Hypertension Board Review Questions, Free CME Quiz
This week's Med-Challenger free CME quiz - Hypertension - the quick quiz covers the conflict in currently accepted guidelines about appropriate first-line medical therapy for hypertension, medications that may cause hypertension, the appropriate imaging modality to confirm renovascular hypertension, and the effects of ACE inhibitors and ARBs on renal function in patients with chronic kidney disease and proteinuria.
A free sample Hypertension question included below. The full Hypertension CME quiz is free online for a limited time. You can earn AMA CME credit - and now you can earn ANCC contact hours as well! Play now.
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Here's this week's sample CME board review question on hypertension:
A 47-year-old woman with long-standing lupus nephritis presents to her physician for her biannual checkup. She is currently taking no medication and she feels generally well.
On physical examination, her blood pressure is 160/98 mm Hg. Pressures were equal in both arms. Previous blood pressures have been in the range of 130/70 mm Hg.
Her physician asked her to return a week later for a recheck of the pressure. At that time, repeat blood pressure was 158/100 mmHg. The remainder of the physical examination was normal.
Laboratory studies:
Serum creatinine: 4.3 mg/dL
Blood urea nitrogen: 38 mg/dL
Serum potassium: 5.1 mEq/L
Urinary protein: 1 g/24 hrs.
These laboratory results were only slightly higher than those taken 6 months earlier. This patient is presumed to have hypertension as the result of her lupus nephritis.
Question:
What is the first-line anti-hypertensive agent for this patient?
Answer Options:
Thiazide diuretic
Angiotensin-converting enzyme (ACE) inhibitor
Sympathetic blocker such as aldomet
Beta-blocker
The correct answer is:
Angiotensin-converting enzyme (ACE) inhibitor
Educational Objective:
Describe the effects of ACE inhibitors and ARBs on renal function in patients with chronic kidney disease and proteinuria.
Key Points:
In chronic kidney disease with proteinuria, either ACE inhibitors or angiotensin receptor blockers (ARBs) reduce urinary protein and slow the progression of renal failure.
Explanation:
Hypertension is present in approximately 80 to 85 percent of patients with CKD and is thought to be multi-factorial (sodium retention, increased activity of the renin-angiotensin system, and enhanced activity of the sympathetic nervous system).
In patients with proteinuric (defined as protein excretion above 500 to 1000 mg/day) CKD, first-line therapy consists of an ACE inhibitor or angiotensin receptor blocker as first-line therapy for the treatment of hypertension (Grade 1A).
ACE inhibitors, in addition to reducing intra-glomerular pressure, reduce the excretion of urinary protein (both of which delay the progression of renal failure). Angiotensin receptor blockers (ARBs) have a similar effect. Aside from blood pressure control, the aim is to reach less than 1000 mg/day of protein spilling into the urine.
In patients with edema, a thiazide diuretic can be added as a second-line drug; chlorthalidone is preferred over hydrochlorothiazide because of its longer duration of action. A dihydropyridine calcium channel blocker is appropriate as a second-line drug for patients without fluid retention. Neither a beta-blocker nor a sympathetic, such as aldactone, demonstrate the protective effect of ACE inhibitors or ARBs.
References:
Mann JFE. Overview of hypertension in acute and chronic kidney disease. UpToDate. Updated Sept 8, 2021, 2018. Accessed Feb 20, 2022.
2020 International Society of Hypertension global hypertension practice guidelines. Unger T, Borghi C, Charchar F, Khan NA, Poulter NR, Prabhakaran D, Ramirez A, Schlaich M, Stergiou GS, Tomaszewski M, Wainford RD, Williams B, Schutte AE. J Hypertens. 2020;38(6):982.
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