Which of the following antihypertensive agents is a known cause of autoimmune hemolytic anemia?
Methyldopa. The central α-agonist methyldopa is known to cause an autoimmune hemolytic anemia in up to 20% of patients taking the medication. Other common side effects include sedation, insulin resistance, and galactorrhea. Methyldopa is not a first-line agent for treatment of hypertension and is usually reserved for pregnant patients and those with resistant hypertension.
A patient is initiated on an ACEI.
What is the recommended cutoff for rise in creatinine before stopping the medication?
35% increase in creatinine. According to the JNC 7 guidelines, patients initiated on an ACEI should be continued on that medication unless the creatinine increases by more than 35% or another indication for discontinuation presents itself.
A 68-year-old man with hypertension and history of a stroke presents for further management of his hypertension. He is currently prescribed a thiazide diuretic; however, his blood pressure remains elevated. From the standpoint of decreasing his future risk of stroke.
which of the following drug classes would be most beneficial?
Calcium channel blocker. The Blood Pressure Lowering Treatment Trialist Collaboration Study found that calcium channel blockers provided a greater benefit in the reduction of stroke when compared with other antihypertensive agents. However, there was no difference in cardiovascular mortality or overall cardiovascular events.
A 56-year-old woman presents to your clinic for physical examination. She has no significant past medical history and is asymptomatic. Her vital signs are significant for a blood pressure of 145/95 mmHg.
What are the next steps in her evaluation for hypertension?
She should have a repeat blood pressure measurement at a later time point during her visit and return in a few weeks to obtain repeat testing if that measurement is elevated. The JNC 7 guidelines suggest that the diagnosis of hypertension requires at least two separate blood pressure measurements during a clinic visit. The patient should be resting in a chair for at least 5 minutes and should have her arm supported at heart level when the blood pressure is measured. Blood pressure measurements should be evaluated in the contralateral arm and while standing as well. Elevations in blood pressure should be confirmed in a timely manner on a repeat visit, the timing of which is dependent on the level of hypertension and the presence of comorbid conditions. The patient in this vignette has mild isolated hypertension and should return in a few weeks (6 to 8 weeks). Those with more elevated blood pressure should return sooner. Antihypertensive medications should not be initiated on this initial visit as diurnal variations in blood pressure are common and she may not have hypertension. Ambulatory monitoring of blood pressure should be attempted. An evaluation for secondary cause is premature as the diagnosis of hypertension is not confirmed. Waiting to reevaluate the patient in 1-year time is unacceptable, as hypertension, if left untreated, increases the risk of stroke, myocardial infarction, heart failure, and renal insufficiency.
A 45-year-old woman with no significant past medical history is noted to have a blood pressure of 145/90 mmHg in the outpatient clinic. This is confirmed on repeat visits.
Which of the following tests would not be indicated at this time?
Urine metanephrines. The initial assessment of any patient with a new diagnosis of hypertension requires evaluation for evidence of hypertensioninduced end-organ damage. All patients with a new diagnosis of hypertension should have the following testing: serum hematocrit, blood urea nitrogen, serum creatinine, serum potassium, serum calcium, blood glucose, an electrocardiogram, an ophthalmologic examination, a fasting lipid panel, and a urinalysis. Evaluation for secondary causes of hypertension should be limited to those with uncontrolled hypertension after treatment.
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