A 79-year-old man who has not had routine medical care presents for a physical examination and is found to have blood pressure of 165/80. He has no other risk factors for heart disease. He is not obese and walks 1 mile a day. Physical examination shows no retinopathy, normal cardiac examination including point of maximal impulse, and normal pulses. There is no abdominal bruit, and neurological examination is normal. ECG, electrolytes, blood glucose, and urinalysis are normal. A low-sodium DASH diet is recommended. The patient returns 6 weeks later, having strictly followed the diet; blood pressure is 168/76.
Which of the following is the best next step in management?
A. Obtain renal artery DopplerThere is now general agreement that systolic hypertension in the elderly should be treated and that low-dose thiazide diuretic is the initial regimen of choice. Treatment reduces the risk of stroke and cardiovascular events, and side effects appear to be minimal. Beta-blockers or ACE inhibitors are generally recommended as second-step therapy. Short-acting calcium channel blockers should be avoided. Workup for secondary causes is not indicated, as they are less common in the elderly; such a workup may be appropriate if hypertension is refractory to medication. Renal artery stenosis due to atherosclerosis (detected by renal artery Doppler) is a common cause of refractory hypertension in the elderly; unfortunately, revascularization is less often curative than in young patients with fibromuscular dysplasia.