A 32-year-old woman comes to the office for a regular follow-up. She was diagnosed with type 2 diabetes mellitus 4 years ago. Her last blood test showed a fasting blood glucose level of 6.6 mmol/L (118.9 mg/dL) and HbA1c of 5.1%. No other significant past medical history. Current medications are metformin and a daily multivitamin. No significant family history. The physician wants to take her blood pressure measurements, but the patient states that she measures it every day in the morning and in the evening and even shows him a blood pressure diary with all the measurements being within normal limits. Which of the following statements is correct?

The physician has to measure the patient’s blood pressure because it is a standard of care for any person with diabetes mellitus who presents for a check-up.

Assessment of blood pressure only needs to be done at the initial visit; it is not necessary to measure blood pressure in this patient at any follow-up appointments.

The physician should not measure the blood pressure in this patient and should simply make a note in a record showing the results from the patient’s diary.

The physician should not measure the blood pressure in this patient because she does not have hypertension or risk factors for hypertension.

The physician should not measure the blood pressure in this patient because the local standards of care in the physician's office differ from the national standards of care so measurements of this patient's blood pressure cannot be compared to diabetes care guidelines.

A 35-year-old African American woman comes to the physician because of intermittent palpitations over the past 2 weeks. During this period she has also had constipation and has felt more tired than usual. She was diagnosed with hypertension 4 weeks ago and treatment with chlorthalidone was begun. Her temperature is 36.5°C (97.7°F), pulse is 75/min, and blood pressure is 158/97 mm Hg. Physical examination shows a soft and nontender abdomen. There is mild weakness of the upper and lower extremities. Deep tendon reflexes are 1+ bilaterally. Laboratory studies show: Hemoglobin 13.5 g/dL Leukocyte count 5,000/mm3 Serum Na+ 146 mEq/L Cl− 100 mEq/L K+ 2.8 mEq/L HCO3− 30 mEq/L Glucose 97 mg/dL Urea nitrogen 10 mg/dL Creatinine 0.8 mg/dL Test of the stool for occult blood is negative. An ECG shows premature atrial complexes. Chlorthalidone is discontinued and oral potassium chloride therapy is begun. One week later, the patient's plasma aldosterone concentration is 26 ng/dL (N=3.6 to 24.0 ng/dL) and plasma renin activity is 0.8 ng/mL/h (N=0.3 to 4.2 ng/mL/h). Which of the following is the most appropriate next step in management?

Perform dexamethasone suppression test

A 56-year-old Caucasian male presents to the clinic to establish care. He has never seen a physician and denies any known medical problems. Physical examination is notable for central obesity, but the patient has regular heart and lung sounds. He has a blood pressure of 157/95 mm Hg and heart rate of 92/min. He follows up 2 weeks later, and his blood pressure continues to be elevated. At this time, you diagnose him with essential hypertension and decide to initiate antihypertensive therapy. Per the Joint National Committee 8 guidelines for treatment of high blood pressure, of the following combinations of drugs, which can be considered for first-line treatment of high blood pressure in the Caucasian population?

ACE inhibitor, ARB, CCB, or thiazide

ACE inhibitor, angiotensin receptor blocker (ARB), beta-blocker (BB), or thiazide

ACE inhibitor, ARB, CCB, or loop diuretic

ACE inhibitor, ARB, alpha-blocker, or loop diuretic

ACE inhibitor, ARB, alpha-blocker, or direct vasodilator

A 55-year-old man with hypertension, hyperlipidemia, type 2 diabetes mellitus, and asthma comes to the physician because of a 2-month history of intermittent dry, hacking cough. He does not have fever, chest pain, or shortness of breath. He does not smoke cigarettes. Current medications include simvastatin, metformin, albuterol, and ramipril. His temperature is 37°C (98.6°F), pulse is 87/min, and blood pressure is 142/88 mm Hg. Cardiopulmonary examination shows no abnormalities. Which of the following is the most appropriate next step in management?

Stop ramipril and start candesartan

Start dextromethorphan and increase frequency of albuterol

Stop simvastatin and start atorvastatin

Stop ramipril and start lisinopril

Stop albuterol and start salmeterol

Resistant hypertension management — USMLE Lesson

Definition & Diagnosis - The Pressure Cooker

Definition: Uncontrolled blood pressure (BP) despite ≥3 antihypertensive drugs from different classes, including a diuretic, at optimal doses.
- Also includes patients whose BP is controlled but require ≥4 medications.
Diagnostic Confirmation:
- Step 1: Exclude Pseudoresistance
  - Verify accurate BP measurement technique.
  - Assess for medication non-adherence.
  - Rule out "white coat" effect with Ambulatory (ABPM) or Home BP Monitoring (HBPM).
- Step 2: Identify Contributing Factors
  - Lifestyle: High salt diet, obesity, alcohol.
  - Interfering substances: NSAIDs, sympathomimetics.

Resistant Hypertension Management Algorithm

⭐ The most common cause of apparent resistant hypertension is poor medication adherence.

Secondary Causes & Workup - Unmasking the Villain

Common Culprits: Renal parenchymal disease, Renal Artery Stenosis (RAS), Primary Aldosteronism, Obstructive Sleep Apnea (OSA), Pheochromocytoma/Paraganglioma, Cushing's syndrome.
Clinical Clues:
- RAS: Abdominal bruit, flash pulmonary edema, significant ↑SCr after starting ACEi/ARB.
- Primary Aldosteronism: Stubborn hypokalemia, metabolic alkalosis.
- Pheochromocytoma: Episodic palpitations, headache, sweating (PHEochromocytoma).
- OSA: Snoring, daytime sleepiness, obesity.

Resistant Hypertension Evaluation and Management Algorithm

⭐ In primary aldosteronism, the initial screening test is the Aldosterone-to-Renin Ratio (ARR). A ratio > 20 with a plasma aldosterone concentration (PAC) > 15 ng/dL strongly suggests the diagnosis. Patients should hold diuretics and mineralocorticoid receptor antagonists before testing.

Pharmacologic Algorithm - The Add-On Game

First, ensure adherence and maximize doses of a 3-drug regimen: ACEi/ARB + CCB + a long-acting thiazide diuretic (e.g., chlorthalidone).

4th Line: MRAs are preferred.
- Spironolactone: 25-50 mg daily. Watch for ↑K+ and gynecomastia.
- Eplerenone: Fewer hormonal side effects.
5th/6th Line: Use if MRA is contraindicated (e.g., GFR <30, K+ >5.0).
- Beta-blockers: Best with compelling indications (HFrEF, IHD).
- Direct vasodilators: Hydralazine, Minoxidil.

⭐ The PATHWAY-2 trial showed spironolactone was the most effective 4th-line agent for lowering BP in resistant hypertension.

Resistant Hypertension Management Algorithm

Resistant hypertension is uncontrolled BP despite ≥3 drugs (including a diuretic) or controlled on ≥4 drugs.

Always rule out secondary causes, especially primary aldosteronism (check renin & aldosterone).

Exclude pseudoresistance from non-adherence or white coat effect with ambulatory monitoring.

The preferred fourth-line agent is a mineralocorticoid receptor antagonist (MRA) like spironolactone.

Watch for hyperkalemia and gynecomastia with spironolactone; eplerenone is an alternative.

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