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MAKING BEST PRACTICE, EVERYDAY PRACTICE

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Case study – Treating a hypertensive patient experiencing episodes of elevated heart rate

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Case study – Treating a hypertensive patient experiencing episodes of elevated heart rate
Case study – Treating a hypertensive patient experiencing episodes of elevated heart rate

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Question 1 of 10
1. Question
1. The latest 2024 European Society of Cardiology (ESC) hypertension guidelines1 state that risk stratification in all hypertensive patients is essential to determine urgency and intensity of pharmacotherapy. Which of the statements below best reflects the ESC recommendations for risk stratification?
A. Confirm uncontrolled hypertension with home BP monitoring (HBPM) or 24-hour ambulatory BP monitoring (ABPM) and apply a standard risk prediction model such as the systematic coronary risk evaluation (SCORE) or atherosclerotic cardiovascular disease (ASCVD) risk estimator to determine the absolute BP threshold and urgency for BP control (3 months)
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B. Screen for target organ damage before treatment decisions are made
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C. Control BP irrespective of risk to <140/90mmHg as soon as possible
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Question 2 of 10
2. Question
2. What is the clinical importance of an elevated heart rate in hypertension?
A. Uncontrolled hypertension is the main cause of an elevated heart rate and should be managed primarily with standard pharmacotherapy
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B. Elevated heart rate is associated with sympathetic overdrive, has additional prognostic information beyond BP, and β1-selective β-blockers are preferred (if tolerated) as initial therapy
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C. Elevated heart rate is most commonly associated with anxiety and poor conditioning, and should be the primary focus of therapy
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Question 3 of 10
3. Question
3. How should pharmacotherapy be initiated when the patient’s hypertension has been confirmed using either HBPM or 24-hour ABPM?
A. Monotherapy, with gradual (monthly) escalation using additional drugs from different classes until BP is controlled (<140/90mmHg)
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B. Initiate a dual therapy treatment using each drug as a discrete/free drug
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C. Initiate dual therapy treatment using a single pill combination (SPC) of two drugs
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D. None of the above
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Question 4 of 10
4. Question
4. Further work-up indicates chronic kidney disease, evidenced by a low estimated glomerular filtration rate (eGFR) of 58ml/min/1.73m2 and with microalbuminuria. Resting electrocardiogram (ECG) is currently in sinus rhythm but consistent with left ventricular hypertrophy (LVH) according to established criteria. How do these findings influence clinical management decisions?
A. The patient is at very high risk for CAD and should be referred for a coronary computed tomography (CT) scan
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B. A SPC treatment (any) is preferred to achieve BP goals sooner and more effectively, and to improve long-term cardiovascular outcomes
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C. A SPC is preferred but the choice of the combination should prioritise drugs with established benefit in patients with target organ remodelling/damage or established cardiovascular disease
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D. A and B only
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Question 5 of 10
5. Question
5. In light of these echocardiogram findings, best current evidence suggests that the ideal treatment for this patient is:
A. Any combination therapy focusing mainly on controlling hypertension
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B. RAAS blockers are essential initial therapy, either an ACEi or angiotensin receptor blocker (ARB)
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C. Quadruple therapy using a RAAS blocker, β-blocker, sodium-glucose co-transporter-2 inhibitor (SGLT-2i) and a mineralocorticoid receptor antagonist (MRA), where preference is given to use of ACEis and, if not tolerated, to use an ARB
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Question 6 of 10
6. Question
6. The patient has obesity with OSA but is motivated to follow a structured diet and exercise programme. Does her current pharmacotherapy limit her ability to achieve metabolic targets and weight loss?
A. No, just focus on standard dietary principles and a regular supervised exercise programme
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B. Yes, atenolol and HCTZ especially are not ideal because of known dysmetabolic effects
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Question 7 of 10
7. Question
7. The 2023 ESH guidelines2 recommendations for initiating β-blocker therapy in patients with hypertension are:
A. Only when there is established CAD, HF and tachyarrhythmias
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B. As first-line therapy for patients with compelling indications (CAD, HF) and numerous other indications for primary/secondary cardiovascular risk
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C. As fourth-line therapy in resistant hypertension
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Question 8 of 10
8. Question
8. When considering the new principles of hypertension management which include treatment compliance, 24-hour BP control, medication side effects, cardiovascular target organ protection and the prevention of cardiovascular death, why should bisoprolol/perindopril SPC be preferred over atenolol and HCTZ?
A. The bisoprolol/perindopril SPC has superior 24-hour BP control
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B. The bisoprolol/perindopril SPC has neutral dysmetabolic effects
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C. The bisoprolol/perindopril SPC has been shown to have superior cardiovascular outcomes for all major adverse cardiac events
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D. All of the above
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Question 9 of 10
9. Question
9. Which of the following medications should be introduced as part of quadruple therapy in patients with complicated hypertensive renal disease and HF?
A. Spironolactone
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B. SGLT-2i
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C. Both of the above
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Question 10 of 10
10. Question
10. Which of the following statements are INCORRECT? In this patient, aspirin should:
A. Be continued because of the stroke risk
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B. Be substituted with a direct oral anticoagulant (DOAC)
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C. Be substituted with a DOAC because this patient has a CHADVASc score ≥4
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