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- Question 1 of 15
1. Question
1. Of South Africans with hypertension, what percentage has poor BP control?
- Question 2 of 15
2. Question
2. The SAHS recommends a universal BP treatment target of <140/90mmHg.
- Question 3 of 15
3. Question
3. In elderly patients (>80 years), which BP target has been shown to be of benefit, particularly with regard to stroke reduction?
- Question 4 of 15
4. Question
4. Lifestyle advice is recommended for:
- Question 5 of 15
5. Question
5. First-line combination therapy is recommended when:
- Question 6 of 15
6. Question
6. Which of the following antihypertensives are contraindicated or need to be used with caution in pregnancy?
- Question 7 of 15
7. Question
7. Which statement about black hypertensive patients is false?
- Question 8 of 15
8. Question
Patient: Mr T, 60 years old
- Sedentary clerical work in office every day
- Past smoker (stopped at least 30 years ago)
- Uses alcohol on occasion
- No illicit drug use
- Has no hobbies
Family history:
- Father died at age 65 of a stroke
- Mother died at age 80 from heart failure; he does not know what the cause was
Past medical history:
- Nil of any importance
The patient came to the doctor because he was worried that he might die early like his father.
Clinical examination:
- His general phenotype: superficially he has central abdominal obesity (metabolic syndrome appearance)
- Vital signs: BP in right arm 145/92mmHg, pulse rate 79/minute, respiratory rate 16/minute, temperature 36.5°C
- Head: no arcus cornea seen, no xanthelasma, no elevated jugular venous pressure
- Heart: apex beat could not be found while lying on the back. S1 normal, S2 normal, no S3 or S4 cardiac murmurs
- Chest: clear
- Abdomen: no overt organomegaly, but liver size clinically is 14cm in the mid-clavicular line (non-tender)
- Neurological system: power and sensory system normal except for a possible reduced vibration sense in the lower limbs. Cerebellar function normal
- Fundoscopy attempted without success
Clinical problem statement:
- 60-year-old asymptomatic male patient with a slightly elevated BP, as measured in the right arm
- Inability to find the apex beat reduces the certainty that the cardiac size is normal
8. Which clinical test should be done before we consider special tests?
View Expert Comment »
Measurement of leg BP is to exclude coarctation of the aorta, in which case the BP in the leg will be lower than the arm BP. A large difference in systolic BP between the two arms may indicate severe atherosclerosis of the proximal aorta.
- Question 9 of 15
9. Question
9. With a provisional diagnosis of hypertension, how can we be certain that he has true hypertension?
View Expert Comment »
The reason that we must be certain of the diagnosis of hypertension is that the patient can be committed to life-long therapy – unnecessary therapy may be associated with harm and little or no benefit.
- Question 10 of 15
10. Question
10. Which special tests would you now do?
View Expert Comment »
It is important to determine if there is target organ damage as this increases the risk of cardiovascular disease, including stroke, myocardial infarction, heart failure, arrhythmias such as atrial fibrillation and peripheral arterial disease. The Framingham study has shown that more than 80% of all hypertensive patients have other cardiovascular risk factors that require treatment; tests for detecting these are also necessary. Smoking should be included in the risk evaluation as it increases cardiovascular risk.
- Question 11 of 15
11. Question
11. Which of the following are important lifestyle changes that may assist in BP control?
View Expert Comment »
Trial data show the DASH diet to be of benefit. Salt should be restricted to <5g per day, with increased intake of vegetables and fruit. Despite this, there is still debate on the optimal diet. Recently, it has been shown that an absence of unrefined carbohydrate is associated with an increased mortality rate. There is ongoing debate as to whether red meat consumption should be reduced. Loss of weight will contribute to easier control of BP.
- Question 12 of 15
12. Question
12. Which drug regimen would you prescribe?
View Expert Comment »
A combination of an ACE-I or ARB plus a CCB or diuretic in a single pill should be the first step for all patients with hypertension. For doctors who are hesitant about using combinations, it is prudent to start with low-dose options first and increase the dose if necessary, as these single-pill combinations have different dose options. The single-pill combination has a better control rate, with control being achieved earlier and more easily. Improved adherence and compliance are also associated with single-pill combinations. It is commonly accepted that control of BP should occur quickly; at least within three months but preferably sooner, as such early control is associated with better event outcomes. The South African guidelines suggest that monotherapy can be considered in the elderly (>80 years of age) or in frail patients in order to minimise the risk of falls.
- Question 13 of 15
13. Question
13. During therapy and follow-up, when would you consider doing 24-hour ambulatory BP monitoring?
View Expert Comment »
Masked hypertension (normal BP in the clinic with elevated BP outside the clinic) commonly presents as left ventricular hypertrophy. This condition is more dangerous than previously thought. White-coat hypertension is common and is associated with elevated BP in the clinic and normal BP outside the clinic. White-coat hypertension can sometimes be the reason for ‘pseudo-resistance’ and consequent severe symptoms of hypotension when increasing the drug dose or number of agents. The bottom line is that increasingly used 24-hour ambulatory BP monitoring gives a better perspective of what is really going on in patients with hypertension.
- Question 14 of 15
14. Question
14. What target BP should we aim for?
View Expert Comment »
BP reduction to <140/90mmHg is of benefit to all patients, including diabetes patients with hypertension. To further reduce cardiovascular events, aim for as close to 130/80mmHg as possible. The AHA/ACC guidelines recommend <130/80mmHg, but the European and South African guidelines are more pragmatic; for instance, the BP goal in diabetic patients with hypertension still causes much debate.
- Question 15 of 15
15. Question
15. What would you do if the BP on a two-drug combination remains above target?
View Expert Comment »
There are many causes of a poor response to BP treatment that should eventually be considered. This requires a lot of experience with the treatment of hypertension, and referral may be considered.
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