CHS Hypertension in Special Populations 2 — Questions and Answers
Question 1: A 72-year-old patient has an SBP of 162 mmHg and DBP of 68 mmHg. What type of hypertension does this represent and what is the primary target organ concern?
- Diastolic hypertension; left ventricular hypertrophy
- Isolated systolic hypertension; increased pulse pressure and cardiovascular risk (Correct answer)
- White coat hypertension; anxiety-related cardiac strain
- Secondary hypertension; renal artery stenosis
Correct answer: Isolated systolic hypertension; increased pulse pressure and cardiovascular risk
Isolated systolic hypertension (ISH) is the most common form in elderly patients and is defined as SBP ≥140 with DBP <90, carrying significant cardiovascular morbidity risk due to arterial stiffness.
Question 2: Which antihypertensive drug class is considered most effective and guideline-recommended as first-line therapy for hypertension in patients with chronic kidney disease (CKD) with proteinuria?
- Calcium channel blockers
- Beta-blockers
- ACE inhibitors or ARBs (Correct answer)
- Thiazide diuretics
Correct answer: ACE inhibitors or ARBs
ACE inhibitors and ARBs reduce intraglomerular pressure and proteinuria, providing both antihypertensive and nephroprotective effects in CKD.
Question 3: A 14-year-old boy has a BP of 138/86 mmHg confirmed on three occasions. According to pediatric guidelines, what is the next appropriate step?
- Reassure and recheck in one year
- Initiate lifestyle modifications and evaluate for secondary causes (Correct answer)
- Start amlodipine immediately
- Prescribe hydrochlorothiazide 25 mg daily
Correct answer: Initiate lifestyle modifications and evaluate for secondary causes
In adolescents with confirmed hypertension, secondary causes must be ruled out and lifestyle modifications (diet, exercise, weight loss) are first-line before pharmacotherapy.
Question 4: A pregnant woman at 34 weeks gestation has BP 158/104 mmHg, 2+ proteinuria, and mild headache. Which diagnosis is most consistent and which drug is contraindicated?
- Gestational hypertension; methyldopa contraindicated
- Preeclampsia; ACE inhibitors contraindicated (Correct answer)
- Chronic hypertension; labetalol contraindicated
- HELLP syndrome; nifedipine contraindicated
Correct answer: Preeclampsia; ACE inhibitors contraindicated
Preeclampsia presents with new-onset hypertension and proteinuria after 20 weeks; ACE inhibitors and ARBs are absolutely contraindicated in pregnancy due to fetal toxicity.
Question 5: In patients with hypertension and heart failure with reduced ejection fraction (HFrEF), which combination of drug classes has been shown to reduce mortality?
- Calcium channel blockers and thiazides
- ACE inhibitors/ARBs, beta-blockers, and mineralocorticoid receptor antagonists (Correct answer)
- Alpha-blockers and loop diuretics
- Direct vasodilators and alpha-2 agonists
Correct answer: ACE inhibitors/ARBs, beta-blockers, and mineralocorticoid receptor antagonists
The combination of ACE inhibitors/ARBs (or ARNI), beta-blockers, and MRAs forms the foundational mortality-reducing therapy in HFrEF per ACC/AHA guidelines.
Question 6: An African American patient with stage 2 hypertension and no compelling indications is started on therapy. Which drug combination is preferred per JNC and ACC/AHA guidelines?
- Beta-blocker + ACE inhibitor
- Thiazide diuretic + calcium channel blocker (Correct answer)
- ARB + beta-blocker
- Alpha-blocker + centrally acting agent
Correct answer: Thiazide diuretic + calcium channel blocker
Thiazide diuretics and calcium channel blockers are preferred in African American patients without compelling indications, as this population has lower renin levels and responds less to RAS blockers as monotherapy.
Question 7: A competitive athlete has resting BP of 148/92 mmHg confirmed over multiple visits. Which antihypertensive class is generally preferred to avoid performance impairment?
- Beta-blockers
- Thiazide diuretics
- ACE inhibitors or calcium channel blockers (Correct answer)
- Centrally acting alpha-2 agonists
Correct answer: ACE inhibitors or calcium channel blockers
ACE inhibitors and dihydropyridine CCBs are preferred in athletes because beta-blockers impair exercise tolerance and diuretics cause electrolyte imbalances and dehydration during exertion.
CHS Hypertension in Special Populations 2
A 72-year-old patient has an SBP of 162 mmHg and DBP of 68 mmHg.
What type of hypertension does this represent and what is the primary target organ concern?