A 34-year-old man with isolated essential hypertension presents to clinic and is found to have a blood pressure of 180/100 mmHg after intensive lifestyle modifications.
What is the most appropriate next step?
Start hydrochlorothiazide and lisinopril. The most appropriate initial step in the management of the patient in this clinical vignette is the initiation of two antihypertensive medications as recommended in the JNC 7 guidelines. In general, if patients have a blood pressure of greater than 20/10 mmHg above goal, they should be initiated on two antihypertensive agents because monotherapy will typically be ineffective in achieving target blood pressure. Most patients should be started on a thiazide diuretic when commencing treatment of hypertension, as confirmed by the results of the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack trial. Care should be taken in patients at risk for hypotension, specifically elderly patients, those with diabetes, and those with autonomic dysfunction.
A 62-year-old man with isolated essential hypertension, currently taking hydrochlorothiazide 25 mg PO daily, comes to you for his first clinic visit. He notes that his blood pressure at home is always less than 140/80 mmHg, but in clinic it is always at least 155/95 mmHg.
What is the next step?
Do nothing as he has white coat hypertension. The patient in the above clinical vignette has a diagnosis of white coat hypertension. It is defined as a clinic blood pressure of >140/80 mmHg in at least three clinic settings, with blood pressure measurements of <140/80 mmHg in at least two nonclinic settings, and with absence of end-organ damage. Multiple studies have been undertaken to evaluate if isolated elevations in blood pressure in the medical setting are associated with increased cardiovascular events. A 10-year follow-up study comparing cardiovascular events between patients with white coat hypertension and those with sustained hypertension found worse outcomes in those with sustained hypertension. The risk of myocardial infarction was two times greater and the risk of a cerebral vascular event was four times greater in the sustained hypertension group. Comparison of normotensive patients with those with white coat hypertension has noted a greater prevalence of left ventricular hypertrophy in the white coat hypertension group. However, there are no clear data that white coat hypertension increases long-term cardiovascular events. Treatment of white coat hypertension is associated with decreases in clinic blood pressure with no significant decrease in ambulatory blood pressure. Patients with white coat hypertension should be monitored closely for development of sustained hypertension, but do not need to be initiated on antihypertensive therapy.
A 48-year-old man with diabetes mellitus, hypertension, and hyperlipidemia presents to the emergency room with hypertensive emergency. His mean arterial pressure is 150 mmHg, pulse 58 bpm. The electrocardiogram is notable for sinus bradycardia with PR prolongation (260 milliseconds) and no ST deviations or T-wave abnormalities.
Which medications would be the most appropriate therapy for this patient?
Intravenous nitroprusside. Treatment of hypertensive emergency requires the use of intravenous medications to decrease the mean arterial blood pressure by 25% in the first few hours. Lower target blood pressure goals increase the risk of inducing a cerebral vascular event from decreased cerebral perfusion. Sublingual nifedipine is no longer used for hypertensive emergencies due to its dramatic and unpredictable blood pressure–lowering effects and the associated adverse clinical outcomes. Nitroprusside, labetalol, and nitroglycerin are all reasonable options. However, given the rapid onset and offset of nitroprusside, and the evidence of conduction delay that may limit labetalol use, nitroprusside would be the most appropriate medication for rapid and safe titration of blood pressure.
A 48-year-old obese man with hypertension, dyslipidemia, and diabetes mellitus presents to the outpatient clinic for his yearly physical. He has refused medications in the past, but now is willing to consider treatment. His blood pressure is 145/95 mmHg with a heart rate of 80 bpm. His laboratory data are significant for a creatinine of 1.3 mg/dL with the presence of microalbuminuria.
Which of the following mediations would be most appropriate?
Lisinopril. The patient in the vignette has a target blood pressure of 130/80 mmHg according to the JNC 7 guidelines. The correct choice of initial blood pressure medication in this patient would be an ACEI. The ALLHAT study suggested that patients with diabetes mellitus have better long-term outcomes when using a thiazide diuretic compared with an ACEI. However, the patient in this vignette has evidence of protein in his urine. JNC 7 recommends that a thiazide diuretic should be first-line therapy, unless there is a specific indication. In this patient, the presence of proteinuria and diabetes mellitus makes the choice of an ACEI a better option than the thiazide. α-Blockers are not considered first-line therapy in hypertensive patients. In the ALLHAT study, there was an increased incidence of heart failure when comparing the α-blocker group (doxazosin) with the thiazide group.
A 34-year-old woman with essential hypertension is considering becoming pregnant.
Which of the following medications would be absolutely contraindicated to control her blood pressure during pregnancy?
Captopril. ACEIs and ARBs are contraindicated during pregnancy, because of the increased risk of congenital malformations. Methyldopa is the medication most commonly used to control blood pressure in pregnancy. There is significant evidence that it does not produce any harmful outcomes to the fetus. β-Blockers have been used in pregnancy with what appear to be safe results. However, the data are contradictory. There is some evidence that β-blockers, especially when used early in pregnancy, may increase the risk of fetal bradycardia, hypoglycemia, small placental weight, and a smallfor-gestational-age fetus. Calcium channel blockers have been used in pregnancy without deleterious results, but the number of published cases is small. In general, methyldopa is the safest antihypertensive during pregnancy. β-Blockers and calcium channel blockers may be used with caution. ACEIs and ARBs are absolutely contraindicated due to teratogenic effects including renal dysplasia and intrauterine growth restriction.
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