Resistant hypertension management — MCQs

10 questions

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?

A 49-year-old man is diagnosed with hypertension. He has asthma. The creatinine and potassium levels are both slightly elevated. Which of the following anti-hypertensive drugs would be appropriate in his case?

A 32-year-old man presents with hypertension that has been difficult to control with medications. His symptoms include fatigue, frequent waking at night for voiding, and pins and needles in the legs. His symptoms started 2 years ago. Family history is positive for hypertension in his mother. His blood pressure is 160/100 mm Hg in the right arm and 165/107 mm Hg in the left arm, pulse is 85/min, and temperature is 36.5°C (97.7°F). Physical examination reveals global hyporeflexia and muscular weakness. Lab studies are shown: Serum sodium 147 mEq/L Serum creatinine 0.7 mg/dL Serum potassium 2.3 mEq/L Serum bicarbonate 34 mEq/L Plasma renin activity low Which of the following is the most likely diagnosis?

A 30-year-old African American woman comes to the physician because of fatigue and muscle weakness for the past 5 weeks. During this period, she has had recurrent headaches and palpitations. She has hypertension and major depressive disorder. She works as a nurse at a local hospital. She has smoked about 6–8 cigarettes daily for the past 10 years and drinks 1–2 glasses of wine on weekends. Current medications include enalapril, metoprolol, and fluoxetine. She is 168 cm (5 ft 6 in) tall and weighs 60 kg (132 lb); BMI is 21.3 kg/m2. Her temperature is 37°C (98.6°F), pulse is 75/min, and blood pressure is 155/85 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender; bowel sounds are normal. Her skin is dry and there is no edema in the lower extremities. Laboratory studies show: Hemoglobin 13.3 g/dL Serum Na+ 146 mEq/L Cl- 105 mEq/L K+ 3.0 mEq/L HCO3- 30 mEq/L Urea nitrogen 10 mg/dL Glucose 95 mg/dL Creatinine 0.8 mg/dL Urine Blood negative Glucose negative Protein negative RBC 0–1/hpf WBC none Which of the following is the most likely diagnosis in this patient?

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?

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?

A 65-year-old African-American man comes to the physician for a follow-up examination after presenting with elevated blood pressure readings during his last visit. He has no history of major medical illness and takes no medications. He is 180 cm (5 ft 9 in) tall and weighs 68 kg (150 lb); BMI is 22 kg/m2. His pulse is 80/min and blood pressure is 155/90 mm Hg. Laboratory studies show no abnormalities. Which of the following is the most appropriate initial pharmacotherapy for this patient?

A 58-year-old man presents for a follow-up appointment. He recently was found to have a history of stage 2 chronic kidney disease secondary to benign prostatic hyperplasia leading to urinary tract obstruction. He has no other medical conditions. His father died at age 86 from a stroke, and his mother lives in an assisted living facility. He smokes a pack of cigarettes a day and occasionally drinks alcohol. His vital signs include: blood pressure 130/75 mm Hg, pulse 75/min, respiratory rate 17/min, and temperature 36.5°C (97.7°F). His physical examination is unremarkable. A 24-hour urine specimen reveals the following findings: Specific gravity 1,050 pH 5.6 Nitrites (-) Glucose (-) Proteins 250 mg/24hrs Which of the following should be prescribed to this patient to decrease his cardiovascular risk?

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?

Q10

A new drug X is being tested for its effect on renal function. During the experiments, the researchers found that in patients taking substance X, the urinary concentration of sodium decreases while urine potassium concentration increase. Which of the following affects the kidneys in the same way as does substance X?

Resistant hypertension management US Medical PG Practice Questions and MCQs

Question 1: 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?

A. 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. (Correct Answer)
B. 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.
C. 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.
D. The physician should not measure the blood pressure in this patient because she does not have hypertension or risk factors for hypertension.
E. 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.

Explanation: **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.** - For individuals with **diabetes mellitus**, regular **blood pressure monitoring** by a healthcare professional is a fundamental component of their routine care, regardless of home measurements. - This practice ensures accuracy, identifies **white coat hypertension**, and allows for early detection and management of **cardiovascular risks** inherent to diabetes. *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.* - This statement is incorrect as **regular blood pressure monitoring** is essential for all follow-up visits in diabetic patients due to their elevated risk of developing **hypertension** and associated complications. - Even if initial measurements are normal, blood pressure can change over time, necessitating continuous assessment to maintain optimal **cardiovascular health**. *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.* - Relying solely on **patient-recorded blood pressure** measurements, while valuable, does not replace the need for an **in-office measurement** by a healthcare provider. - This is crucial for verifying the accuracy of home devices, assessing for **masked hypertension**, and ensuring compliance with **clinical guidelines**. *The physician should not measure the blood pressure in this patient because she does not have hypertension or risk factors for hypertension.* - This is incorrect; the patient's diagnosis of **Type 2 Diabetes Mellitus** itself is a significant **risk factor for hypertension** and cardiovascular disease. - All individuals with diabetes require ongoing **blood pressure monitoring**, irrespective of their current blood pressure status or other obvious risk factors. *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.* - This statement is generally incorrect and illogical; **national guidelines** for diabetes care, including blood pressure monitoring, are established to ensure consistent and high-quality care across different settings. - Healthcare providers are expected to adhere to these **national standards of care** or explain any deviations, making the measurement of blood pressure a critical part of a diabetic patient's visit.

Question 2: A 49-year-old man is diagnosed with hypertension. He has asthma. The creatinine and potassium levels are both slightly elevated. Which of the following anti-hypertensive drugs would be appropriate in his case?

A. Amlodipine (Correct Answer)
B. Hydrochlorothiazide (HCT)
C. Enalapril
D. Spironolactone
E. Propranolol

Explanation: ***Amlodipine*** - **Amlodipine** is a **calcium channel blocker** that is safe and effective in patients with **asthma** as it does not exacerbate bronchoconstriction. - It is **renal protective** and does not significantly affect **potassium levels**, making it ideal for this patient with elevated creatinine and potassium. - This is the **best choice** given all three clinical considerations. *Hydrochlorothiazide (HCT)* - While generally safe in asthma, **HCT** is a **thiazide diuretic** that can worsen renal function and **increase creatinine levels**, which is problematic given the patient's already elevated creatinine. - Although HCT causes **hypokalemia** (low potassium), it is not the preferred agent for managing hyperkalemia, and worsening renal function is a more significant concern here. - **Amlodipine is safer overall** in this patient. *Enalapril* - **Enalapril** is an **ACE inhibitor** that can cause **hyperkalemia**, further worsening the patient's already elevated potassium levels. - It can also transiently increase **creatinine**, particularly in patients with underlying renal impairment, making it an unfavorable option in this scenario. *Spironolactone* - **Spironolactone** is a **potassium-sparing diuretic** that frequently causes **hyperkalemia**, which would be dangerous given the patient's elevated potassium levels. - It is **contraindicated** in patients with significant hyperkalemia or renal impairment. *Propranolol* - **Propranolol** is a **non-selective beta-blocker** that is **contraindicated** in patients with **asthma** as it can cause **bronchospasm** and severe respiratory compromise. - Beta-blockers should be avoided in asthmatic patients.

Question 3: A 32-year-old man presents with hypertension that has been difficult to control with medications. His symptoms include fatigue, frequent waking at night for voiding, and pins and needles in the legs. His symptoms started 2 years ago. Family history is positive for hypertension in his mother. His blood pressure is 160/100 mm Hg in the right arm and 165/107 mm Hg in the left arm, pulse is 85/min, and temperature is 36.5°C (97.7°F). Physical examination reveals global hyporeflexia and muscular weakness. Lab studies are shown: Serum sodium 147 mEq/L Serum creatinine 0.7 mg/dL Serum potassium 2.3 mEq/L Serum bicarbonate 34 mEq/L Plasma renin activity low Which of the following is the most likely diagnosis?

A. Renal artery stenosis
B. Coarctation of aorta
C. Cushing syndrome
D. Primary aldosteronism (Correct Answer)
E. Essential hypertension

Explanation: ***Primary aldosteronism*** - The patient presents with **resistant hypertension**, **hypokalemia** (2.3 mEq/L), **metabolic alkalosis** (bicarbonate 34 mEq/L), and **low plasma renin activity**, which are classic features of primary aldosteronism. - Symptoms like **fatigue**, **nocturia**, and **paresthesias** (pins and needles) in the legs are consistent with severe hypokalemia, directly resulting from excessive aldosterone secretion. *Renal artery stenosis* - This condition typically causes **secondary hypertension** with **elevated renin levels** due to decreased renal perfusion, which contradicts the low plasma renin activity seen in this patient. - While it can cause hypokalemia because of increased renin-angiotensin-aldosterone system activation, the **primary driver** in this case, based on low renin, points away from renal artery stenosis. *Coarctation of aorta* - Characterized by **differential blood pressures** between the upper and lower extremities and sometimes between the arms, and a **systolic murmur** that is often present. - It does not typically present with severe **hypokalemia** or metabolic alkalosis or the low plasma renin activity observed in this patient. *Cushing syndrome* - This syndrome is caused by **excessive cortisol** and can lead to hypertension and hypokalemia, but it is also associated with distinct clinical features like **central obesity**, buffalo hump, moon facies, and proximal muscle weakness, which are not described. - While it can cause similar electrolyte imbalances, the lack of classic Cushingoid features makes it less likely, and the specific **low plasma renin** points more strongly to aldosterone excess. *Essential hypertension* - This is a diagnosis of exclusion, typically presenting without a clear secondary cause and with **normal electrolyte levels**. - The presence of severe **hypokalemia**, **metabolic alkalosis**, and **low plasma renin activity** indicates a secondary cause, ruling out essential hypertension.

Question 4: A 30-year-old African American woman comes to the physician because of fatigue and muscle weakness for the past 5 weeks. During this period, she has had recurrent headaches and palpitations. She has hypertension and major depressive disorder. She works as a nurse at a local hospital. She has smoked about 6–8 cigarettes daily for the past 10 years and drinks 1–2 glasses of wine on weekends. Current medications include enalapril, metoprolol, and fluoxetine. She is 168 cm (5 ft 6 in) tall and weighs 60 kg (132 lb); BMI is 21.3 kg/m2. Her temperature is 37°C (98.6°F), pulse is 75/min, and blood pressure is 155/85 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender; bowel sounds are normal. Her skin is dry and there is no edema in the lower extremities. Laboratory studies show: Hemoglobin 13.3 g/dL Serum Na+ 146 mEq/L Cl- 105 mEq/L K+ 3.0 mEq/L HCO3- 30 mEq/L Urea nitrogen 10 mg/dL Glucose 95 mg/dL Creatinine 0.8 mg/dL Urine Blood negative Glucose negative Protein negative RBC 0–1/hpf WBC none Which of the following is the most likely diagnosis in this patient?

A. Cushing syndrome
B. Aldosteronoma (Correct Answer)
C. Laxative abuse
D. Pheochromocytoma
E. Renal artery stenosis

Explanation: ***Aldosteronoma*** - This patient presents with **hypertension**, **muscle weakness**, fatigue, **hypokalemia** (K+ 3.0 mEq/L), and **metabolic alkalosis** (HCO3- 30 mEq/L), which are classic signs of **primary hyperaldosteronism**. - **Aldosteronomas** are a common cause of primary hyperaldosteronism due to autonomous aldosterone production, leading to sodium retention, potassium excretion, and subsequent hypertension and hypokalemia. *Cushing syndrome* - While Cushing syndrome can cause hypertension and muscle weakness, it typically presents with features like **central obesity**, **moon facies**, **buffalo hump**, **striae**, and **hyperglycemia**, which are not described in this patient. - Although it can cause hypokalemia, the overall clinical picture is more suggestive of primary hyperaldosteronism given the constellation of symptoms. *Laxative abuse* - Laxative abuse can cause hypokalemia and metabolic alkalosis, but it typically presents with **diarrhea**, **abdominal pain**, and potentially features of **dehydration**, which are absent here. - Chronic laxative abuse would not typically be the primary cause of sustained hypertension in this context without other tell-tale signs. *Pheochromocytoma* - **Pheochromocytoma** causes episodic or sustained hypertension, often accompanied by **palpitations**, **headaches**, and **sweating** due to excessive catecholamine release. - However, it does not typically cause hypokalemia or metabolic alkalosis unless there is co-secretion of other hormones, making it less likely than aldosteronoma with the presented lab abnormalities. *Renal artery stenosis* - **Renal artery stenosis** can cause hypertension and sometimes hypokalemia due to increased renin secretion, leading to secondary hyperaldosteronism. - However, the primary cause would be renal ischemia, and the hyperaldosteronism would be reactive, whereas in this case, the hypokalemia and metabolic alkalosis strongly point towards autonomous aldosterone production.

Question 5: 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?

A. Perform adrenalectomy
B. Perform saline infusion test (Correct Answer)
C. Measure urine pH and anion gap
D. Perform CT scan of the abdomen
E. Perform dexamethasone suppression test

Explanation: ***Perform saline infusion test*** - The patient's **hypokalemia**, **hypertension**, and **high aldosterone-to-renin ratio (ARR)**, even after discontinuing chlorthalidone, are highly suggestive of **primary hyperaldosteronism (Conn's syndrome)**. - A **saline infusion test** is the most appropriate next step to confirm primary hyperaldosteronism by assessing **aldosterone suppressibility**. Failure to suppress aldosterone after saline infusion confirms the diagnosis. *Perform adrenalectomy* - Adrenalectomy is a treatment for aldosterone-producing adenomas, but it is not the next step before confirming the diagnosis and localizing the lesion. - The diagnosis of primary hyperaldosteronism first needs biochemical confirmation, usually with a saline suppression test. *Measure urine pH and anion gap* - Measuring urine pH and anion gap is useful in evaluating acid-base disorders or certain renal tubular conditions, but it is not directly relevant to diagnosing primary hyperaldosteronism. - The primary concern here is the workup of hypertension and hypokalemia with suspected endocrine etiology. *Perform CT scan of the abdomen* - While an abdominal CT scan is used to localize an adrenal adenoma, it should be done after biochemical confirmation of primary hyperaldosteronism. - Imaging should not precede diagnostic confirmation, as incidentalomas are common and may lead to unnecessary procedures. *Perform dexamethasone suppression test* - A dexamethasone suppression test is used to evaluate **Cushing's syndrome** (hypercortisolism), which is characterized by symptoms different from this patient's presentation. - This patient's symptoms of hypokalemia and hypertension point toward mineralocorticoid excess, not glucocorticoid excess.

Question 6: 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?

A. ACE inhibitor, ARB, CCB, or thiazide (Correct Answer)
B. ACE inhibitor, angiotensin receptor blocker (ARB), beta-blocker (BB), or thiazide
C. ACE inhibitor, ARB, CCB, or loop diuretic
D. ACE inhibitor, ARB, alpha-blocker, or loop diuretic
E. ACE inhibitor, ARB, alpha-blocker, or direct vasodilator

Explanation: **ACE inhibitor, ARB, CCB, or thiazide** - The **JNC 8 guidelines** recommend **ACE inhibitors**, **ARBs**, **calcium channel blockers (CCBs)**, and **thiazide diuretics** as first-line agents for essential hypertension in the general non-Black population. - These drug classes have demonstrated efficacy in reducing cardiovascular events and are generally well-tolerated. *ACE inhibitor, angiotensin receptor blocker (ARB), beta-blocker (BB), or thiazide* - While **ACE inhibitors**, **ARBs**, and **thiazides** are first-line, **beta-blockers** are generally not considered first-line for uncomplicated hypertension unless there are specific compelling indications (e.g., post-MI, heart failure). - **Beta-blockers** are less effective than other first-line agents in preventing stroke in the elderly and may have more side effects in some populations. *ACE inhibitor, ARB, CCB or loop diuretic* - **ACE inhibitors**, **ARBs**, and **CCBs** are first-line options, but **loop diuretics** are typically reserved for patients with fluid overload or chronic kidney disease, not for initial management of essential hypertension. - **Loop diuretics** have a shorter duration of action and a greater electrolyte-wasting effect compared to thiazide diuretics, making them less suitable for long-term monotherapy. *ACE inhibitor, ARB, alpha-blocker, or loop diuretic* - **Alpha-blockers** and **loop diuretics** are not considered first-line agents for essential hypertension. **Alpha-blockers** are typically used for benign prostatic hyperplasia or as add-on therapy for resistant hypertension. - **Alpha-blockers** can cause significant orthostatic hypotension, particularly with the first dose, and have not shown the same cardiovascular protective benefits as true first-line agents. *ACE inhibitor, ARB, alpha-blocker, or direct vasodilator* - **Alpha-blockers** and **direct vasodilators** (e.g., hydralazine, minoxidil) are not first-line treatments for essential hypertension. - **Direct vasodilators** are potent but often cause reflex tachycardia and fluid retention, requiring co-administration with other agents, and are typically reserved for severe or resistant hypertension.

Question 7: A 65-year-old African-American man comes to the physician for a follow-up examination after presenting with elevated blood pressure readings during his last visit. He has no history of major medical illness and takes no medications. He is 180 cm (5 ft 9 in) tall and weighs 68 kg (150 lb); BMI is 22 kg/m2. His pulse is 80/min and blood pressure is 155/90 mm Hg. Laboratory studies show no abnormalities. Which of the following is the most appropriate initial pharmacotherapy for this patient?

A. Chlorthalidone (Correct Answer)
B. Captopril
C. Metoprolol
D. Valsartan
E. Aliskiren

Explanation: ***Chlorthalidone*** - **Thiazide diuretics** (like chlorthalidone) are recommended as **first-line agents** for hypertension in most patients, and particularly for African-American patients, due to their superior efficacy and cardiovascular outcome benefits. - This patient has uncomplicated hypertension, normal BMI, and no comorbidities, making a thiazide diuretic an appropriate initial choice. *Captopril* - **ACE inhibitors** (like captopril) are first-line agents but are generally less effective as monotherapy in African-American patients compared to thiazide diuretics or calcium channel blockers. - While useful in conditions like diabetes or chronic kidney disease, which this patient does not have, its use as an initial standalone therapy in this demographic is not preferred. *Metoprolol* - **Beta-blockers** (like metoprolol) are not recommended as first-line therapy for uncomplicated hypertension unless there are specific compelling indications (e.g., angina, post-myocardial infarction). - Their efficacy in preventing cardiovascular events as monotherapy in uncomplicated hypertension is generally inferior to other first-line agents. *Valsartan* - **ARBs** (like valsartan) are similar to ACE inhibitors in their efficacy and are generally less effective as monotherapy in African-American patients without compelling indications. - They are often chosen for patients who cannot tolerate ACE inhibitors due to cough, but this patient has no such indications. *Aliskiren* - **Direct renin inhibitors** (like aliskiren) are not considered first-line therapy for hypertension and are generally reserved for specific cases or when other first-line agents are not sufficient or contraindicated. - They have not demonstrated superior outcomes compared to other established antihypertensive agents that would warrant their initial use.

Question 8: A 58-year-old man presents for a follow-up appointment. He recently was found to have a history of stage 2 chronic kidney disease secondary to benign prostatic hyperplasia leading to urinary tract obstruction. He has no other medical conditions. His father died at age 86 from a stroke, and his mother lives in an assisted living facility. He smokes a pack of cigarettes a day and occasionally drinks alcohol. His vital signs include: blood pressure 130/75 mm Hg, pulse 75/min, respiratory rate 17/min, and temperature 36.5°C (97.7°F). His physical examination is unremarkable. A 24-hour urine specimen reveals the following findings: Specific gravity 1,050 pH 5.6 Nitrites (-) Glucose (-) Proteins 250 mg/24hrs Which of the following should be prescribed to this patient to decrease his cardiovascular risk?

A. Enalapril (Correct Answer)
B. Ezetimibe
C. Amlodipine
D. Carvedilol
E. Aspirin

Explanation: ***Enalapril*** - **Enalapril**, an ACE inhibitor, is indicated for patients with **chronic kidney disease** and **proteinuria** to reduce cardiovascular risk and slow kidney disease progression. - The patient has stage 2 CKD and **250 mg/24hrs of protein in urine**, which, when coupled with hypertension, makes ACE inhibitors the preferred choice to mitigate cardiovascular risk. *Ezetimibe* - **Ezetimibe** is a **cholesterol absorption inhibitor** used to lower LDL-C, but there is no information in the vignette to suggest hyperlipidemia. - It is an inappropriate choice without evidence of dyslipidemia or a strong indication for lipid-lowering therapy. *Amlodipine* - **Amlodipine** is a **calcium channel blocker** used to treat hypertension but does not provide specific renal-protective benefits in patients with proteinuria. - It would be a consideration for blood pressure control if an ACE inhibitor were contraindicated or insufficient. *Carvedilol* - **Carvedilol** is a **beta-blocker** used for hypertension, heart failure, and post-MI, but there is no indication for its use here. - It is not the first-line agent for cardiovascular risk reduction in patients with chronic kidney disease and proteinuria without other specific cardiac indications. *Aspirin* - **Aspirin** is used for primary or secondary prevention of cardiovascular events due to its **antiplatelet effects**. However, in the absence of established cardiovascular disease, its use for primary prevention in CKD patients needs careful consideration of bleeding risk. - While patients with CKD are at higher cardiovascular risk, an ACE inhibitor addresses both the hypertension and proteinuria, which directly contribute to cardiovascular and kidney disease progression in this patient.

Question 9: 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?

A. Start dextromethorphan and increase frequency of albuterol
B. Stop ramipril and start candesartan (Correct Answer)
C. Stop simvastatin and start atorvastatin
D. Stop ramipril and start lisinopril
E. Stop albuterol and start salmeterol

Explanation: ***Stop ramipril and start candesartan*** - The patient's **dry, hacking cough** is a common side effect of **ACE inhibitors** like ramipril, occurring in up to 20% of patients [1], [4]. Switching to an **angiotensin receptor blocker (ARB)** like candesartan avoids this side effect as ARBs do not inhibit bradykinin breakdown [1], [4]. - Given the patient's other well-controlled chronic conditions and the absence of other respiratory symptoms (fever, chest pain, shortness of breath), an **ACE inhibitor-induced cough** is the most likely diagnosis [2]. *Start dextromethorphan and increase frequency of albuterol* - **Dextromethorphan** is a cough suppressant, but it does not address the underlying cause of the cough if it is medication-induced, and the cough is likely due to the ramipril. - Increasing the frequency of **albuterol** (a short-acting beta-agonist) is inappropriate as the patient does not have symptoms of asthma exacerbation (e.g., shortness of breath, wheezing), and the cough is dry and persistent, not typical of asthmatic bronchoconstriction [3]. *Stop simvastatin and start atorvastatin* - There is no indication to change the **statin** medication. **Simvastatin** is an effective HMG-CoA reductase inhibitor, and it is not associated with cough. - This change would not address the patient's presenting symptom of a dry, hacking cough. *Stop ramipril and start lisinopril* - Both **ramipril** and **lisinopril** are **ACE inhibitors** and share the same mechanism of action [1]. - Switching from one ACE inhibitor to another would likely result in the continuation of the **cough** side effect, as it is a class effect [4]. *Stop albuterol and start salmeterol* - This patient's dry cough is unlikely to be an asthma symptom given the chronic nature and lack of other respiratory symptoms, suggesting the albuterol is not the issue. - **Salmeterol** is a long-acting beta-agonist (LABA) used for maintenance therapy in asthma; switching to it from albuterol would not address a medication-induced cough and could be inappropriate without further asthma assessment [3].

Question 10: A new drug X is being tested for its effect on renal function. During the experiments, the researchers found that in patients taking substance X, the urinary concentration of sodium decreases while urine potassium concentration increase. Which of the following affects the kidneys in the same way as does substance X?

A. Aldosterone (Correct Answer)
B. Furosemide
C. Spironolactone
D. Atrial natriuretic peptide
E. Hydrochlorothiazide

Explanation: ***Aldosterone*** - **Aldosterone** acts on the **principal cells** of the **collecting duct** to increase sodium reabsorption and potassium secretion. - This action leads to a decrease in urinary sodium concentration and an increase in urinary potassium concentration, matching the effects of drug X. *Furosemide* - **Furosemide** is a **loop diuretic** that inhibits the **Na-K-2Cl cotransporter** in the **thick ascending limb** of the loop of Henle. - This inhibition leads to increased excretion of sodium, potassium, and water, resulting in higher urinary sodium concentration. *Spironolactone* - **Spironolactone** is an **aldosterone antagonist** that blocks aldosterone's effects on the collecting duct. - This leads to increased sodium excretion and decreased potassium excretion (potassium-sparing effect), which is the opposite of drug X. *Atrial natriuretic peptide* - **Atrial natriuretic peptide (ANP)** is released in response to atrial stretch and causes **natriuresis** (increased sodium excretion) and **diuresis**. - It works by dilating afferent arterioles and constricting efferent arterioles, increasing GFR, and inhibiting sodium reabsorption, thus increasing urinary sodium concentration. *Hydrochlorothiazide* - **Hydrochlorothiazide** is a **thiazide diuretic** that inhibits the **Na-Cl cotransporter** in the **distal convoluted tubule**. - This leads to increased sodium and chloride excretion but typically causes potassium wasting (hypokalemia), which differs from the increased urinary potassium concentration seen with drug X.

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