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Hypertension — ABIM Board MCQ

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EasyCardiologyHypertensionABIM Board

A 48-year-old patient with newly diagnosed hypertension has an office blood pressure of 164/96 mm Hg, confirmed by home BP monitoring averages. There are no compelling indications for antihypertensive therapy (no prior cardiovascular disease, chronic kidney disease, or diabetes). Laboratory results are normal. What is the recommended initial pharmacologic approach?

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Correct answer: B — Start two first-line antihypertensive agents of different classes in combination

The ACC/AHA 2017 guideline explicitly recommends initiating two first-line antihypertensive agents from different classes for stage 2 hypertension when BP exceeds the target (<130/80) by >20/10 mm Hg. This patient's BP of 164/96 is 34/16 mm Hg above target, meeting this criterion. Preferred initial combinations pair an ACE inhibitor or ARB with either a thiazide/thiazide-like diuretic or calcium channel blocker. Monotherapy (options A, C, E) is inadequate for this severity of elevation and delays BP control, increasing cardiovascular risk. Option D (lifestyle alone) is insufficient for stage 2 HTN, though nonpharmacologic measures should accompany drug therapy. Clonidine (C) is reserved as last-line therapy due to side effects and discontinuation concerns. Hydralazine (E) is not recommended as monotherapy and requires concurrent diuretic and beta-blocker use.

Reference: American College of Cardiology. 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults