1 . Approximately how many U.S. adults have hypertension?
| A) | | 6 million |
| B) | | 27 million |
| C) | | 122 million |
| D) | | 190 million |
EPIDEMIOLOGY OF HYPERTENSION
Approximately 122 million Americans (47%) have hypertension
(defined as systolic blood pressure [SBP] ≥130 mm Hg and/or diastolic blood pressure [DBP] ≥80
mm Hg), while another 28.2% have prehypertension [1]. Prehypertension is defined as blood
pressures ranging from 120–139 mm Hg systolic and/or 80–89 mm Hg diastolic in those
individuals identified at high risk for developing hypertension and as potentially receiving
benefit from early intervention with antihypertensive therapy [1,10]. However, these data do not reflect how many patients suffer from
hypertension but remain undiagnosed. Analysis of electronic medical records reveals that the
diagnosis rate of prevalent hypertension is 62.9% while the diagnosis rate of incident
hypertension is 19.9%, leaving many patients underdiagnosed [11]. Underdiagnosis is particularly common among survivors of transient
ischemic attack (TIA) or minor stroke, due largely to medium-term variability in blood
pressure measurements [12].
2 . Approximately what percentage of U.S. adults have prehypertension?
EPIDEMIOLOGY OF HYPERTENSION
Approximately 122 million Americans (47%) have hypertension
(defined as systolic blood pressure [SBP] ≥130 mm Hg and/or diastolic blood pressure [DBP] ≥80
mm Hg), while another 28.2% have prehypertension [1]. Prehypertension is defined as blood
pressures ranging from 120–139 mm Hg systolic and/or 80–89 mm Hg diastolic in those
individuals identified at high risk for developing hypertension and as potentially receiving
benefit from early intervention with antihypertensive therapy [1,10]. However, these data do not reflect how many patients suffer from
hypertension but remain undiagnosed. Analysis of electronic medical records reveals that the
diagnosis rate of prevalent hypertension is 62.9% while the diagnosis rate of incident
hypertension is 19.9%, leaving many patients underdiagnosed [11]. Underdiagnosis is particularly common among survivors of transient
ischemic attack (TIA) or minor stroke, due largely to medium-term variability in blood
pressure measurements [12].
3 . Which racial/ethnic group is most likely to have the poorest rates of blood pressure control?
| A) | | Mexican Americans |
| B) | | Non-Hispanic Black Americans |
| C) | | Non-Hispanic White Americans |
| D) | | None of the above |
EPIDEMIOLOGY OF HYPERTENSION
While efforts to raise awareness about hypertension and the
importance of receiving antihypertensive treatment have been successful, substantial ethnic
disparities remain in adequately controlling hypertension. Non-Hispanic Black Americans, for
example, have the poorest rates of blood pressure control, with 70% higher odds of poorly
controlled blood pressure than that of White Americans [1].
4 . Among men and women 80 years of age and older, what percentage meet blood pressure targets recommended in clinical practice guidelines (i.e., 140/90 mm Hg)?
| A) | | 8% of men and 3% of women |
| B) | | 38% of men and 23% of women |
| C) | | 48% of men and 33% of women |
| D) | | 88% of men and 73% of women |
EPIDEMIOLOGY OF HYPERTENSION
Treatment disparities associated with hypertension are not
limited to a particular race or ethnicity; the elderly are also affected. While awareness,
treatment, and control of hypertension in individuals 65 years of age and older have
improved, 78% have blood pressures greater than 140/90 mm Hg [1]. Indeed, among those 80 years of age and
older, only 38% of men and 23% of women meet blood pressure targets advocated in clinical
guidelines [18]. Hypertension control is
extremely poor in women 50 to 79 years of age, with only 36.1% of hypertensive women in this
age-group having adequately controlled blood pressure [19]. In postmenopausal women receiving hormonal therapy, hypertension is the
most common comorbidity, with a prevalence of 34%, and is associated with significantly
higher medical expenditures [20].
5 . What percentage of patients with a first stroke have a blood pressure greater than 140/90 mm Hg?
EPIDEMIOLOGY OF HYPERTENSION
In addition to being a significant risk factor for CVD,
hypertension is also a significant risk factor for stroke. For every 20/10 mm Hg increase in
blood pressure, the mortality from ischemic heart disease and stroke doubles. Therefore,
effectively reducing blood pressure will significantly reduce cardiovascular risk [21]. More specifically, antihypertensive
therapy can reduce the incidence of myocardial infarction (20% to 25%), stroke (35% to 40%),
and heart failure (>50%) [22]. Thus,
effective antihypertensive treatment is critical in reducing the morbidity and mortality
associated with hypertension. Hypertension is frequently comorbid with adverse
cardiovascular outcomes and contributes to significant healthcare utilization; 69% of
patients with a first myocardial infarction, 77% with a first stroke, and 74% with
congestive heart failure have blood pressure >140/90 mm Hg [3]. Furthermore, essential hypertension
contributes to nearly 18 million hospitalizations, nearly 34 million office visits, 914,000
emergency department visits, and 3.7 million outpatient visits annually [1].
6 . In the elderly, age-associated increases in hypertension may be characterized by
| A) | | coronary stenosis. |
| B) | | limited organ perfusion. |
| C) | | increased myocardial oxygen demand. |
| D) | | All of the above |
UNDERSTANDING THE PATHOPHYSIOLOGY OF HYPERTENSION
In the elderly, alterations in arterial structure and function
promote age-associated increases in hypertension. Large blood vessels become less flexible,
which initiates a complex cardiovascular cascade that ultimately results in increased
myocardial oxygen demand and limited organ perfusion. These effects are further enhanced by
coronary stenosis. Progressive renal dysfunction further promotes hypertension through
increased sodium, reduced sodium-calcium exchange, and decreased potassium excretion, which
may lead to hyperkalemia [36].
7 . At about what age does diastolic blood pressure tend to level off and systolic blood pressure become a more predominant cardiovascular risk factor?
| A) | | 30 years |
| B) | | 40 years |
| C) | | 50 years |
| D) | | 65 years |
UNDERSTANDING THE PATHOPHYSIOLOGY OF HYPERTENSION
Changes occur in blood pressure with increasing age. SBP
rises continuously throughout life, whereas DBP rises until about 50 years of age and then
plateaus [40]. Thus, diastolic hypertension
(with or without elevated SBP) is a prominent cardiovascular risk factor before 50 years of
age, and systolic hypertension is after 50 years of age [41]. Importantly, studies show that controlling isolated systolic
hypertension reduces total and cardiovascular mortality, stroke, and heart failure [42,43,44]. As the population
ages, greater emphasis should be placed on treating systolic hypertension, because
unattended SBP will lead to increased cardiovascular and renal disease [39].
8 . Patients who are considered to have elevated blood pressure should have a follow-up screening in
| A) | | one month. |
| B) | | two months. |
| C) | | three to six months. |
| D) | | two years. |
SCREENING FOR HYPERTENSION
HYPERTENSION SCREENING RECOMMENDATIONS
| Classification | Systolic/Diastolic Blood Pressure (mm Hg) | Follow-Up |
|---|
| Normal | <120/80 | Two years |
| Elevated | 120–129/<80 | Three to six months |
| Stage 1 | 130–139/80–89 | Within two monthsa |
| Stage 2 | ≥140/≥90 | Within one monthb |
| aBased on physician's clinical judgment of
patient's status and cardiovascular risk factors. | | bIf >160/>100 mm Hg, evaluate and treat
immediately. |
|
9 . Increasing aerobic physical activity to at least 30 minutes most days can reduce systolic blood pressure by approximately
| A) | | 2–4 mm Hg. |
| B) | | 4–9 mm Hg. |
| C) | | 8–14 mm Hg. |
| D) | | 5–20 mm Hg. |
NONPHARMACOLOGIC INTERVENTIONS FOR HYPERTENSION
LIFESTYLE MODIFICATIONS TO PREVENT AND MANAGE HYPERTENSION
| Lifestyle Modification | Recommendation | Approximate Systolic Reduction (mm Hg) |
|---|
| Physical activity | ↑aerobic physical activity to at least 30 min/day, most days | 4–9 |
| DASH eating plan | ↑fruits, vegetables, and low-fat dairy products; ↓saturated and total fat | 8–14 |
| Restrict sodium intake | ↓daily dietary sodium intake to 2.4 g sodium | 2–8 |
| Moderate alcoholic intake | Limit daily intake to 1 drink for women and 2 for men | 2–4 |
| Weight loss | Maintain normal body weight (body mass index 18.5–24.9 kg/m2) | 5–20 per 10 kg weight loss |
| Stress reduction | Practice stress reduction measures | 5 |
| Smoking cessation | Any smoking cessation program | 3–4 |
10 . Which of the following would NOT be emphasized by the DASH diet?
| A) | | Lean red meat |
| B) | | Poultry and nuts |
| C) | | Fruits and vegetables |
| D) | | Whole-grain products |
NONPHARMACOLOGIC INTERVENTIONS FOR HYPERTENSION
Nutrition is a key component for the prevention and management
of hypertension. Adoption of the DASH eating plan can be very beneficial in reducing blood
pressure in hypertensive and normotensive patients and in reducing overall CVD [65,76,81]. The DASH eating plan
reinforces reductions in saturated fat, cholesterol, and total fat while emphasizing fruits,
vegetables, fat-free or low-fat milk, whole-grain products, fish, poultry, and nuts, and
reducing lean red meat, sweets, added sugars, and sugar-containing beverages [82]. DASH also focuses on increasing intake of
potassium, calcium, and magnesium. Importantly, the DASH diet is highly endorsed by the
AHA/ACC as an effective treatment option for patients with elevated blood pressure [67]. Key nutritional provisions of the DASH
eating plan are listed inTable 3. When combined with exercise and
weight loss in overweight or obese patients with high blood pressure, the DASH diet results in
even greater reductions of blood pressure (−11.2/−7.5 mm Hg [DASH alone] vs. −3.4/−3.8 mm Hg
[usual diet controls]) and provides physiologic benefits, including improvements in vascular
function and reduction in left ventricular mass [83].
11 . Approximately what percentage of patients with hypertension will require two or more antihypertensive agents to reduce and control blood pressure within acceptable ranges?
PHARMACOLOGIC INTERVENTIONS FOR HYPERTENSION
As discussed, the goals of hypertensive management are to
reduce blood pressure, reduce overall cardiovascular risk, and prevent end-organ damage
without adversely affecting quality of life, and effectively treating hypertension
significantly reduces the incidence of fatal stroke, myocardial infarction, and heart failure
and prolongs life expectancy [22,39,99,100]. While lifestyle
modifications and nonpharmacologic treatment options are beneficial in reducing blood
pressure, approximately 70% of patients with hypertension will require at least two
antihypertensive agents to reduce blood pressure to within acceptable ranges [3,39,46,99] To reduce cardiovascular risk in patients
with hypertension, antihypertensive agents should ideally provide effective and sustained
blood pressure reduction throughout the 24-hour dosing period while attenuating early morning
surges in blood pressure and reducing blood pressure variability [101]. After antihypertensive therapy is
initiated, patients should be monitored and treatment adjustments made monthly until the
desired blood pressure goal is reached [39].
The JNC 7 recommended that serum potassium and creatinine should be monitored every 6 to 12
months for patients receiving antihypertensive therapy; however, monitoring these levels is
not addressed by the JNC 8 [3,39,46]
12 . Which of the following diuretics is considered potassium-sparing?
| A) | | Amiloride |
| B) | | Torsemide |
| C) | | Bumetanide |
| D) | | Bendroflumethiazide |
PHARMACOLOGIC INTERVENTIONS FOR HYPERTENSION
SELECTED ANTIHYPERTENSIVE TREATMENT OPTIONS
| Drug Class | Agents |
|---|
| Thiazide diuretics | Bendroflumethiazide, hydrochlorothiazide, chlorthalidone, indapamide |
| Loop diuretics | Bumetanide, furosemide, torsemide |
| Potassium-sparing diureticsa | Amiloride, triamterene |
| Aldosterone receptor antagonistsa | Eplerenone, spironolactone |
| α1-adrenergic antagonistsb | Doxazosin, prazosin, terazosin |
| β-blockersa | Acebutolol, atenolol, bisoprolol, metoprolol, nadolol, nebivolol,
propranolol |
| α- and β-blockersa | Carvedilol, labetalol |
| ACE inhibitors | Benazepril, enalapril, fosinopril, lisinopril, perindopril, quinapril, ramipril,
trandolapril |
| Angiotensin II receptor blockers | Azilsartan, candesartan, eprosartan, irbesartan, losartan, olmesartan,
telmisartan, valsartan |
| Calcium channel blockers | Amlodipine, clevidipine, diltiazem, felodipine, isradipine, nifedipine,
nitrendipine, verapamil |
| Direct renin inhibitors | Aliskiren |
| Central α2 agonistsa | Clonidine, methyldopa, reserpine, guanfacine |
| Direct vasodilatorsa | Hydralazine, minoxidil |
| aThe JNC 8 does not recommend for the initial
treatment of hypertension. | | bThe JNC 8 does not recommend for the treatment
of hypertension. |
|
13 . For uncomplicated hypertension in the general non-Black population, initial antihypertensive therapy as recommended by the JNC 8 might consist of a(n)
| A) | | ARB. |
| B) | | ACE inhibitor. |
| C) | | thiazide-type diuretic. |
| D) | | Any one of the above |
PHARMACOLOGIC INTERVENTIONS FOR HYPERTENSION
For uncomplicated hypertension in the general non-Black
population, the JNC 8 recommends the use of a thiazide-type diuretic, CCB, ACE inhibitor, or
ARB as initial antihypertensive therapy due to their propensity to prevent cardiovascular
complications associated with hypertension [39]. In the Black population, the preferred first-line agents are thiazide
diuretics or CCBs. The panel noted that heart failure outcomes were improved with initial
treatment with a thiazide diuretic compared to a CCB or ACE inhibitor; all other outcomes
measures were similar among the four drug classes [39]. Thiazide-type diuretics are generally well-tolerated and effective at
low doses; higher doses may be associated with hypokalemia and adverse effects such as
increased uric acid and sexual dysfunction, with little added benefit [3]. At particularly high doses,
thiazide-induced hypokalemia may contribute to ventricular ectopy [106]. Other medication classes (e.g., statins)
may be considered if the patient does not respond to initial treatment or combination
therapy with these agents [39].
14 . According to the American Society of Hypertension clinical practice guidelines for hypertension, what is the recommended first-line drug for a patient with hypertension and clinical coronary artery disease?
| A) | | ARB or ACE inhibitor + beta-blocker |
| B) | | Calcium channel blocker + diuretic |
| C) | | Calcium channel blocker + beta-blocker |
| D) | | ACE inhibitor + calcium channel blocker |
PHARMACOLOGIC INTERVENTIONS FOR HYPERTENSION
AMERICAN SOCIETY OF HYPERTENSION RECOMMENDATIONS FOR DRUG SELECTION IN HYPERTENSIVE
PATIENTS WITH OR WITHOUT OTHER MAJOR CONDITIONS
| Patient Type | First Drug | Add Second Drug If Needed to Achieve a BP <140/90 mm Hg | If Third Drug is Needed to Achieve a BP <140/90 mm Hg |
|---|
| When hypertension is the only or main
condition |
| Black patients (African | | ancestry): All ages |
| CCBa or thiazide diuretic |
| ARBb or ACE inhibitor | | (If unavailable, can add alternative first drug choice) |
| Combination of CCB + ACE inhibitor or ARB + thiazide diuretic |
| White and other non-Black patients: Younger than 60 years of age | ARBb or ACE inhibitor | CCBa or thiazide diuretic | Combination of CCB + ACE inhibitor or ARB + thiazide diuretic |
| White and other non-Black patients: 60 years of age and older | CCBa or thiazide diuretic (although ACE inhibitors
or ARBs are also usually effective) | ARBb or ACE inhibitor (or CCB or thiazide if ACE
inhibitor or ARB used first) | Combination of CCB + ACE inhibitor or ARB + thiazide diuretic |
| When hypertension is associated with other
conditions |
| Hypertension and diabetes |
| ARB or ACE inhibitor | | Note: In Black patients, it is acceptable to start with a CCB or
thiazide. |
|
| CCB or thiazide diuretic | | Note: In Black patients, if starting with a CCB or thiazide, add an ARB
or ACE inhibitor. |
| The alternative second drug (thiazide or CCB) |
| Hypertension and chronic kidney
disease |
| ARB or ACE inhibitor | | Note: In Black patients, good evidence for renal protective effects of
ACE inhibitors |
| CCB or thiazide diureticc | The alternative second drug (thiazide or CCB) |
| Hypertension and clinical coronary artery
diseased | β-blocker plus ARB or ACE inhibitor | CCB or thiazide diuretic | The alternative second step drug (thiazide or CCB) |
| Hypertension and stroke
historye | ACE inhibitor or ARB | Thiazide diuretic or CCB | The alternative second drug (CCB or thiazide) |
| Hypertension and heart failure | Patients with symptomatic heart failure should
usually receive an ARB or ACE inhibitor + β-blocker + diuretic + spironolactone
regardless of BP. A dihydropyridine CCB can be added if needed for BP
control. |
| ACE = angiotensin-converting enzyme, ARB = angiotensin receptor blocker,
BP = blood pressure, CCB = calcium channel blocker, eGFR = estimated
glomerular filtration rate. | | aCCBs are generally preferred, but thiazides
may cost less. | | bARBs can be considered because ACE
inhibitors can cause cough and angioedema, although ACE inhibitors may cost
less. | | cIf eGFR <40 mL/min, a loop diuretic
(e.g., furosemide or torsemide) may be needed. | | dIf history of myocardial infarction, a
β-blocker and ARB/or ACE inhibitor are indicated regardless of blood
pressure. | | eIf using a diuretic, there is good evidence
for indapamide (if available). |
|
15 . Meta-analyses indicate which class of drug is probably the least effective for hypertension?
| A) | | Diuretics |
| B) | | Beta-blockers |
| C) | | ACE inhibitors |
| D) | | Calcium channel blockers |
PHARMACOLOGIC INTERVENTIONS FOR HYPERTENSION
Data show that the combination of the CCB amlodipine plus
hydrochlorothiazide is well-tolerated and has similar mortality reduction to valsartan
[109,121]. The combination of a dihydropyridine CCB plus a β-blocker (e.g.,
felodipine and metoprolol) may effectively reduce blood pressure, although β-blockers
should be used cautiously with the CCBs diltiazem and verapamil due to their synergistic
effects on heart rate and atrioventricular conduction potentially leading to bradycardia
or heart block [99,109]. Although β-blockers reduce
cardiovascular end points, meta-analyses indicate less effectiveness in treating
hypertension than diuretics, ACE inhibitors, ARBs, and CCBs [122,123,124]. However, there
is some evidence that β-blockers may be a reasonable first-line choice in
younger-to-middle-aged (younger than 60 years of age) individuals [125,126]. β-blockers in combination with thiazide diuretics effectively lower
blood pressure, but they may be associated with an increased risk of glucose intolerance,
fatigue, and sexual dysfunction [99].
16 . What is the most common reason for patients not taking antihypertensive medication?
| A) | | Cost |
| B) | | Side effects |
| C) | | Simply forgetting |
| D) | | Lack of insurance |
Factors that contribute to suboptimal patient adherence to
antihypertensive therapy are multifactorial, complex, and involve both the patient and his or
her healthcare providers. Data from the World Health Organization have categorized factors
associated with long-term adherence as social and economic, disease-related, therapy-related,
patient-related, and healthcare system/healthcare team-related [136]. Clearly, a number of issues can potentially
adversely influence patient adherence. Interestingly, simply forgetting is the most common
reason patients give for not taking antihypertensive medication [137]. Other barriers that contribute to
nonadherence include cost of care and medication, lack of insurance, transportation issues,
and comorbidities [134].
17 . Switching from twice-daily to once-daily antihypertensive agents can improve patient adherence by up to
| A) | | 10%. |
| B) | | 20%. |
| C) | | 30%. |
| D) | | 50%. |
Increasingly complex antihypertensive treatment regimens and
unfavorable tolerability profiles are associated with poorer adherence [132,138,139]. Simply switching
from twice-daily to once-daily antihypertensive agents can improve adherence up to 20% [140]. Moreover, use of single-pill, fixed-dose
combination therapy can improve adherence by 26% [141]. Commercially available fixed-dose product formulations may incorporate
two or three separate antihypertensive agents.
18 . Compared with White individuals, for every 10-mm Hg increase in systolic blood pressure in Black individuals, the risk of stroke is
| A) | | similar. |
| B) | | double. |
| C) | | triple. |
| D) | | quadruple. |
TREATMENT CONSIDERATIONS IN SPECIAL POPULATIONS
As noted, the prevalence and control of hypertension differ
across racial subgroups. In Black individuals, hypertension is more common, more severe,
develops at an earlier age, and is associated with greater sequelae (e.g., higher rates of
stroke, heart disease, end-stage renal disease, and mortality) than in non-Hispanic White
individuals [1,150]. Blacks have a greater prevalence of other
cardiovascular risk factors, especially obesity [151]. In fact, hypertension is the single most common contributor to the
mortality gap between Black and White Americans [3]. For every 10-mm Hg increase in SBP, the risk of stroke in Black
Americans is triple that of White Americans (24% vs. 8%, respectively) [152]. Non-Hispanic Black and Mexican Americans
have poorer blood pressure control rates than non-Hispanic White Americans [1]. Differences in outcomes may be attributable
to differences in socioeconomic conditions, access to healthcare services, attitudes
regarding health care, and cultural beliefs [3].
19 . Which diuretic may be particularly beneficial in treating hypertension in low-renin patients, the elderly, and patients with diabetes?
| A) | | Furosemide |
| B) | | Triamterene |
| C) | | Chlorthalidone |
| D) | | Spironolactone |
TREATMENT CONSIDERATIONS IN SPECIAL POPULATIONS
Before initiation of antihypertensive therapy, weight and
sodium reduction are particularly effective in minorities [153]. For example, the low-sodium DASH eating
plan is associated with significant blood pressure reductions in Black patients [154]. However, monotherapy with ACE inhibitors,
ARBs, or β-blockers is less effective in lowering blood pressure in Black patients than
White patients [3,104]. Moreover, Black and Asian patients have a
three- to fourfold higher risk of angioedema and have more cough attributed to ACE
inhibitors than White patients [3,155]. The use of combination antihypertensive
drug therapy, including a thiazide diuretic, will lower blood pressure and reduce the
cardiovascular and renal burden in minorities [39,104,153]. Chlorthalidone is particularly beneficial
in low-renin patients as well as the elderly and patients with diabetes [155]. Importantly, identifying and addressing
treatment barriers is critical to improving outcomes in minority populations [150].
20 . Thiazide diuretics in the elderly may exacerbate
| A) | | dyslipidemia. |
| B) | | hyperuricemia. |
| C) | | glucose intolerance. |
| D) | | All of the above |
TREATMENT CONSIDERATIONS IN SPECIAL POPULATIONS
In the elderly, thiazide diuretics are recommended for
initiating therapy and are generally well tolerated [36]. Thiazide diuretics reduce cardiovascular events in the elderly but may
also exacerbate hyperuricemia, glucose abnormalities, and dyslipidemia, which are frequently
seen in the elderly [36]. A 2015 scientific
statement from the AHA/ACC/ASH urges caution when using thiazide diuretics in the elderly to
avoid decreases in DBP due to reduced coronary perfusion [158]. β-blockers are best suited for patients with migraine and/or
cardiovascular comorbidities such as heart failure and coronary artery disease [36]. All β-blockers may result in a decreased
response in the elderly as compared with younger adults. Dose reduction, initial lower dose,
or dose titrated to the response should be considered [105]. In the elderly, α-adrenergic antagonists are not recommended as
first-line therapy due to a possible increase in cardiovascular events [36,39,158]. Similar to
β-blockers, CCBs are considered safe and effective in elderly patients with cardiovascular
comorbidities (e.g., angina, supraventricular arrhythmias) [36,105]. However, dosing should start at the lower end of dosing range and be
titrated to response [36]. Elderly patients
have shown a decreased clearance of amlodipine [105]. Immediate-release nifedipine should be avoided due to the potential for
postural hypotension, which may precipitate dizziness and falls [36]. Generic versions of verapamil that are
bioequivalent in young adults may not be bioequivalent in the elderly [105]. The CCBs verapamil and diltiazem may
precipitate heart block in those with underlying defects in cardiac conduction [36]. ACE inhibitors and ARBs are well
tolerated, are renal protective, and reduce cardiovascular morbidity and mortality [36]. As with younger patients, combination
therapy in the elderly offers an opportunity for enhanced effectiveness, more convenience,
and potentially more favorable tolerability in a simplified antihypertensive regimen.
