Hypertension and Hypertensive Emergencies MCQs

Medicine · 67 free questions with answers & explanations.

  1. A 45-year-old man presents to the ER with BP 225/130 mmHg, severe headache, blurred vision, and confusion. Fundoscopy shows papilledema and flame-shaped hemorrhages. Serum creatinine is 2.8 mg/dL (was 1.0 mg/dL 2 months ago). Urine shows RBC casts and +++ proteinuria. What is the correct approach to lowering blood pressure in this hypertensive emergency?
  2. A 45-year-old woman presents with BP 220/130 mmHg, severe headache, and confusion. Fundoscopy reveals bilateral papilloedema with flame-shaped hemorrhages and exudates (Grade IV). Serum creatinine is 2.6 mg/dL (baseline 0.9 mg/dL) with red cell casts in urine. What is the recommended target for BP reduction in the first hour?
  3. A 48-year-old man presents to the emergency department with BP 230/140 mmHg, severe headache, papilloedema, and serum creatinine rising from 1.0 to 2.4 mg/dL in 24 hours. Urine microscopy shows RBC casts. What is this condition and the target for BP reduction in the first hour?
  4. A 55-year-old man presents with BP 210/125 mmHg, severe headache, blurred vision, and papilloedema. ECG shows LVH. Serum creatinine has risen from 1.0 to 2.8 mg/dL over 48 hours. CT head is normal. This represents malignant hypertension. What is the most appropriate initial blood pressure management target?
  5. A 55-year-old woman presents with severe headache, BP 220/130 mmHg, papilloedema, and serum creatinine rising from 1.0 to 2.8 mg/dL over 48 hours. Peripheral smear shows schistocytes. Which is the MOST appropriate initial antihypertensive choice for this hypertensive emergency with microangiopathic haemolytic anaemia (MAHA)?
  6. Hypertensive emergency with acute aortic dissection requires BP reduction to systolic <120 mmHg within 20 minutes. The preferred initial drug combination is a beta-blocker plus a vasodilator. Why must a vasodilator NOT be used alone without beta-blockade first in aortic dissection?
  7. The SPRINT trial demonstrated that intensive SBP target <120 mmHg reduced cardiovascular events and mortality compared to standard <140 mmHg. However, this trial EXCLUDED patients with which conditions (making generalisation of its results limited)?
  8. A 55-year-old man presents to the emergency department with a blood pressure of 225/140 mmHg, altered sensorium, papilloedema, and serum creatinine rising from 1.1 to 3.8 mg/dL over 72 hours. Peripheral smear shows schistocytes. The CORRECT initial blood pressure management strategy is:
  9. A 38-year-old woman with hypertension refractory to three antihypertensive drugs (including a diuretic) is found to have a right renal artery stenosis >70% on CT angiography. Plasma renin activity is markedly elevated. Which investigation should be performed BEFORE considering renal artery revascularisation?
  10. A 56-year-old man presents to the emergency department with BP 218/128 mmHg, altered consciousness (GCS 12), and fundoscopy shows bilateral flame hemorrhages, cotton wool spots, and bilateral disc edema (papilledema). Serum creatinine is 3.8 mg/dL (baseline 1.1 mg/dL) with microangiopathic hemolytic anemia. This represents hypertensive emergency. The target and rate of BP reduction in the first hour is:
  11. A 65-year-old man presents to the ER with BP 220/130 mmHg and sudden onset severe tearing chest pain radiating to the back. CT angiography shows a type A aortic dissection (DeBakey Type I, involving ascending aorta). What is the MOST critical immediate pharmacological intervention before surgery?
  12. A 42-year-old woman with resistant hypertension (BP 175/110 mmHg on 3 antihypertensives including a diuretic) undergoes workup. Plasma aldosterone-to-renin ratio is 42 (elevated). CT adrenals are normal (bilateral). Saline infusion test fails to suppress aldosterone. Adrenal vein sampling confirms bilateral hypersecretion. What is the treatment of choice for bilateral primary hyperaldosteronism?
  13. A 52-year-old man is brought in with BP 230/140 mmHg, new grade IV hypertensive retinopathy, and serum creatinine rising from 110 to 185 µmol/L over 12 hours. Urinalysis shows proteinuria 2+, haematuria 2+. The MOST appropriate management strategy for BP control in this hypertensive emergency is:
  14. A 55-year-old woman presents with BP 220/130 mmHg, severe headache, papilledema, and urinalysis showing RBC casts and protein 3+. Serum creatinine has risen from 1.0 to 2.8 mg/dL over 3 days. This is hypertensive emergency with thrombotic microangiopathy on kidney biopsy. What is the target BP reduction in the first hour?
  15. A 58-year-old man presents with BP 215/138 mmHg, severe headache, and papilloedema. Creatinine is 3.2 mg/dL (baseline 1.0). There is no aortic dissection. This constitutes hypertensive emergency with hypertensive nephrosclerosis. The recommended target BP reduction in the first hour is:
  16. In hypertensive emergency with acute hypertensive encephalopathy, the target blood pressure reduction in the first hour according to current AHA/ACC guidelines is:
  17. In patients with resistant hypertension (uncontrolled on 3 drugs including a diuretic at optimal doses), which of the following options is MOST supported by current evidence as add-on fourth-line antihypertensive therapy?
  18. A 52-year-old man presents with a blood pressure of 228/136 mmHg, severe headache, and fundoscopy reveals papilloedema with flame-shaped haemorrhages (hypertensive encephalopathy). His serum creatinine has risen from a baseline of 0.9 to 2.4 mg/dL acutely. What is the target blood pressure reduction in the first hour of treatment?
  19. A 45-year-old woman has resistant hypertension — BP remains 162/98 mmHg despite three maximally tolerated antihypertensives including a thiazide diuretic. Aldosterone-renin ratio (ARR) is markedly elevated. Adrenal CT shows a left-sided 1.4 cm adenoma. Adrenal vein sampling (AVS) confirms left-sided aldosterone excess. What is the definitive treatment?
  20. A 52-year-old man presents with a hypertensive emergency: BP 228/134 mmHg, GCS 13, papilloedema and retinal haemorrhages (hypertensive encephalopathy), creatinine rising from 1.2 to 2.8 mg/dL over 24 hours, and microangiopathic haemolytic anaemia on blood film. This represents hypertensive crisis with TMA (thrombotic microangiopathy). The most critical target for BP reduction in the first hour is:
  21. A 55-year-old hypertensive woman presents with BP 210/130 mmHg, sudden severe headache, confusion, papilloedema, and serum creatinine 2.8 mg/dL rising over 24 hours. She has Grade IV hypertensive retinopathy and microangiopathic haemolytic anaemia (MAHA) on peripheral smear. Which is the most appropriate initial management?
  22. A 55-year-old hypertensive patient presents with BP 220/130 mmHg, normal mental status, no papilledema, no AKI, and no chest pain. This represents:
  23. A 45-year-old man with hypertension and suspected renovascular disease (renal artery stenosis) is being evaluated. Which investigation is MOST appropriate as an initial non-invasive screen?
  24. A 55-year-old woman presents to the ED with BP 220/130 mmHg, GCS 14/15, and new onset visual blurring. Fundoscopy shows flame-shaped hemorrhages, AV nipping, and bilateral papilledema. Creatinine is 2.1 mg/dL (baseline 0.9 six months ago). This presentation represents:
  25. A 58-year-old man presents with a blood pressure of 218/132 mmHg, severe headache, and blurred vision. Fundoscopy shows bilateral flame-shaped haemorrhages, cotton wool spots, and papilloedema. Serum creatinine is 2.4 mg/dL (baseline 1.0 mg/dL), urinalysis shows 2+ protein and RBC casts. ECG shows LVH. This is a hypertensive emergency. What is the target BP reduction in the FIRST HOUR of treatment, and which IV agent is PREFERRED when hypertensive emergency is associated with AKI and microangiopathic haemolytic anaemia?
  26. A 55-year-old hypertensive man presents with BP 210/128 mmHg, severe headache, and papilledema. Serum creatinine is 2.8 mg/dL (baseline 1.1 mg/dL). ECG shows LV strain pattern. This constitutes a hypertensive emergency. The most appropriate immediate management is:
  27. A 48-year-old pregnant woman (32 weeks gestation) presents with BP 168/108 mmHg, severe headache, and 24-hour proteinuria of 3.6 g. She has hyperreflexia and brisk ankle clonus. The antihypertensive of choice to prevent eclamptic seizures is:
  28. A 50-year-old woman presents with BP 220/138 mmHg, severe headache, papilloedema, serum creatinine rising from 0.9 to 2.4 mg/dL over 24 hours, and microangiopathic haemolytic anaemia on blood film. This is hypertensive emergency with acute hypertensive nephropathy. What is the recommended target BP reduction in the first hour, and why?
  29. A 55-year-old man with resistant hypertension (BP 158/96 mmHg on maximum doses of ACE inhibitor, amlodipine, and chlorthalidone) undergoes further workup. Serum aldosterone is 28 ng/dL and plasma renin activity is 0.4 ng/mL/hour, giving an aldosterone-renin ratio of 70 (> 30 is significant). CT adrenals show bilateral adrenal hyperplasia. What is the most appropriate management?
  30. A 52-year-old woman presents to the ER with BP 220/130 mmHg, severe headache, and fundoscopy showing flame haemorrhages, cotton wool spots, and papilloedema. Urinalysis shows 2+ proteinuria and red cell casts. Creatinine has risen from 0.9 to 2.1 mg/dL in the last 24 hours. This is best characterised as:
  31. A 35-year-old pregnant woman at 36 weeks has BP 158/104 mmHg on two occasions 4 hours apart. She has no proteinuria but new-onset thrombocytopenia (platelets 88,000/µL) and elevated liver enzymes (ALT 180 U/L). What is the MOST likely diagnosis?
  32. A 52-year-old man presents with BP 220/130 mmHg, severe headache, visual disturbance, and papilloedema on fundoscopy. Urinalysis shows 3+ protein and RBC casts. Creatinine is 3.1 mg/dL (baseline unknown). ECG shows LVH. This constitutes a hypertensive emergency. The TARGET for BP reduction in the FIRST HOUR of treatment is:
  33. The SPRINT trial compared intensive (systolic BP target < 120 mmHg) versus standard (systolic BP target < 140 mmHg) BP control in non-diabetic adults at high cardiovascular risk. Its primary finding and the primary concern with intensive therapy were:
  34. The SPRINT trial demonstrated cardiovascular benefit from targeting systolic BP <120 mmHg versus <140 mmHg in non-diabetic hypertensives with high CV risk. Which group was explicitly EXCLUDED from the SPRINT trial, limiting applicability of its results?
  35. A 55-year-old man presents with BP 235/140 mmHg, chest pain, and an ECG showing new ST changes. Troponin is mildly elevated. He has acute hypertensive emergency with presumed type 2 myocardial infarction. Which antihypertensive is the MOST appropriate intravenous agent, and what is the BP reduction target in the first hour?
  36. A 55-year-old man with blood pressure 200/120 mmHg develops acute ischemic stroke. Neuroimaging confirms an anterior circulation ischemic infarct. He is not a candidate for thrombolysis. According to AHA/ASA guidelines on BP management in acute ischemic stroke without thrombolysis, what is the recommended blood pressure target in the first 24 hours?
  37. A 40-year-old woman presents with BP 240/140 mmHg, severe headache, papilloedema, and serum creatinine 3.2 mg/dL (baseline 0.9 mg/dL). This is hypertensive emergency with hypertensive encephalopathy. The target BP reduction in the first HOUR is:
  38. A 55-year-old man presents with BP 230/130 mmHg, severe headache, blurred vision, and confusion. Fundoscopy shows bilateral papilledema and flame-shaped hemorrhages. Creatinine is 2.8 mg/dL (baseline 1.0). Which statement about initial BP management is MOST appropriate?
  39. A 40-year-old woman with hypertension has unprovoked hypokalemia (K+ 3.0 mEq/L), metabolic alkalosis, and elevated 24-hour urine aldosterone despite suppressed plasma renin activity (PRA <0.1 ng/mL/hr). She is not on diuretics. CT adrenal glands show a right adrenal adenoma. What is the most important confirmatory test before deciding between surgery and medical therapy?
  40. A 52-year-old woman presents with BP 220/130 mmHg, severe headache, blurring of vision and confusion. Fundoscopy shows flame-shaped haemorrhages, cotton-wool spots and papilloedema. Creatinine has risen from baseline of 1.0 to 2.8 mg/dL over 2 weeks. Blood film shows schistocytes. This represents:
  41. A 35-year-old woman with resistant hypertension (on 3 agents including a diuretic) has hypokalemia 2.9 mEq/L and an incidental 2.2 cm right adrenal nodule on CT. Plasma aldosterone-to-renin ratio (ARR) is markedly elevated at 45 (normal <30). This is consistent with primary aldosteronism. Which test is required before planning surgical versus medical management?
  42. A 55-year-old man presents with BP 220/130 mmHg, headache, and papilledema on fundoscopy, but is otherwise neurologically intact. Serum creatinine is 1.8 mg/dL (baseline 1.0). This is classified as hypertensive emergency. What is the target BP reduction in the first hour?
  43. A 42-year-old woman has hypertension requiring 3 antihypertensive drugs, episodic flushing, and hypokalemia (serum K 3.0 mEq/L) without diuretic use. Aldosterone-to-renin ratio (ARR) is 42 (ng/dL)/(ng/mL/hr). CT adrenal shows a 1.2 cm left adrenal nodule. What is the DEFINITIVE diagnostic step before deciding between adrenalectomy and medical therapy?
  44. A 55-year-old man presents to the emergency department with severe headache, BP 230/140 mmHg, and papilloedema on fundoscopy. Creatinine has risen from baseline 100 to 280 µmol/L, and urinalysis shows 2+ proteinuria and red cell casts. He has no chest pain and ECG is unchanged. This represents:
  45. A 52-year-old woman presents with BP 226/132 mmHg, headache, blurred vision, and confusion. Fundoscopy shows flame haemorrhages, cotton wool spots, and bilateral papilloedema. Creatinine has risen from 0.9 to 2.1 mg/dL over 3 days. Urinalysis shows haematuria and proteinuria. What is the MOST appropriate initial blood pressure target?
  46. A 45-year-old man presents to the emergency department with tearing chest pain radiating to the back, BP 200/110 mmHg in the right arm and 165/95 mmHg in the left arm. CT aortogram confirms a Type A aortic dissection. What is the IMMEDIATE pharmacological priority?
  47. A 38-year-old pregnant woman at 34 weeks gestation is found to have BP 158/102 mmHg on two readings 4 hours apart. She has no proteinuria, no oedema, and no symptoms. Maternal platelet count and liver enzymes are normal. Fetal CTG is reactive. What is the MOST appropriate antihypertensive agent?
  48. A 45-year-old woman presents to the emergency department with BP 210/130 mmHg, severe headache, visual blurring, and papilloedema with flame-shaped haemorrhages. Serum creatinine is 2.8 mg/dL (baseline 0.9). What is the target BP reduction in the first hour and the preferred agent?
  49. A 52-year-old man on hydrochlorothiazide and amlodipine has BP 158/96 mmHg. He has an eGFR of 62 mL/min, urine protein:creatinine ratio of 0.45 g/g, and no diabetes. What antihypertensive class should be added as the third agent to maximally protect his kidneys?
  50. A 52-year-old man presents with BP 228/134 mmHg, confusion, retinal haemorrhages and papilloedema, serum creatinine 2.8 mg/dL (baseline 1.0), and proteinuria. Which is the CORRECT approach to BP reduction in this hypertensive emergency?
  51. A 55-year-old man presents to the emergency department with BP 220/130 mmHg, severe headache, blurred vision, and papilloedema on fundoscopy. Creatinine has risen from baseline 1.1 to 3.4 mg/dL acutely. He is alert without focal neurological deficit. This is classified as:
  52. A 42-year-old woman with resistant hypertension (BP 158/96 mmHg on maximum doses of amlodipine, ramipril, and hydrochlorothiazide) has serum potassium of 3.1 mEq/L and a CT abdomen showing a 1.8 cm right adrenal nodule. Plasma aldosterone concentration (PAC) is 42 ng/dL and plasma renin activity (PRA) is 0.2 ng/mL/hr. The aldosterone-to-renin ratio (ARR) is:
  53. A 55-year-old woman presents with BP 220/130 mmHg, papilloedema, serum creatinine 3.2 mg/dL (baseline 1.0), and 3+ proteinuria. Peripheral blood smear shows fragmented red cells (schistocytes). This represents which hypertensive emergency, and what is the target BP reduction in the first hour?
  54. The SPRINT trial (2015) randomised hypertensive patients without diabetes to intensive (SBP target < 120 mmHg) versus standard (SBP < 140 mmHg) blood pressure control. The primary finding was:
  55. A 55-year-old man presents with blood pressure 220/130 mmHg, serum creatinine rising from 1.2 to 3.1 mg/dL over 48 hours, urinalysis showing haematuria and RBC casts, fundoscopic haemorrhages and papilloedema, and Hb 8.5 g/dL with fragmented red cells. What is the diagnosis and most critical initial treatment?
  56. A 40-year-old woman with treatment-resistant hypertension (BP 162/98 mmHg on amlodipine 10 mg + lisinopril 40 mg + chlorthalidone 25 mg) is evaluated. Aldosterone-to-renin ratio is 42 (ng/dL)/(ng/mL/h), with aldosterone 22 ng/dL and suppressed PRA <0.5 ng/mL/h. What is the next confirmatory test?
  57. In the SPRINT trial (NEJM 2015), intensive blood pressure control to a systolic target <120 mmHg compared to standard target <140 mmHg in high-cardiovascular-risk (non-diabetic) adults showed which primary outcome?
  58. A 35-year-old woman has hypertension refractory to three drugs. She is found to have fibromuscular dysplasia of the renal artery on CT angiography (multifocal 'string-of-beads' pattern). What is the most appropriate revascularization strategy?
  59. A 55-year-old hypertensive woman presents with BP 240/140 mmHg, headache, blurred vision, papilloedema, and creatinine rising from 1.0 to 2.8 mg/dL over 48 hours. This represents:
  60. A 62-year-old man with resistant hypertension (BP 165/98 mmHg on 3 antihypertensives including a diuretic at maximal doses) is found to have a serum potassium of 2.9 mEq/L. Plasma aldosterone-to-renin ratio is markedly elevated. CT adrenals show a right adrenal adenoma 1.8 cm. What is the definitive management?
  61. The SPRINT trial changed hypertension management targets. What was the key finding and what is the current controversy regarding intensive BP targets?
  62. A 38-year-old pregnant woman at 34 weeks presents with BP 158/104 mmHg, severe headache, and 2+ proteinuria. There is no seizure. Which antihypertensive is most appropriate for acute management in this setting?
  63. A 58-year-old man with long-standing uncontrolled hypertension presents with BP 230/130 mmHg, severe headache, altered consciousness, bilateral papilledema, and serum creatinine 3.2 mg/dL (baseline 1.1 mg/dL). Urinalysis shows proteinuria and microscopic hematuria. This represents:
  64. A 32-year-old woman has resistant hypertension despite triple-drug therapy (amlodipine 10 mg, telmisartan 80 mg, indapamide 2.5 mg). She has paroxysmal headaches, sweating, and palpitations. BP 185/110 mmHg. 24-hour urine shows elevated metanephrines and normetanephrines. CT adrenal is normal, but MIBG scan shows bilateral adrenal uptake. The genetic mutation most commonly associated with bilateral pheochromocytoma is:
  65. A 70-year-old diabetic woman with CKD (eGFR 35 mL/min) and an uncomplicated history is found to have BP 155/90 mmHg on repeat measurements. Per ACC/AHA 2017 hypertension guidelines, the recommended BP target for this patient is:
  66. A 55-year-old man presents with BP 220/130 mmHg, acute confusion, bilateral papilloedema, and creatinine rising from baseline 1.0 to 3.4 mg/dL over 48 hours. There is no aortic dissection on imaging. What is the target BP reduction in the first hour?
  67. A 48-year-old woman with resistant hypertension (BP 162/104 mmHg on three antihypertensives including a diuretic at optimal doses) has confirmed medication adherence. Aldosterone-renin ratio is elevated at 42 (ng/dL)/(ng/mL/hr). CT adrenals show bilateral normal adrenals. What is the next diagnostic step?
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