A 42-year-old woman comes for follow-up after a recent urinary tract infection treated with a short course of antibiotics. During her emergency department visit, the patient was told that her blood pressure was "mildly elevated." She currently has no symptoms. Medical history is otherwise insignificant, and the patient does not regularly see a physician. Family history is unremarkable. The patient jogs twice a week and eats a healthy diet. She takes no medications. Blood pressure is 142/91 mm Hg. BMI is 28 kg/m2. Physical examination is unremarkable. ECG and laboratory tests, including a basic metabolic panel, are unremarkable. Which of the following is the best next step in managing this patient?
This patient has had 2 separate episodes of mildly elevated blood pressure (BP) while she was in a medical setting (in the office and the emergency department), which suggest hypertension. However, office-based BP measurements are a poor predictor of high BP outside of the office because of the relatively common occurrence of white coat hypertension (eg, BP 5-10 mm Hg higher in the office than at home). Therefore, in the absence of end-organ damage, the diagnosis of hypertension must be confirmed by one of the following:
Ambulatory BP readings, as measured by an automatic device worn continuously by the patient for 24-48 hours. The device monitors BP at regular intervals (eg, 15-60 min).
If continuous ambulatory BP monitoring is not available, an acceptable alternative is home BP monitoring done twice a day (morning and evening) for a week.
If home BP monitoring is not possible, 3 office readings (preferably by an automated machine while the patient is alone) at least a week apart are needed.
In contrast, if end-organ damage (eg, left ventricular hypertrophy, retinopathy, nephropathy) is present or if the patient has a systolic BP ≥180 mm Hg or diastolic BP ≥120 mm Hg, then the diagnosis of hypertension can be established in the office without additional confirmation, and therapy should be started quickly. This patient has neither end-organ damage nor confirmed hypertension, so antihypertensive therapy does not need to be started yet (Choices D and E).
(Choice A) Weight loss is unlikely to improve BP significantly in this nonobese patient who is already exercising and following a good diet. In addition, waiting 12 months for an evaluation is too long and risks the patient being lost to follow-up or developing end-organ damage; a shorter interval is advised.
(Choice C) Polysomnography is used to diagnose obstructive sleep apnea (OSA), which is associated with hypertension and obesity. This patient does not have confirmed hypertension, and although she is overweight, she is not at high risk for OSA. In general, OSA screening is typically considered in patients with excessive daytime somnolence who have 2 other clinical manifestations (eg, hypertension, loud snoring, choking while asleep).
Educational objective:
Patients with severe hypertension or evidence of end-organ damage should be prescribed antihypertensive therapy immediately. For those with only mild blood pressure elevations, the diagnosis should first be confirmed outside of a health care setting with ambulatory blood pressure monitoring or home measurement.