A 62-year-old man with type 1 diabetes mellitus receives intermittent hemodialysis for his end-stage renal disease. His blood pressure has become elevated over the past year and has not reached goal levels despite initiation of three antihypertensive medications. He takes several medications for comorbid conditions, several of which may be exacerbating his elevated blood pressure.
Medications for which of the following conditions would not be expected to have a side effect of hypertension?
Diabetes. There are no established links between hypertension and oral or subcutaneous therapies for diabetes. However, all four other conditions can be treated with medications that may be iatrogenic causes or contributors to hypertension. Approximately 20% to 30% of patients who receive erythropoietin intravenously for anemia of CKD develop an elevation in diastolic pressure of 10 mmHg or more. Secondary hyperparathyroidism is common in CKD patients, and cinacalcet can lower parathyroid hormone levels by increasing the sensitivity of the calcium-sensing receptor to extracellular calcium. However, hypertension is an adverse effect in approximately 7% of patients. Systemic absorption of ophthalmic drops is limited, but α-adrenergic agonists such as brimonidine may raise the pulse and blood pressure. Nonsteroidal anti-inflammatory medications such as ibuprofen are a common cause of fluid retention and hypertension exacerbation, especially for patients with renal dysfunction.
A 58-year-old man with resistant hypertension returns for outpatient followup. His blood pressure is 168/79 mmHg and pulse 70 bpm, despite 25 mg hydrochlorothiazide daily, 200 mg metoprolol XL daily, 320 mg valsartan daily, 10 mg amlodipine daily, and a 0.1 mg/24 hour clonidine patch. He is considering entering a sympathetic denervation trial and has some questions about the procedure.
Which of the following is the most accurate brief description of the denervation procedure?
Access through a femoral artery, radiofrequency ablation of bilateral renal arteries. Current renal denervation catheters are introduced via standard femoral artery access. These catheters have a radiofrequency energy electrode tip that delivers a series of 2-minute ablations along the lumen of each renal artery to disrupt the sympathetic nerve fibers. Symplicity HTN-2 was a randomized, controlled trial comparing 54 patients receiving standard medical therapy for resistant hypertension with 52 patients who underwent percutaneous renal sympathetic denervation. The denervation group demonstrated a mean 32/12 mmHg blood pressure reduction at 6 months, compared with a 1/0 mmHg reduction in controls. However, the larger Symplicity 2 study did not show any difference. Thus, at this time, renal denervation cannot be recommended as therapy.
Which of the following patient characteristics is a risk factor for development of angiotensin-converting enzyme inhibitor (ACEI)-induced angioedema?
Female gender. ACEIs are the leading cause of drug-induced angioedema in the United States because they are so widely prescribed, accounting for 20% to 40% of all emergency room visits for angioedema. ACEIs induce angioedema in approximately 0.2% of recipients and the risk appears equivalent between the different ACEI medications. Severe reactions can be observed many months or even years after initiation of ACEI therapy. One large Veteran’s Affairs study by Miller et al. documented an almost fourfold higher rate of ACEI angioedema in blacks compared with whites, a 50% higher rate in women and a 12% lower rate in patients with diabetes. Patient age quartiles were unassociated with angioedema risk.
A 76-year-old man with hypertension has inadequate blood pressure control on chlorthalidone 25 mg daily. His primary care doctor is choosing a second antihypertensive agent.
Which of the following comorbidities would be an evidence-based indication for choosing ramipril over amlodipine as the second agent?
Peripheral arterial disease. There is now evidence to support the specific use of ramipril in patients with peripheral arterial disease and intermittent claudication. Ramipril has been associated with a significant increase in pain-free and maximum treadmill walking times at 6 months, as compared with placebo. Relative to placebo, ramipril also significantly improved the physical functioning component of a quality of life score. Although blood pressure control is an important management component for hypertensive patients with HFPEF, there is no compelling evidence for superiority of one medication over another in this setting. There is also no strong evidence to guide a specific antihypertensive choice for a patient with sleep apnea, although the presence of increased sympathetic nerve activity and a nocturnal diuresis in sleep apnea patients may explain reports that βblockers tend to lower blood pressure more than thiazide diuretics in this setting. β-Blockers and ACEIs or ARBs are commonly used for blood pressure control in patients with aortic aneurysms.
A 30-year-old man with no past medical history presents to his primary care physician complaining of new-onset morning headaches that have been ongoing for the past few weeks. His blood pressure is noted to be 220/100 mmHg with a gradient between his brachial and popliteal arteries. On auscultation, there is a II/VI systolic crescendo–decrescendo murmur heard across the precordium. His electrocardiogram is significant for left ventricular hypertrophy. A chest X-ray shows cardiomegaly with evidence of rib notching.
The patient most likely has what valvular abnormality?
Bicuspid aortic valve. This young man has a classic presentation of coarctation of the aorta. This secondary cause of hypertension is the result of stenosis of the aorta, usually at the embryonic site of the ligamentum arteriosum and is typically distal to the origin of the left subclavian artery. The presentation in adulthood is varied and is twice as common in men. Symptoms of hypertension or congestive heart failure are common. The electrocardiogram is characterized by left ventricular hypertrophy. Right ventricular hypertrophy is common if a concomitant ventricular septal defect is present. The most common associated valvular abnormality is a bicuspid aortic valve seen in 22% to 42% of cases. Intracranial aneurysms are seen in up to 10% of cases. Patients will often have a characteristic systolic precordial murmur secondary to the development of collateral arteries. Long-term management involves surgical or transcatheter correction. Patients will often continue to have systemic hypertension after repair and should be treated accordingly.
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