Item ~?Mark <?

[> ai ~ ~ , GJIIA)
0 . ld : 3914 PreVIous Next Lab Values Notes Calculator Reverse Color Text Zoom

A 37-year-old woman comes to the physician for a follow-up blood pressure check. On
previous visits over the last 12 months. the patient's blood pressure readings ranged from
145/90-150/95 mm Hg. She measured her blood pressure during a health fair 2 weeks
ago and it was 145/90 mm Hg. The patient currently feels well, has no other medical
problems, and has never been pregnant. Her current medications include a combination
oral contraceptive for the past 5 years and occasional acetaminophen for relief of tension
headaches. She does not use tobacco, alcohol, or illicit drugs. There is no family history
of hypertension, stroke, deep venous thrombosis. or heart attack. Her current blood
pressure is 150/90 mm Hg, pulse is 80/min, and BMI is 22 kg/m2 . The physical
examination shows no abnormalities. The electrocardiogram (ECG) is normal. Her total
cholesterol level was 170 mg/dL 6 months ago. Complete blood count, urinalysis, and
basic metabolic panel are unremarkable. Which of the following is the most appropriate
next step in the management of this patient?

0 A Begin a diet and exercise regimen

B. Discontinue the oral contraceptive and switch to an alternate birth control
0
method
0 C. Initiate a low-dose thiazide diuretic
0 D. Perform aCT angiogram of the abdomen
0 E. Reassure the patient as no intervention is required at this time

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Item ~\='Mark <? [> ai ~ ~ , GJIIA)
0. ld: 3914 PreVIous Next Lab Values Notes Calculator Reverse Color Text Zoom

A 37-year-old woman comes to the physician for a follow-up blood pressure check. On
previous visits over the last 12 months, the patient's blood pressure readings ranged from
145/90-150/95 mm Hg. She measured her blood pressure during a health fair 2 weeks
ago and it was 145/90 mm Hg. The patient currently feels well, has no other medical
problems, and has never been pregnant. Her current medications include a combination
oral contraceptive for the past 5 years and occasional acetaminophen for relief of tension
headaches. She does not use tobacco, alcohol, or illicit drugs. There is no family history
of hypertension, stroke, deep venous thrombosis, or heart attack. Her current blood
pressure is 150/90 mm Hg, pulse is 80/min, and BMI is 22 kg/m•. The physical
examination shows no abnormalities. The electrocardiogram (ECG) is normal. Her total
cholesterol level was 170 mg/dl 6 months ago. Complete blood count, urinalysis, and
basic metabolic panel are unremarkable. Which of the following is the most appropriate
next step in the management of this patient?

A. Begin a diet and exercise regimen [22%)

B. Discontinue the oral contraceptive and switch to an alternate birth control
method [53%]
C. Initiate a low-dose thiazide diuretic [19%]
D. Perform aCT angiogram of the abdomen [4%)
'~' E. Reassure the patient as no intervention is required at this time [1 %]

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Explanation: User ld
This patient has mild but persistent hypertension, defined as ~2 separate occasions of an
elevated blood pressure reading over 140/90 mm Hg. When evaluating a patient with
hypertension, one should look for secondary causes (eg, medications, as seen in this
case). Oral contraceptive pills (OCPs) can cause mild elevations in blood pressure and
sometimes lead to overt hypertension (up to 5% of chronic OCP users). Women who
developed hypertension during a previous pregnancy or have a family history of
hypertension are more likely to develop hypertension from OCP use.

The mechanism is unclear but possibly due to an estrogen-mediated increase in hepatic

angiotensinogen synthesis or other effects on the renin-angiotensin
system. Discontinuing OCPs can reduce the blood pressure over a 2- to 12-month
period and can often correct the problem. However, there should be a discussion with
the patient about the risk of continuing the OCP versus the benefit of stopping the drug in

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 Explanation: User ld

This patient has mild but persistent hypertension, defined as <:2 separate occasions of an
elevated blood pressure reading over 140/90 mm Hg. When evaluating a patient with
hypertension, one should look for secondary causes (eg, medications, as seen in this
case). Oral contraceptive pills (OCPs) can cause mild elevations in blood pressure and
sometimes lead to overt hypertension (up to 5% of chronic OCP users). Women who
developed hypertension during a previous pregnancy or have a family history of
hypertension are more likely to develop hypertension from OCP use.

The mechanism is unclear but possibly due to an estrogen-mediated increase in hepatic

angiotensinogen synthesis or other effects on the renin-angiotensin
system. Discontinuing OCPs can reduce the blood pressure over a 2- to 12-month
period and can often correct the problem. However, there should be a discussion with
the patient about the risk of continuing the OCP versus the benefit of stopping the drug in
addition to considering alternate contraceptive methods.

(Choice A) If the elevated blood pressure persists after OCP discontinuation, then
essential hypertension is the most probable diagnosis and lifestyle modification can be
attempted. Diet and exercise are effective for reducing blood pressure in obese patients
(5-20 mm Hg systolic reduction per 10-kg loss) but not as effective in nonobese patients,
such as this one.

(Choice C) If discontinuing the OCP and starting a diet and exercise program fail to
correct the hypertension, the next step in medical management can be a low-dose
thiazide diuretic.

(Choice D) Although renovascular hypertension or fibromuscular dysplasia could be

possible in this patient, routine Investigation for secondary causes of hypertension with
CT angiogram of the abdomen Is not recommended. Secondary investigation Is usually
reserved for patients with difficult-to-control hypertension or a family history of the
secondary etiology.

(Choice E) Reassurance without intervention is inappropriate as hypertension is an

important cardiovascular risk factor that should be treated properly to reduce the risk of
future cardiovascular events.

Educational objective:
An oral contraceptive can cause hypertension, and discontinuing its use can correct the
problem in most patients.

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Item ~\='Mark <? [> at ~ ~ , GJIIA)
0. ld: 3914 PreVIous Next Lab Values Notes Calculator Reverse Color Text Zoom
sometimes lead to overt hypertension (up to 5% of chronic OCP users). Women who
developed hypertension during a previous pregnancy or have a family history of
hypertension are more likely to develop hypertension from OCP use.
The mechanism is unclear but possibly due to an estrogen-mediated increase in hepatic
angiotensinogen synthesis or other effects on the renin-angiotensin
system. Discontinuing OCPs can reduce the blood pressure over a 2- to 12-month
period and can often correct the problem. However, there should be a discussion with
the patient about the risk of continuing the OCP versus the benefit of stopping the drug in
addition to considering alternate contraceptive methods.
(Choice A) If the elevated blood pressure persists after OCP discontinuation, then
essential hypertension is the most probable diagnosis and lifestyle modification can be
attempted. Diet and exercise are effective for reducing blood pressure in obese patients
(5-20 mm Hg systolic reduction per 10-kg loss) but not as effective in nonobese patients,
such as this one.
(Choice C) If discontinuing the OCP and starting a diet and exercise program fail to
correct the hypertension, the next step in medical management can be a low-dose
thiazide diuretic.
(Choice 0) Although renovascular hypertension or fibromuscular dysplasia could be
possible in this patient, routine investigation for secondary causes of hypertension with
CT angiogram of the abdomen is not recommended. Secondary investigation is usually
reserved for patients with difficult-to-control hypertension or a family history of the
secondary etiology.
(Choice E) Reassurance without intervention is inappropriate as hypertension is an
important cardiovascular risk factor that should be treated properly to reduce the risk of
future cardiovascular events.

Educational objective :
An oral contraceptive can cause hypertension, and discontinuing its use can correct the
problem in most patients.

References:
1. Prospective study of oral contraceptives and hypertension among
women in the United States
2. Drug-induced hypertension: an unappreciated cause of secondary
hypertension.

Time Spent: 4 seconds Copyright © UWorld Last updated: [1 0/28/2016]

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