PHARM 6521 Hypertension Case Study HM is a 77 year old African American male

Hypertension Case Study
HM is a 77 year old African American male who presents to your clinic to establish care as a new patient.
He and his wife recently moved to the area to be closer to family. His complaints that he is seeing you for
today include severe gouty arthritis pain in his left great toe, and increasing frequency of headaches over
the last few weeks.
PMH:
He believes that he has been treated for high blood pressure in the past, but is not a good historian
regarding treatments. He also does not recall how long he has been off the medication.
He does not smoke now, but has a 10-12 pack year history.
Current Medications:
No prescription medications are taken at this time.
OTC medications include:
Multivitamin – 1 QD
Calcium + Vit D 600 mg/800 IU – 1 QD
Ibuprofen 200 mg – 4 tabs every 6-8 hrs prn pain
Vitals:
BP:
158/88 R arm/sitting
162/89 L arm/sitting
HR:
77
Ht:
73 inches
Wt:
254 lbs
Labs:
CMP:
Sodium
Potassium
Glucose
Calcium
Albumin
AST
ALT
Cr

139 mmol/L
4.1 mmol/L
101 mg/dL
9.4 mg/dL
4.1 g/dL
26 U/L
31 U/L
1.62 mg/dL

Lipid Panel:
Cholesterol
TG
HDL
LDL

165 mg/dL
228 mg/dL
37 mg/dL
82 mg/dL

TSH
Uric Acid

2.40 uIU/ml
9.7 mg/dL

Answer the following questions using the information above.
1. Which of the following is FALSE?
a. Cardiovascular disease is the leading cause of death in the US and worldwide
b. Hypertension prevalence increases as age increases over 65 years
c. Hypertension is the most common chronic disorder
d. Education has improved hypertension awareness by 99%
2. Which of the following is the best classification of HM’s blood pressure at your clinic today?
a. Normal
b. Pre-hypertensive
c. Stage I
d. Stage II
3. Which of the following modifiable risk factors is most likely contributing to HM’s hypertension?
a. Age
b. Smoking
c. Obesity
d. Use of NSAIDs
4. Which of the following are TRUE?
a. There are significant differences in guideline statements for assessment of BP
b. The 2014 JNC 8 did not comment on assessment of BP
c. Practitioners should avoid checking BP immediately after the patient enters the office
d. Orthostatic or standing BP should be checked at 1-3 minutes after standing
e. All of the above
5. For which of the following causes of secondary hypertension should HM undergo screening?
a. Primary aldosteronism
b. Pheochromocytoma
c. Renovascular hypertension
d. None of the above
6. Which of the following statements is correct regarding the Hypertension in the Very Elderly Trial
(HYVET)?
a. Antihypertensive treatment reduced the primary outcome of stroke
b. Antihypertensive treatment increased 5-year survival at the expense of increased serious
hypotensive events
c. Antihypertensive treatment reduced total mortality and risk of heart failure
d. Antihypertensive treatment should only be attempted for secondary stroke prophylaxis

7. Which of the following statements best reflects the changes in HM’s BP target between JNC7 and
JNC8?
a. No change in BP target
b. BP target increased from < 140/90 mmHg to < 150/90 mmHg
c. BP target increased from < 140/90 mmHg to < 150/80 mmHg

d. BP target increased from < 140/90 mmHg to < 160/90 mmHg
8. You discuss the goal BP with HM, but he is skeptical of a higher target. He even shows you an
article that he got online stating that 115/75 mmHg is the optimal BP and the risk of CV disease
increases for every 20/10 mmHg increase thereafter. He wonders why you don’t treat to that BP
goal since it is “the best.” What information from the ACCORD-BP trial can you use to help
explain your reasoning?
a. There are no benefits to additional blood pressure lowering beyond < 140/90 mmHg
b. There is not enough evidence that the benefits of targeting a blood pressure < 120/80
mmHg justify the additional risks of therapy
c. Blood pressure of 115/75 mmHg is optimal and the data supports this level of therapy
d. Being aggressive with blood pressure lowering in the elderly not only decreases the
chance of CV disease, but can also greatly reduce the risk of stroke
9. In which of the following patient groups would thiazides be considered a first-line
antihypertensive pharmacotherapy option?
a. A 72 year old Caucasian female with stage IV CKD and proteinuria
b. A 85 year old African American female with primary aldosteronism
c. A 66 year old African American male with diabetes
d. A 73 year old Caucasian male with pre-hypertension
10. You decided at HM’s initial visit since he was new to you, to defer therapy and RTC in 1 month,
during which time he would try nonpharmacologic interventions. At that time you also drew labs
to get a baseline. You instructed him to take his BP at home and bring the readings to his next
appt. Upon returning he has no acute complaints, but looking over his BP log you determine an
average BP of 161/92 (based on 3 selected readings). You take his BP in office today and it is
161/91 mmHg and his standing BP in the office 145/76 mmHg. What therapy would be the most
appropriate at this time?
a. Lisinopril 40 mg daily
b. Furosemide 40 mg daily
c. Chlorthalidone 12.5 mg QD
d. Verapamil 120 mg ER daily

11. HM returns to clinic for his first f/u visit after starting BP treatment. He stated he didn’t like how
the medication made him feel, and he had another gout flare, so he stopped it 5 days ago. Despite
stopping the medication, he reports that his urinary frequency continues to increase and he is
feeling thirsty throughout the day. Although he is fasting this morning, his in office glucose
finger stick is 157 mg/dL. Rapid urine screen also shows 1+ protein. Which of the following
options is the most appropriate for HM today?
a. Lisinopril 20 mg QD

b. HCTZ 50 mg QD
c. Amlodipine 10 mg QD
d. Lisinopril 40 mg QD
12. HM returns for f/u 4 weeks later. At last visit you started him on Allopurinol 100 mg daily, which
he is still taking and symptom free. You look at his home BP log at this visit and the readings are
better, but his average is still elevated at 152/89 mmHg. Which of the following would be the
best agent to add for combination therapy?
a. Carvedilol 12.5 mg BID
b. Losartan 25 mg QD
c. Amlodipine 5 mg QD
d. HCTZ 25 mg QD
13. HM’s BP is now well controlled upon f/u after starting combination therapy, as his home log
average is 138/87 mmHg, and his in office BP today was 138/86 mmHg. Now that you have his
hypertension controlled, it is time to think about his cardiovascular risk. What is his current 10year risk of heart disease or stroke?
a. 10%
b. 25%
c. 33%
d. 45%
14. Based on the score you calculated, what treatment would you recommend for HM?
a. No treatment necessary
b. Initiate low intensity statin
c. Initiate moderate intensity statin
d. Initiate high intensity statin
15. You decide that it would be beneficial to start HM on a statin. Which statin would be the most
appropriate?
a. Crestor 40 mg QD
b. Atorvastatin 40 mg QD
c. Simvastatin 80 mg QD
d. Lovastatin 20 mg QD