Hypertension Case Study with Board-Style Questions
Clinical Vignette
A 58-year-old non-Black male presents to your clinic for routine follow-up. He has no significant past medical history. His blood pressure readings over the past two visits have been 152/94 mmHg and 148/92 mmHg. Home blood pressure monitoring confirms an average of 146/90 mmHg. His BMI is 31 kg/m², and he reports drinking 3-4 beers daily. He is sedentary and consumes a high-sodium diet. Laboratory studies show normal renal function (eGFR >60 mL/min/1.73m²), no proteinuria, fasting glucose 98 mg/dL, and normal lipid panel. He has no history of cardiovascular disease, diabetes, or chronic kidney disease.
Question 1: Initial Management Strategy
What is the MOST appropriate initial management for this patient?
A) Start lisinopril 10 mg daily immediately
B) Initiate lifestyle modifications alone and reassess in 6 months
C) Start lisinopril 10 mg daily AND initiate intensive lifestyle modifications simultaneously
D) Start combination therapy with lisinopril 10 mg and hydrochlorothiazide 12.5 mg daily
Answer: C
Explanation: This patient requires immediate pharmacologic therapy combined with lifestyle modifications because he has Grade 1 hypertension (140-159/90-99 mmHg) without high-risk features. 1 According to the 2020 International Society of Hypertension guidelines, patients with Grade 1 hypertension who are low-to-moderate risk should start drug treatment after 3-6 months of lifestyle intervention if BP remains elevated. 1 However, the 2024 ESC guidelines recommend that office BP ≥140/90 mmHg be treated with both lifestyle advice AND BP-lowering medication simultaneously. 1
For non-Black patients, the recommended first-line agent is a low-dose ACE inhibitor or ARB. 1 Lisinopril 10 mg daily is the appropriate starting dose for initial therapy in adults with hypertension. 2 The patient should not delay pharmacologic treatment for 3-6 months (eliminating option B) given current evidence favoring earlier intervention. 1
Combination therapy (option D) is reserved for patients with BP ≥150/90 mmHg or those with BP >20/10 mmHg above goal. 3 This patient's BP of 148/92 mmHg does not meet these criteria for initial dual therapy. 1, 3
Question 2: Lifestyle Modifications
Which lifestyle modification would provide the GREATEST blood pressure reduction for this patient?
A) Sodium restriction to <2,300 mg/day
B) Weight loss of 10 kg
C) Reducing alcohol to ≤2 drinks/day
D) DASH diet implementation
Answer: B
Explanation: Weight loss provides the most substantial blood pressure reduction among individual lifestyle interventions, particularly in overweight and obese patients. 4, 5 This patient has a BMI of 31 kg/m², placing him in the obese category, making weight reduction the highest-yield intervention.
The DEW-IT trial demonstrated that a comprehensive lifestyle intervention including weight loss (mean 4.9 kg) resulted in 24-hour ambulatory systolic BP reduction of 9.5 mmHg and diastolic BP reduction of 5.3 mmHg. 5 Weight loss through caloric restriction is specifically recommended by the American Heart Association for overweight individuals with BP >120/80 mmHg. 3
While sodium restriction (<2,300 mg/day) is effective and recommended by the ESC 3, alcohol moderation (≤2 drinks/day for men) 3, and DASH diet implementation 3 all provide meaningful BP reductions, weight loss typically produces the largest magnitude of effect in obese patients. 4, 5 The BP-lowering effects of individual lifestyle components are partially additive, so all should be implemented simultaneously. 4
Question 3: Medication Titration
The patient returns in 4 weeks. His home BP averages 138/86 mmHg on lisinopril 10 mg daily. What is the NEXT best step?
A) Continue current dose and reassess in 3 months
B) Increase lisinopril to 20 mg daily
C) Add hydrochlorothiazide 12.5 mg daily
D) Switch to losartan 50 mg daily
Answer: B
Explanation: The patient has not achieved target BP (<130/80 mmHg for adults <65 years), so medication intensification is required. 1, 3 The 2024 ESC guidelines recommend a target systolic BP of 120-129 mmHg for most adults when treatment is well tolerated. 3
The appropriate next step is to increase the ACE inhibitor to full dose before adding a second agent. 1 According to the ISH 2020 guidelines, the treatment algorithm for non-Black patients is: (1) low-dose ACE inhibitor/ARB, (2) increase to full dose, (3) add thiazide/thiazide-like diuretic. 1 Lisinopril can be titrated from 10 mg to 20-40 mg daily, with the usual dosage range being 20-40 mg per day. 2
Adding a diuretic (option C) is premature because the ACE inhibitor has not been maximized. 1 The ISH guidelines specifically state to increase to full dose before adding additional agents. 1 Switching to an ARB (option D) is unnecessary since the patient is tolerating the ACE inhibitor without adverse effects. 1 Continuing the current inadequate dose (option A) would delay achieving BP control, which should be attained within 3 months. 1
Question 4: Resistant Hypertension
Six months later, the patient's BP remains 142/88 mmHg despite lisinopril 40 mg and hydrochlorothiazide 25 mg daily. Medication adherence is confirmed. What should be added NEXT?
A) Amlodipine 5 mg daily
B) Spironolactone 25 mg daily
C) Metoprolol 50 mg daily
D) Doxazosin 2 mg daily
Answer: A
Explanation: This patient requires a third antihypertensive agent, and a dihydropyridine calcium channel blocker (DHP-CCB) is the appropriate next step before considering agents for resistant hypertension. 1 The patient is currently on an ACE inhibitor and thiazide diuretic but has not yet received the standard three-drug combination.
According to the ISH 2020 guidelines, the treatment algorithm for non-Black patients progresses as follows: (1) ACE inhibitor/ARB, (2) add DHP-CCB, (3) increase to full dose, (4) add thiazide/thiazide-like diuretic. 1 While this patient's regimen differs slightly from the exact sequence, the standard three-drug combination consists of an ACE inhibitor/ARB, calcium channel blocker, and thiazide diuretic. 1, 4
Spironolactone (option B) is reserved for resistant hypertension, defined as uncontrolled BP despite three BP-lowering drugs including a diuretic. 1 The 2024 ESC guidelines recommend adding low-dose spironolactone only after optimizing the three-drug combination. 1 Beta-blockers (option C) and alpha-blockers (option D) are fourth- or fifth-line agents used when spironolactone is not tolerated or contraindicated. 1
Amlodipine 5 mg daily is the correct choice as it completes the standard triple-therapy regimen before escalating to resistant hypertension treatments. 1, 4
Question 5: Monitoring Parameters
After starting amlodipine, which laboratory test should be checked in 7-14 days?
A) Serum creatinine and potassium
B) Liver function tests
C) Fasting glucose
D) No laboratory monitoring needed
Answer: D
Explanation: Calcium channel blockers do not require routine laboratory monitoring after initiation or dose adjustment. 3 Unlike ACE inhibitors, ARBs, and mineralocorticoid receptor antagonists, which require monitoring of serum creatinine and potassium levels 7-14 days after initiation or dose changes 3, DHP-CCBs like amlodipine do not cause hyperkalemia or affect renal function in a manner requiring routine monitoring.
Serum creatinine and potassium monitoring (option A) is specifically indicated when using ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists. 3 This patient is already on lisinopril, so these parameters should have been checked when that medication was started or adjusted, but adding amlodipine does not trigger additional laboratory requirements.
Liver function tests (option B) are not routinely required for calcium channel blockers. 3 Fasting glucose (option C) is not affected by calcium channel blockers and does not require monitoring unless clinically indicated for other reasons. 3
The key monitoring for calcium channel blockers is clinical assessment for peripheral edema, which is the most common side effect of DHP-CCBs, but this does not require laboratory testing. 4