Recent findings demonstrate a high sensitivity of plasma levels of metanephrines for pheochromocytoma, possibly as high as 99%. Reported sensitivities for plasma catecholamine, urine catecholamine, urine metanephrine, and urine vanillylmandelic acid levels are 85%, 83%, 76%, and 63%, respectively.

hypertensive emergencies related to cocaine abuse

Sedation with a benzodiazepine is considered important. benzodiazepines not only reduce heart rate and systemic arterial pressure, but also attenuate cocaine's toxic effects on the heart and the nervous system.hemodynamic effects. In addition, by reducing the central stimulatory effects of cocaine, benzodiazepines also reduce anxiety, which often leads to resolution of the hypertension and tachycardia. When sedation is not successful, recommended antihypertensive agents include nitroglycerin, phentolamine, and nitroprussideBy blocking only β-receptors, resulting in an unopposed α-adrenergic effect, β-blockers can exacerbate vasoconstriction and should therefore be avoided. Although labetalol is both an α- and β-blocker, because it blocks β-receptors substantially more it is thought to offer no advantages over a β-blocker. Calcium channel blockers may worsen mortality rates, and short-acting nifedipine should never be used in this situation.

A 75-year-old male with a history of hypertension sees you for a follow-up visit. His current medications are lisinopril (Prinivil, Zestril), 40 mg daily, and chlorthalidone, 25 mg daily. His blood pressure is 136/84 mm Hg. You tell him this level is acceptable and he comments that he read on the internet that the SPRINT study recommended his blood pressure be lower. Which one of the following statements would be an accurate explanation of the SPRINT trial findings? A) Lowering blood pressure to a target of <120/80 mm Hg was beneficial only in patients with type 2 diabetes B) Lowering blood pressure to a target of <120/80 mm Hg was beneficial in patients with type 2 diabetes, as well as patients who did not have diabetes C) The SPRINT trial was limited to patients determined to be at high cardiovascular risk D) Intensive blood pressure lowering was associated with an absolute cardiovascular risk reduction of 15% E) The number of patients who benefited from intensive blood pressure therapy exceeded those who suffered significant adverse events

The Systolic Blood Pressure Intervention Trial (SPRINT) included 9361 adults age 50 or older who were at high hisk for cardiovascular disease but did not have a previous history of diabetes mellitus or stroke. Subjects were randomly assigned to either intensive lowering of systolic blood pressure (SBP) to 120 mm Hg, or to a lower goal systolic pressure of 140 mm Hg. High cardiovascular risk was defined as one of the following: clinical or subclinical cardiovascular disease other than stroke; chronic kidney disease (eGFR 20-59 ml/min/1.73 m2, excluding those with polycystic kidney disease), a 10-year risk of cardiovascular disease of 15% or greater on the basis of the Framingham risk score, or an age of 75 years or older. After a median follow-up of 3.26 years, a 25% relative risk reduction in primary composite outcome (myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes) was demonstrated in the intensive SBP-lowering treatment group (1.65% per year vs. 2.19% per year; hazard ratio with intensive treatment, 0.75; 95% confidence interval [CI], 0.64 to 0.89; P<0.001). The corresponding absolute risk reduction was only 1.6 % (primary composite outcome was seen in 5.2% of intensive treatment group versus 6.8% in the standard therapy group) resulting in a number needed to treat (NNT) of 61. Rates of serious adverse events of hypotension, syncope, electrolyte abnormalities, and acute kidney injury or failure were higher in the intensive-treatment group than in the standard-treatment group. A total of 220 participants in the intensive-treatment group (4.7%) and 118 participants in the standard treatment group (2.5%) had serious adverse events that were classified as possibly or definitely related to the intervention, which corresponds to an absolute risk increase in adverse events of 2.2% in the intensive-therapy group. Thus, the number needed to harm (NNH) in the SPRINT trial was 45. Although 2017 ACC/AHA hypertension guidelines recommending a target SBP of <130 mm Hg for adults >65 years of age is supported by the findings of the SPRINT trial, it is important to note that a 2017 clinical practice guideline jointly developed by the American College of Physicians and the American Academy of Family Physicians recommends an SBP treatment threshold of 150 mm Hg in adults aged 60 years or older, and that a target SBP of <140 mm Hg be a consideration in older adults who either have a history of cerebrovascular disease or who have a high cardiovascular risk. Regardless of the guideline followed, decisions regarding treatment and specific blood pressure targets should reflect shared decision-making between clinicians and patients, with due consideration of the potential benefits and harms.

A 52-year-old male who is an avid golfer and tennis player is diagnosed with stage 1 hypertension. His past medical history is unremarkable except for a history of mild hypercholesterolemia treated with diet. His EKG is shown below. Given the EKG findings, which of the following drugs would be safe to use in this patient? (Mark all that are true.) Dihydropyridine calcium channel blockers Nondihydropyridine calcium channel blockers β-Blockers Central α2-agonists

The presence of first degree atrioventricular block, as shown in the EKG, does not contraindicate the use of any of these options. The sinus bradycardia and first degree block seen in this patient are consistent with physical conditioning effects that would not contraindicate β-blockers or nondihydropyridine calcium channel blockers. However, β-blockers and nondihydropyridine calcium channel blockers should not be used in patients with heart block greater than first degree.

A 62-year-old homeless male has a long history of hypertension treated with clonidine (Catapres), 0.6 mg twice a day. You see him at the clinic at the homeless shelter, and he tells you that he ran out of his medication 2 days ago. He reports no complaints other than feeling "sort of on edge." A physical examination is notable only for a blood pressure of 170/105 mm Hg. Which of the following classes of antihypertensive agents can increase the severity of his rebound hypertension? (Mark all that are true.) Thiazide diuretics ACE inhibitors Angiotensin II antagonists xβ-Blockers Long-acting dihydropyridine calcium channel blockers

The sudden cessation of clonidine, a centrally-acting α2-agonist, can result in an abrupt rise in hypertension as a result of a rebound phenomenon causing sympathetic overactivity. In this state of increased levels of catecholamines, β-blockers will neutralize the vasodilatory effects of peripheral vascular β-receptors. This effectively leaves the vasoconstrictor α-receptors unopposed and can result in a further rise in blood pressure.

An agent other than a thiazide diuretic should be considered for initial antihypertensive therapy in patients with which of the following? (Mark all that are true.) ○ Recurrent calcium kidney stones ○ Diabetes mellitus x○ Bipolar disorder treated with lithium x○ Chronic renal insufficiency, with a serum creatinine level of 2.6 mg/dL ○ A past history of stroke

Thiazide diuretics are ineffective in patients with renal insufficiency. In addition, by their enhancement of renal tubular resorption of lithium, diuretics can raise serum lithium levels and increase the risk for toxicity. Thiazide-type diuretics have been shown to improve clinical outcomes in patients with diabetes mellitus, as well as following a stroke. In addition, by reducing urine calcium excretion, thiazide-type diuretics have been shown to significantly reduce recurrence rates of calcium stones by up to 50% over a 3-year period.

Antidepressant agents associated with a dose-dependent rise in blood pressure include which of the following? (Mark all that are true.) Venlafaxine Nefazodone Mirtazapine (Remeron) Fluoxetine (Prozac) Fluvoxamine

Venlafaxine is associated with a dose-dependent elevation of blood pressure. Compared to patients taking placebo, those taking venlafaxine at a dosage less than 100 mg/day have a 1% increase in hypertension, and those taking more than 300 mg/day have an 11% increase in hypertension.

vInterventions shown to be beneficial in the management of hypertension include which of the following? (Mark all that are true.) xWeight loss xDietary sodium restriction xAdequate dietary intake of potassium Elimination of caffeine intake Elimination of alcohol intake

Weight reduction and dietary sodium reduction have been associated with a reduction in systolic blood pressure of 5 to 20 mm Hg and 2 to 8 mm Hg, respectively. Clinical trials and meta-analyses suggest that potassium supplementation may lower blood pressure; a diet rich in potassium and calcium is recommended in JNC-7. Although there is no evidence that long-term use of coffee is associated with increased blood pressure, the 2017 ACC/AHA hypertension guidelines recommend that caffeine intake be limited to <300 mg daily. Limited consumption of alcohol (2 drinks/day in men and 1 drink/day in women) may lower systolic blood pressure by 2-4 mm Hg.

Hypertensive emergency rate of decrease

lower mean arterial blood pressure by no more than 25% within minutes to 1 hour. IIf the patient remains stable, the goal is to further reduce the blood pressure to 160/100-110 mm Hg within the next 2-6 hours.

Which one of the following is the most common cause of secondary hypertension in the preadolescent child? Renovascular hypertension xRenal parenchymal disease Coarctation of the aorta Congenital adrenal hyperplasia

vIn the preadolescent child, renal parenchymal disease is the most common secondary cause of elevated blood pressure. Less common causes include renovascular hypertension, and coarctation of the aorta, as well as endocrine causes.