MCQ Quiz: Hypertension

Welcome, PharmD students, to this comprehensive MCQ quiz on Hypertension! As one of the most prevalent chronic diseases and a major risk factor for cardiovascular, cerebrovascular, and renal disease, a thorough understanding of hypertension is essential for pharmacists. This quiz will test your knowledge on its definition, classification, pathophysiology, risk factors, diagnosis, treatment goals, non-pharmacological management, and the pharmacology and therapeutics of various antihypertensive drug classes, including considerations for special populations and resistant hypertension. Let’s assess your expertise in managing high blood pressure!

1. According to current ACC/AHA guidelines, Stage 1 Hypertension in adults is defined as a blood pressure reading of:

• a) <120 mmHg systolic AND <80 mmHg diastolic
• b) 120-129 mmHg systolic AND <80 mmHg diastolic
• c) 130-139 mmHg systolic OR 80-89 mmHg diastolic
• d) ≥140 mmHg systolic OR ≥90 mmHg diastolic

Answer: c) 130-139 mmHg systolic OR 80-89 mmHg diastolic

2. “Essential” or “Primary” hypertension refers to high blood pressure for which:

• a) A specific, identifiable underlying cause can always be found.
• b) No specific identifiable cause is found in the vast majority (90-95%) of cases.
• c) It is always secondary to kidney disease.
• d) It only occurs in elderly patients.

Answer: b) No specific identifiable cause is found in the vast majority (90-95%) of cases.

3. The Renin-Angiotensin-Aldosterone System (RAAS) plays a crucial role in blood pressure regulation. Angiotensin II primarily causes:

• a) Vasodilation and decreased aldosterone secretion.
• b) Vasoconstriction and increased aldosterone secretion.
• c) Decreased sympathetic nervous system activity.
• d) Increased sodium excretion.

Answer: b) Vasoconstriction and increased aldosterone secretion.

4. Which of the following is a common non-modifiable risk factor for developing primary hypertension?

• a) High sodium intake
• b) Physical inactivity
• c) Advancing age and family history/genetics
• d) Obesity

Answer: c) Advancing age and family history/genetics

5. The DASH (Dietary Approaches to Stop Hypertension) diet is characterized by being rich in fruits, vegetables, low-fat dairy products, and reduced in:

• a) Potassium and calcium.
• b) Saturated fat, total fat, and cholesterol.
• c) Fiber and whole grains.
• d) Unsaturated fats.

Answer: b) Saturated fat, total fat, and cholesterol.

6. Thiazide diuretics (e.g., hydrochlorothiazide, chlorthalidone) lower blood pressure primarily by:

• a) Blocking beta-adrenergic receptors in the heart.
• b) Inhibiting angiotensin-converting enzyme.
• c) Initially increasing sodium and water excretion, leading to decreased plasma volume and cardiac output, and later by reducing peripheral vascular resistance.
• d) Directly relaxing vascular smooth muscle via calcium channel blockade.

Answer: c) Initially increasing sodium and water excretion, leading to decreased plasma volume and cardiac output, and later by reducing peripheral vascular resistance.

7. A common adverse effect associated with thiazide diuretics is:

• a) Hyperkalemia
• b) Hypokalemia, hyponatremia, hyperuricemia, and hyperglycemia.
• c) Dry cough
• d) Angioedema

Answer: b) Hypokalemia, hyponatremia, hyperuricemia, and hyperglycemia.

8. ACE Inhibitors (e.g., lisinopril, enalapril) exert their antihypertensive effect by:

• a) Blocking angiotensin II receptors.
• b) Inhibiting the conversion of angiotensin I to angiotensin II and reducing bradykinin degradation.
• c) Directly blocking aldosterone receptors.
• d) Inhibiting renin release.

Answer: b) Inhibiting the conversion of angiotensin I to angiotensin II and reducing bradykinin degradation.

9. A characteristic dry, persistent cough is a well-known side effect of which class of antihypertensive agents?

• a) Angiotensin II Receptor Blockers (ARBs)
• b) Calcium Channel Blockers (CCBs)
• c) ACE Inhibitors (ACEIs)
• d) Beta-Blockers

Answer: c) ACE Inhibitors (ACEIs)

10. Angiotensin II Receptor Blockers (ARBs) (e.g., losartan, valsartan) lower blood pressure by:

• a) Inhibiting renin.
• b) Selectively blocking the binding of angiotensin II to the AT1 receptor.
• c) Increasing bradykinin levels.
• d) Blocking aldosterone synthesis directly.

Answer: b) Selectively blocking the binding of angiotensin II to the AT1 receptor.

11. Dihydropyridine calcium channel blockers (e.g., amlodipine, nifedipine) primarily cause:

• a) A decrease in heart rate and contractility.
• b) Vasodilation by blocking L-type calcium channels in vascular smooth muscle.
• c) Increased renin release.
• d) Inhibition of sodium reabsorption in the kidneys.

Answer: b) Vasodilation by blocking L-type calcium channels in vascular smooth muscle.

12. A common side effect of dihydropyridine calcium channel blockers like amlodipine is:

• a) Hyperkalemia
• b) Dry cough
• c) Peripheral edema (e.g., ankle swelling)
• d) Bradycardia

Answer: c) Peripheral edema (e.g., ankle swelling)

13. Non-dihydropyridine calcium channel blockers (e.g., verapamil, diltiazem) differ from dihydropyridines in that they also have significant effects on:

• a) Only vascular smooth muscle.
• b) The sinoatrial (SA) and atrioventricular (AV) nodes of the heart, reducing heart rate and contractility.
• c) The renin-angiotensin-aldosterone system.
• d) Beta-adrenergic receptors.

Answer: b) The sinoatrial (SA) and atrioventricular (AV) nodes of the heart, reducing heart rate and contractility.

14. Beta-blockers (e.g., metoprolol, atenolol) are generally NOT recommended as first-line therapy for uncomplicated hypertension unless there is a compelling indication (e.g., post-MI, heart failure) because:

• a) They are ineffective at lowering blood pressure.
• b) They have a less favorable side effect profile for some patients and potentially less stroke prevention compared to other first-line agents in some populations.
• c) They cause severe hyperkalemia.
• d) They always increase heart rate.

Answer: b) They have a less favorable side effect profile for some patients and potentially less stroke prevention compared to other first-line agents in some populations.

15. Abrupt discontinuation of long-term beta-blocker therapy can lead to:

• a) Severe hypotension.
• b) Rebound tachycardia, hypertension, or worsening of angina due to upregulation of beta-receptors.
• c) Hypoglycemia.
• d) No significant effects.

Answer: b) Rebound tachycardia, hypertension, or worsening of angina due to upregulation of beta-receptors.

16. Alpha-1 blockers (e.g., prazosin, doxazosin) lower blood pressure by causing vasodilation. A significant adverse effect, especially with the first dose or dose escalation, is:

• a) Reflex bradycardia
• b) Orthostatic hypotension and syncope (“first-dose effect”)
• c) Hyperglycemia
• d) Dry cough

Answer: b) Orthostatic hypotension and syncope (“first-dose effect”)

17. Clonidine, a central alpha-2 adrenergic agonist, lowers blood pressure by:

• a) Increasing sympathetic outflow from the CNS.
• b) Reducing sympathetic outflow from the CNS, leading to decreased heart rate, cardiac output, and peripheral resistance.
• c) Directly blocking alpha-1 receptors in blood vessels.
• d) Inhibiting ACE.

Answer: b) Reducing sympathetic outflow from the CNS, leading to decreased heart rate, cardiac output, and peripheral resistance.

18. Which of the following is a compelling indication for using an ACE inhibitor or ARB as part of an antihypertensive regimen?

• a) Gout
• b) Diabetes with albuminuria or chronic kidney disease (CKD)
• c) Asthma
• d) Bradycardia

Answer: b) Diabetes with albuminuria or chronic kidney disease (CKD)

19. “Resistant hypertension” is typically defined as blood pressure that remains above goal despite adherence to an optimal three-drug regimen that includes a diuretic, or blood pressure controlled on _______ or more medications.

• a) two
• b) three
• c) four
• d) five

Answer: c) four

20. For patients with resistant hypertension and preserved kidney function, which class of diuretics might be added if not already optimized?

• a) Osmotic diuretics
• b) Aldosterone antagonists (e.g., spironolactone, eplerenone)
• c) Carbonic anhydrase inhibitors
• d) Loop diuretics if thiazide is already at max and GFR allows

Answer: b) Aldosterone antagonists (e.g., spironolactone, eplerenone) (Loop diuretics are used if GFR is low or volume overload).

21. A “hypertensive emergency” is characterized by severely elevated blood pressure (e.g., >180/120 mmHg) AND:

• a) No symptoms.
• b) Evidence of acute or ongoing target organ damage (e.g., encephalopathy, stroke, myocardial infarction, acute kidney injury).
• c) A gradual onset over several weeks.
• d) Normal findings on physical exam.

Answer: b) Evidence of acute or ongoing target organ damage (e.g., encephalopathy, stroke, myocardial infarction, acute kidney injury).

22. The initial goal of treatment in a hypertensive emergency is typically to:

• a) Lower blood pressure to normal (<120/80 mmHg) within 1 hour.
• b) Gradually reduce mean arterial pressure by no more than 10-20% in the first hour, then 5-15% over the next 23 hours (with exceptions like aortic dissection or eclampsia).
• c) Increase blood pressure to improve organ perfusion.
• d) Administer oral antihypertensives only.

Answer: b) Gradually reduce mean arterial pressure by no more than 10-20% in the first hour, then 5-15% over the next 23 hours (with exceptions like aortic dissection or eclampsia).

23. “White coat hypertension” is best diagnosed using:

• a) A single high blood pressure reading in the clinic.
• b) Consistently normal blood pressure readings in the clinic.
• c) Ambulatory blood pressure monitoring (ABPM) or properly performed home blood pressure monitoring (HBPM) showing normal out-of-office readings.
• d) An exercise stress test.

Answer: c) Ambulatory blood pressure monitoring (ABPM) or properly performed home blood pressure monitoring (HBPM) showing normal out-of-office readings.

24. Which antihypertensive class is generally contraindicated in pregnancy due to the risk of fetal harm (teratogenicity)?

• a) Thiazide diuretics
• b) Beta-blockers like labetalol
• c) ACE inhibitors, ARBs, and direct renin inhibitors
• d) Methyldopa

Answer: c) ACE inhibitors, ARBs, and direct renin inhibitors

25. In African American patients with hypertension and no compelling indications like heart failure or CKD, initial therapy often includes:

• a) A beta-blocker as monotherapy.
• b) A thiazide diuretic or a calcium channel blocker.
• c) An ACE inhibitor as monotherapy (may be less effective as monotherapy in this population compared to thiazides/CCBs).
• d) An alpha-blocker.

Answer: b) A thiazide diuretic or a calcium channel blocker.

26. Home blood pressure monitoring (HBPM) is a useful tool for self-care. Patients should be counseled to:

• a) Take multiple readings immediately after exercise.
• b) Use a validated device, take readings at consistent times (e.g., morning and evening), and record them accurately.
• c) Adjust their medication doses based on single high readings.
• d) Only check their blood pressure when they feel symptoms.

Answer: b) Use a validated device, take readings at consistent times (e.g., morning and evening), and record them accurately.

27. Untreated or poorly controlled hypertension can lead to target organ damage in the kidneys, manifesting as:

• a) Improved glomerular filtration.
• b) Nephrosclerosis, proteinuria, and progression to chronic kidney disease or end-stage renal disease.
• c) Kidney stones.
• d) Acute pyelonephritis.

Answer: b) Nephrosclerosis, proteinuria, and progression to chronic kidney disease or end-stage renal disease.

28. From a medicinal chemistry perspective, ACE inhibitors typically contain a functional group (e.g., carboxyl, phosphinyl) that chelates the _______ ion in the active site of angiotensin-converting enzyme.

• a) Calcium (Ca²⁺)
• b) Magnesium (Mg²⁺)
• c) Zinc (Zn²⁺)
• d) Iron (Fe²⁺)

Answer: c) Zinc (Zn²⁺)

29. Which of the following lifestyle modifications has the potential for the largest average reduction in systolic blood pressure in hypertensive individuals?

• a) Reducing dietary sodium.
• b) Adopting the DASH diet.
• c) Weight reduction in overweight/obese individuals.
• d) Moderation of alcohol consumption.

Answer: c) Weight reduction in overweight/obese individuals. (Though DASH diet is also very effective).

30. The mechanism of action of aldosterone antagonists (e.g., spironolactone) in lowering blood pressure involves:

• a) Blocking beta-1 receptors in the heart.
• b) Inhibiting sodium and water reabsorption (and promoting potassium retention) in the distal nephron by blocking aldosterone’s effects.
• c) Direct vasodilation of arterioles.
• d) Inhibition of renin release.

Answer: b) Inhibiting sodium and water reabsorption (and promoting potassium retention) in the distal nephron by blocking aldosterone’s effects.

31. A common side effect related to the non-selectivity of spironolactone for the aldosterone receptor is:

• a) Hypokalemia
• b) Gynecomastia in males and menstrual irregularities in females (due to antiandrogenic/progestogenic effects).
• c) Dry cough
• d) Peripheral edema

Answer: b) Gynecomastia in males and menstrual irregularities in females (due to antiandrogenic/progestogenic effects). (Eplerenone is more selective).

32. Direct vasodilators like hydralazine and minoxidil are not typically used as monotherapy for hypertension because they can cause:

• a) Severe bradycardia.
• b) Reflex tachycardia, fluid retention, and (for minoxidil) hirsutism; often require co-administration with a beta-blocker and diuretic.
• c) Hypokalemia.
• d) Bronchoconstriction.

Answer: b) Reflex tachycardia, fluid retention, and (for minoxidil) hirsutism; often require co-administration with a beta-blocker and diuretic.

33. “Masked hypertension” is defined as:

• a) Normal office blood pressure but elevated blood pressure on out-of-office (e.g., home or ambulatory) monitoring.
• b) Elevated office blood pressure but normal out-of-office readings.
• c) Blood pressure that is only elevated at night.
• d) Hypertension that does not respond to any medications.

Answer: a) Normal office blood pressure but elevated blood pressure on out-of-office (e.g., home or ambulatory) monitoring.

34. Which of the following is an important counseling point for patients starting an ACE inhibitor or ARB regarding renal function?

• a) These drugs always improve GFR immediately.
• b) A small, transient increase in serum creatinine may occur upon initiation but generally stabilizes; significant increases or hyperkalemia warrant evaluation.
• c) They cause severe nephrotoxicity in all patients.
• d) They should be discontinued if the patient has diabetes.

Answer: b) A small, transient increase in serum creatinine may occur upon initiation but generally stabilizes; significant increases or hyperkalemia warrant evaluation.

35. Combination therapy with an ACE inhibitor and an ARB is generally:

• a) Recommended as first-line for all hypertensive patients.
• b) Not recommended due to increased risk of adverse effects (e.g., hyperkalemia, renal dysfunction) without significant additional benefit in most populations.
• c) The most effective combination for lowering blood pressure.
• d) Only used in pregnant women.

Answer: b) Not recommended due to increased risk of adverse effects (e.g., hyperkalemia, renal dysfunction) without significant additional benefit in most populations.

36. For patients with hypertension and benign prostatic hyperplasia (BPH), which class of antihypertensives can provide benefit for both conditions?

• a) Beta-blockers
• b) Alpha-1 blockers (e.g., doxazosin, terazosin)
• c) Thiazide diuretics
• d) ACE inhibitors

Answer: b) Alpha-1 blockers (e.g., doxazosin, terazosin)

37. Which medication is a direct renin inhibitor that blocks the conversion of angiotensinogen to angiotensin I?

• a) Lisinopril
• b) Losartan
• c) Aliskiren
• d) Spironolactone

Answer: c) Aliskiren

38. The “J-curve” phenomenon in hypertension treatment suggests that:

• a) Higher blood pressure is always better.
• b) Lowering blood pressure too aggressively or below a certain point in some high-risk patients (e.g., those with CAD) might paradoxically increase cardiovascular risk.
• c) All patients should have a diastolic BP below 60 mmHg.
• d) Blood pressure naturally follows a J-shaped pattern throughout the day.

Answer: b) Lowering blood pressure too aggressively or below a certain point in some high-risk patients (e.g., those with CAD) might paradoxically increase cardiovascular risk.

39. The medicinal chemistry of thiazide diuretics involves a benzothiadiazine dioxide core. Their diuretic effect is related to inhibition of the _______ in the distal convoluted tubule.

• a) Na⁺/K⁺/2Cl⁻ cotransporter
• b) Na⁺/Cl⁻ cotransporter (NCC)
• c) Na⁺/H⁺ exchanger
• d) Aldosterone receptor

Answer: b) Na⁺/Cl⁻ cotransporter (NCC)

40. The presence of a sulfhydryl (-SH) group in the structure of captopril (an ACEI) was initially thought to be important for zinc binding but also contributed to:

• a) A longer half-life.
• b) A higher incidence of certain side effects like rash and taste disturbances compared to some other ACEIs.
• c) Resistance to degradation by ACE.
• d) Its inability to cross the blood-brain barrier.

Answer: b) A higher incidence of certain side effects like rash and taste disturbances compared to some other ACEIs.

41. In the event of a hypertensive urgency (severely elevated BP without acute target organ damage), the primary goal is to:

• a) Lower BP to normal within minutes using IV medications.
• b) Gradually lower BP over 24-48 hours, often with oral medications, to avoid rapid drops that could cause hypoperfusion.
• c) Admit the patient to the ICU for aggressive IV therapy.
• d) Ignore the reading as there is no target organ damage.

Answer: b) Gradually lower BP over 24-48 hours, often with oral medications, to avoid rapid drops that could cause hypoperfusion.

42. Which of the following is a key factor in ensuring accurate office blood pressure measurement?

• a) Using a cuff that is too small for the patient’s arm.
• b) Having the patient sit in a chair with feet flat on the floor, back supported, and arm supported at heart level, after a rest period.
• c) Taking the measurement immediately after the patient rushes into the clinic.
• d) Allowing the patient to talk during the measurement.

Answer: b) Having the patient sit in a chair with feet flat on the floor, back supported, and arm supported at heart level, after a rest period.

43. Secondary causes of hypertension, while less common than primary hypertension, can include:

• a) Regular exercise.
• b) Renal artery stenosis, primary aldosteronism, obstructive sleep apnea, and certain medications.
• c) A low-sodium diet.
• d) Young age.

Answer: b) Renal artery stenosis, primary aldosteronism, obstructive sleep apnea, and certain medications.

44. For pregnant women with chronic hypertension requiring treatment, which antihypertensive is often considered a first-line option due to its safety profile?

• a) Lisinopril
• b) Losartan
• c) Methyldopa or Labetalol
• d) Aliskiren

Answer: c) Methyldopa or Labetalol

45. A pharmacist’s role in managing hypertension includes patient education on adherence. Non-adherence to antihypertensive medication can lead to:

• a) Better blood pressure control.
• b) Uncontrolled hypertension and increased risk of cardiovascular complications.
• c) Reduced side effects.
• d) Lower healthcare costs.

Answer: b) Uncontrolled hypertension and increased risk of cardiovascular complications.

46. Which of the following statements regarding beta-blockers is true?

• a) All beta-blockers are cardioselective.
• b) Non-selective beta-blockers can cause bronchoconstriction and should be used with caution in patients with asthma or COPD.
• c) Beta-blockers always cause weight loss.
• d) They are the preferred first-line agents for hypertension in all patient populations.

Answer: b) Non-selective beta-blockers can cause bronchoconstriction and should be used with caution in patients with asthma or COPD.

47. The “STEP” trials (e.g., SPRINT, ACCORD) were seminal clinical trials in hypertension that generally supported:

• a) More lenient blood pressure targets (e.g., <150/90 mmHg).
• b) More intensive blood pressure targets (e.g., systolic BP <120 mmHg or <130 mmHg) in certain high-risk populations for improved cardiovascular outcomes, while also noting potential for increased adverse events.
• c) The use of beta-blockers as first-line therapy for everyone.
• d) That lifestyle modifications are ineffective.

Answer: b) More intensive blood pressure targets (e.g., systolic BP <120 mmHg or <130 mmHg) in certain high-risk populations for improved cardiovascular outcomes, while also noting potential for increased adverse events.

48. From a medicinal chemistry standpoint, many ARBs (e.g., losartan, valsartan) are designed as _______ that mimic the structure of angiotensin II to block its receptor.

• a) peptide molecules
• b) non-peptide molecules (often containing a biphenyltetrazole or similar motif)
• c) carbohydrate derivatives
• d) steroid analogs

Answer: b) non-peptide molecules (often containing a biphenyltetrazole or similar motif)

49. Health literacy and social determinants of health can significantly impact hypertension management by affecting:

• a) The patient’s understanding of their condition and treatment plan.
• b) Access to medications and healthy food choices.
• c) Adherence to lifestyle modifications and medication regimens.
• d) All of the above.

Answer: d) All of the above.

50. A key counseling point for a patient starting a thiazide diuretic for hypertension is the importance of monitoring for symptoms of:

• a) Hyperkalemia and dry cough.
• b) Hypokalemia (e.g., muscle weakness, cramps) and ensuring adequate potassium intake if necessary.
• c) Severe bradycardia.
• d) Angioedema.

Answer: b) Hypokalemia (e.g., muscle weakness, cramps) and ensuring adequate potassium intake if necessary.