Hypertension

Question 1

Administration of digoxin to a patient with poorly controlled hypertension and atrial fibrillation with an irregular ventricular rate of 130-150 bpm will:
a. Decrease stroke volume
b. Decrease ventricular automaticity
c. Increase the AV node refractory period
d. Decrease the vagal tone

Answer 1

c. Increase the AV node refractory period

It may also increase stroke volume through positive inotropy

Question 2

Which of the following is least appropriate for treating a patient with mild hypertension and moderate asthma?
a. Nonselective oral beta antagonist like propanolol
b. ACE-I like captopril
c. Calcium channel blocker like diltiazem
d. Selective oral beta antagonist like atenolol

Answer 2

a. Nonselective oral beta antagonist like propanolol

Beta antagonists can worsen asthma symptoms

Question 3

For the same BP value, competing guidelines dictate different modes of treatment.

A woman, aged 64 years, BMI 29, has a BP 148/86 x 3 office visits over a 3 month period of time (+/- 2 mmHg), both arms. The BP is measured with best practices. She has no symptoms. She has no meds.

Match the BP treatment goals witht he correct guidelines.

a. < 130/80
b. < 140/90
c. < 150/90

1. 2018 European Society of Hypertension/European Society of Cardiology
2. 2017 ACP/AAFP
3. 2017 ACC/AHA

Answer 3

a. <130/80 3. 2017 ACC/AHA

b. <140/90 1. 2018 ESH/ESC

c. < 150/90 2017 ACP/AFFP

Question 4

According to the ACC/AHA guidelines suggest a 64 yo woman with BP 146/86, no symptoms, overweight, should start on 1 antihypertensive.
a. True
b. False

Answer 4

a. True

ESH/ESC 2018 say start on 2 anti-HTN meds

ACP/AAFP say no anti-HTN meds

Question 5

If you follow the ACP/AAP guidelines, what is a 64 yo woman with BP 146/86, no symptoms, and overweight CV mortality risk?

Answer 5

c. 14%

5% if she hits the guideline treatment targets for ACC/AHA

8% if she hits treatment targets for ESH/ESC

14% if she hits treatment targets for ACP/AAFP

Question 6

The evidence for each of the guidelines (2017 ACC/AHA; 2018 ESH/ESC; 2017 ACP/AAFP) is based on outcomes fromt he study, SPRINT. Why do their SBP baselines vary by 20 mmHg?
a. The answer is unclear
b. The evidence is all at level A
c. Different experts have different calculating tools

Answer 6

a. The answer is unclear

Only a fraction of the evidence on which we base HTN treatment is at level A (highest, most reproducible)

Question 7

Treating low risk patients with mild hypertension may lead to more harm than benefit.
a. True
b. False

Answer 7

a. True

Experts mostly agree on this. Treatment offers little benefit against mortality or CV disease, but ADRs tick up in this mild HTN population. Be cautious when following guidelines from trials conducted in high-risk individuals to those at lower risk.

One reason the ACC/AHA 2017 guidelines are a little controversial - and should be.

SPRINT results:
mediun f/u 5.8 years
No association between treatment, CVD (inclu MI, stroke, HF)
No association btw treatment, mortality
Positive association with ADRs: hypotension, syncope, electrolyate abnormalities, acute kidney injury

Question 8

For patients with HTN, even mild HTN, lifestyle should be addressed with every visit and modfications offered.
a. True
b. False

Answer 8

a. True

Question 9

Before 2017, only BP obtained in a clinic setting was able to be used to seek reimbursement for a new diagnosis of chronic/primary hypertension.
a. True
b. False

Answer 9

a. True

After 2017, CMS and insurance companies began to accept ambulatory blood pressure monitoring/measurement. This change in reimbursement is congruent with ACC/AHA and USPSTF and the American Society of Hypertension - all recommend out-of-office blood pressure measurements before making a new diagnosis of hypertension.

Question 10

Many providers don’t follow HTN guidelines.
a. True
b. False

Answer 10

a. True

Data are pretty consistent on this - not using BP values (such as 130/80 as a goal in certain populations) or not changing prescriptions in the prsence of not meeting goals, or not using first-line agents regularly. Even not using best practices for obtaining a valid and reliable BP (rest for 5 min, feet on the floor, arm at heart level, correct cuff, and so on). Or using out-of-office values to diagnose or monitor response to treatment. “Significant gaps in knowledge, beliefs, and the use of recommended practices”

Question 11

The goal of 130/80 for BP management in some populations is somewhat controversial.
a. True
b. False

Answer 11

a. True

Data on mortality and morbidity for some populations is important and significant, some societies oppose this threshold.