2010(3) ANSWER: E

Difficult-to-control hypertension has many possible causes, including nonadherence or the use of alcohol, NSAIDs, certain antidepressants, or sympathomimetics. Secondary hypertension can be caused by relatively common problems such as chronic kidney disease, obstructive sleep apnea, or primary hyperaldosteronism, as in the case described here.

As many as 20% of patients referred to specialists for poorly controlled hypertension have primary
hyperaldosteronism. It is more common in women and often is asymptomatic. A significant number of
these individuals will not be hypokalemic. Screening can be done with a morning plasma aldosterone/renin ratio. If the ratio is 20 or more and the aldosterone level is >15 ng/dL, then primary hyperaldosteronism is likely and referral for confirmatory testing should be considered.

2010(67) ANSWER: A

Cigarette smokers are five times more likely than nonsmokers to develop an abdominal aortic aneurysm
(AAA).  The risk is associated with the number of years the patient has smoked, and declines with
cessation.  Diabetes mellitus is protective, decreasing the risk of AAA by half.  Women tend to develop
AAA in their sixties, 10 years later than men.  Whites are at greater risk than African-Americans.
Hypertension is less of a risk factor than cigarette smoking (SOR A).
Ref: Schermerhorn M: A 66-year-old man with an abdominal aortic aneurysm. JAMA 2009;302(18):2015-2022.

2010(75) ANSWER: D
This patient has stage 2 hypertension, and his history of stroke is a compelling indication to use specific
classes of antihypertensives. For patients with a history of previous stroke, JNC-7 recommends using
combination therapy with a diuretic and an ACE inhibitor to treat the hypertension, as this combination
has been clinically shown to reduce the risk of recurrent stroke. Other classes of drugs have not been
shown to be of benefit for secondary stroke prevention. Although blood pressure should not be lowered
quickly in the setting of acute ischemic stroke, this patient is not having an acute stroke, so treatment of
his hypertension is warranted.
Ref: Ressel GW; NHLBI: NHLBI releases new high blood pressure guidelines. Am Fam Physician 2003;68(2):376, 379.  2)
Chobanian AV, Bakris GL, Black HR, et al: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 report. JAMA 2003;289(19):2560-2572.

2011(102) ANSWER: A
Diuretics such as hydrochlorothiazide are known to increase serum uric acid levels, but losartan has been shown to decrease uric acid.  Metoprolol, simvastatin, and acetaminophen have no specific effect on serum uric acid levels.
Ref: Richette P, Bardin T: Gout. Lancet 2010;375(9711):318-328.

2011(214) ANSWER: A
Duplex Doppler ultrasonography is the preferred initial test for renovascular hypertension in patients with impaired renal function.  Tests involving intravenous radiographic contrast material may cause
deterioration in renal function.  Captopril renography is not reliable in the setting of poor renal function.
Magnetic resonance angiography also could be considered, but the association between the use of
gadolinium contrast agents and nephrogenic systemic fibrosis in patients with renal dysfunction would be a concern.
Ref: Hartman RP, Kawashima A: Radiologic evaluation of suspected renovascular hypertension. Am Fam Physician 2009;80(3):273-279.

2011 (228) ANSWER: C
Treatment of hypertension reduces the risk of stroke, myocardial infarction, and heart failure. For most
patients, JNC-7 recommends a goal blood pressure of <140/90 mm Hg. However, the goal for patients
with chronic kidney disease (CKD) or diabetes mellitus is <130/80 mm Hg. Both conditions are
independent risk factors for cardiovascular disease. The National Kidney Foundation and the American
Society of Nephrology recommend treating most patients with CKD with an ACE inhibitor or angiotensin
receptor blocker (ARB), plus a diuretic, with a goal blood pressure of <130/80 mm Hg. Most patients
with CKD will require two drugs to reach this goal.

Ref: K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Am J Kidney Dis 2002;39(2 Suppl 1):S1-S266.  2) Chobanian AV, Bakris GL, Black HR, et al: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure—The JNC 7 Report. National Heart Lung and Blood Institute (NHLBI), 2003.

2011 (236) ANSWER: D
The retinal findings shown are consistent with central retinal artery occlusion.  The painless, unilateral,
sudden loss of vision over a period of seconds may be caused by thrombosis, embolism, or vasculitis.
Acute narrow-angle glaucoma is an abrupt, painful, monocular loss of vision often associated with a red
eye, which will lead to blindness if not treated.  In persons with optic neuritis, funduscopy reveals a
blurred disc and no cherry-red spot.  Occlusion of the central retinal vein causes unilateral, painless loss
of vision, but the retina will show engorged vessels and hemorrhages.

Ref: Yanoff M, Duker JS (eds): Ophthalmology, ed 3. Mosby, 2008, pp 589-592.  2) Pokhrel PK, Loftus SA: Ocular emergencies. Am Fam Physician 2007;76(6):829-836.