A 50-year-old man with CKD and hypertension has a blood pressure of 165/110 mmHg.
What is this patient’s target blood pressure according to the JNC 8 guidelines?
140/90 mmHg. JNC 8 guidelines recommend that in patients with CKD or diabetes mellitus, the target blood pressure should be <140/90 mmHg.
A 36-year-old patient, status post heart transplantation, is found to have hypertension. He is currently taking prednisone, mycophenolate, and cyclosporine.
Which of the following antihypertensive medications would increase cyclosporine levels?
Diltiazem. Patients who have undergone heart transplantation often have preexisting hypertension or develop hypertension subsequent to the heart transplant. This is a unique patient population as many of the immunosuppressive medications used after transplantation have multiple drug interactions. With respect to antihypertensive agents, most if not all calcium channel blockers have been shown to increase cyclosporine levels. Diltiazem and verapamil, in particular, are potent inhibitors of protein Pglycoprotein and CYP3A4. These enzymes are critical for the metabolism of diltiazem, and their inhibition can increase cyclosporine levels up to sixfold. It is recommended that patients who require diltiazem and are on cyclosporine have their cyclosporine dose decreased by 25% to 50%. Diltiazem can also increase tacrolimus levels.
A 56-year-old man with resistant hypertension begins to take a new antihypertensive agent. Within the next few weeks he is diagnosed with pericarditis.
Which of the following agents is most likely responsible?
Minoxidil. Pericarditis is a known complication of the direct vasodilator minoxidil often accompanied by a pericardial effusion. Its other major side effect is hirsutism. Prompt withdrawal of the medication once the diagnosis of a pericardial effusion or pericarditis is made is recommended. Minoxidil is a potent peripheral vasodilator and is typically reserved for patients with severe or difficult-to-control hypertension.
A 27-year-old woman presents to the cardiology clinic for evaluation of uncontrolled hypertension. She was diagnosed 2 years ago and is currently taking hydrochlorothiazide, lisinopril, and amlodipine. She denies nonadherence and has a blood pressure of 170/100 mmHg that is equal in both arms. On routine laboratory examination, she has a potassium level of 2.9 mEq/L with a sodium level of 148 mEq/L.
What is the most appropriate diagnostic test?
Morning renin and aldosterone concentrations. The patient in this vignette has secondary hypertension from Conn syndrome. This is primary hyperaldosteronism from uncontrolled secretion of aldosterone. Classic laboratory findings include hypokalemia and mild hypernatremia. The initial diagnostic test of choice is an aldosterone-renin ratio. A ratio of >20 is considered diagnostic. In this patient, the presence of lisinopril complicates the testing. ACEIs are known to decrease renin levels, and ideally the test should be done in the early morning after withdrawal of ACEI therapy. Adrenal vein sampling would be helpful in the diagnosis of primary hyperaldosteronism; however, it is not the initial test of choice. A 24-hour urine test would be more appropriate if Cushing syndrome were suspected. The patient’s clinical description is not consistent with this diagnosis. The presence of FMD should be suspected in any young woman with suspected secondary hypertension. However, the laboratory abnormalities are more suggestive of Conn syndrome than renal artery stenosis.
A 58-year-old obese man with hypertension, diabetes mellitus, hyperlipidemia, and recent myocardial infarction presents for his annual physical examination. He is currently prescribed atenolol, hydrochlorothiazide, amlodipine, and quinapril. His blood pressure is at target values. His HbA1c is at goal. However, he has noted increasing lower extremity edema over the past few months and had a near-fatal car accident after falling asleep while driving. His echocardiogram reveals an ejection fraction of 65% with no evidence of diastolic dysfunction.
Which of the following management decisions would be most appropriate at this time?
Polysomnography. The patient’s clinical history is consistent with the presence of obstructive sleep apnea; therefore, polysomnography (an overnight sleep study) would be the best option. Multiple studies have found evidence for increased risk of hypertension in patients with obstructive sleep apnea. There is no definitive evidence that treating patients with sleep apnea can lower blood pressure; however, there is an increasing hypertension risk as the number of overnight apneic episodes increases. Patients with >30 apnea or hypopnea episodes per hour have an odds ratio of 1.37 of developing hypertension versus those patients with <1.5 apnea or hypopnea episodes per hour.
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