A 34-year-old woman comes to the office for a follow-up blood pressure check. Over the last 12 months, the patient's blood pressure readings have ranged from 145/90 to 150/95 mm Hg. Her blood pressure was measured during a health fair 2 weeks ago and it was 145/90 mm Hg. The patient feels well, has no other medical conditions, and has never been pregnant. Medications include a combination oral contraceptive for the past 5 years and, occasionally, 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. Blood pressure is 150/90 mm Hg and pulse is 80/min. BMI is 22 kg/m2. Physical examination and ECG are normal. Six months ago, the patient's total cholesterol level was 170 mg/dL. Complete blood count, urinalysis, and basic metabolic panel are unremarkable. Which of the following is the most appropriate next step in management of this patient's hypertension?
This patient has stage 2 hypertension, defined as systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg. Oral contraceptives (OCs) commonly cause a mild elevation in blood pressure and sometimes (in up to 5% of chronic users) can lead to overt hypertension. The mechanism is unclear but is possibly due to an estrogen-mediated increase in hepatic angiotensinogen synthesis or other effects on the renin-angiotensin system. The risk of hypertension increases with the duration of OC use and is elevated in those who have a family history of hypertension or who developed hypertension during a previous pregnancy.
The Centers for Disease Control and Prevention recommends against the use of combination estrogen-progestin OCs in women with hypertension. In patients whose hypertension is caused by OC use, discontinuation can reduce blood pressure and often corrects the condition. The physician should have a discussion with the patient about the benefit of stopping the OC, the risks of drug continuation, and alternate contraceptive methods.
(Choices A and E) If elevated blood pressure persists after OC discontinuation, lifestyle modification and/or medication (eg, low-dose thiazide diuretic) may be required.
(Choice B) Renovascular hypertension and fibromuscular dysplasia are uncommon causes of hypertension; therefore, routine CT angiogram of the abdomen is not recommended. Investigation for secondary causes of hypertension is considered for patients with more severe or refractory hypertension or with other signs of renovascular disease (eg, acute kidney injury after initiation of an ACE inhibitor, recurrent flash pulmonary edema).
(Choice D) Reassurance without intervention is inappropriate because hypertension is an important cardiovascular risk factor that should be treated properly to reduce the risk of cardiovascular events.
Educational objective:
Oral contraceptives (OCs) commonly cause a mild elevation in blood pressure and can sometimes lead to overt hypertension. OCs should not be used in patients with hypertension, and those who develop hypertension while taking OCs should discontinue the medication.