A 35-year-old woman comes to the physician for follow-up of hypertension. When the patient was seen in the office 2 weeks ago, her blood pressure was 145/95 mm Hg initially and 140/92 mm Hg after recheck. Since then, she had her blood pressure taken 3 times at a nearby pharmacy, with readings averaging 120/80 mm Hg. The patient has no symptoms and feels "pretty healthy." She takes no medications.
The patient's father has hypertension and coronary artery disease, which required coronary artery bypass grafting. Her mother has hypertension and type 2 diabetes mellitus. The patient regularly salts her food before tasting it. She drinks alcohol socially and does not use tobacco or illicit drugs. The patient works as an information technology consultant and exercises moderately 3 times a week.
Blood pressure during this visit is 149/94 mm Hg initially and 138/94 mm Hg after 20 minutes. BMI is 28 kg/m². The ocular fundi appear normal. Physical examination is unremarkable.
A complete blood count, urinalysis, and comprehensive metabolic panel are normal. Serum creatinine is 0.9 mg/dL. ECG shows normal sinus rhythm and T-wave inversion in leads V1 and V2.
Which of the following is the best next step in management of this patient's blood pressure?

Question

Quizplus · Accepted Answer

11ec193a_974a_0237_853d_57732be89969_MD0002_00 This patient has elevated blood pressure in the physician's office and normal blood pressure outside the office, consistent with "white coat" hypertension. Given the discrepancy, 24-hour ambulatory blood pressure monitoring (ABPM) is indicated to characterize the blood pressure pattern more fully as it is more predictive of future cardiovascular events than either physician's office or home blood pressure measurements. ABPM records pulse and blood pressure at 15- to 20-minute intervals during the day and 30- to 60-minute intervals at night. This patient has no signs of end-organ damage, with no abnormalities in creatinine, urinalysis, and ECG; T-wave inversion in leads V1 and V2 is a relatively common finding, particularly in young patients, that does not typically indicate left ventricular dysfunction or hypertensive heart disease. If ABPM results are normal, antihypertensive therapy may be deferred (Choice E). However, patients with white coat hypertension have an increased risk of developing sustained hypertension and warrant close long-term follow-up. (Choice A) In addition to causing hypertension, pheochromocytoma also causes episodic palpitations, tremor, and diaphoresis. Pheochromocytoma is a rare disorder, and this patient's lack of symptoms makes it even less likely. Additional evaluation could be considered if episodic, severe hypertension is noted on ABPM. (Choice B) Echocardiography is not necessary for routine evaluation of hypertension in asymptomatic patients. T-wave inversion in only the right precordial leads is usually a normal finding and does not indicate left ventricular dysfunction or hypertensive heart disease. (Choice D) Initial elevations in blood pressure taken during office visits often decline on subsequent checks, possibly due to increased patient comfort or statistical regression to the mean. However, this patient has mild but persistent office blood pressure elevations, and ABPM can more readily differentiate white coat hypertension from sustained hypertension. Educational objective: White coat hypertension refers to elevated blood pressure in the physician's office with normal blood pressure readings elsewhere. In such patients, 24-hour ambulatory blood pressure monitoring can more fully characterize the blood pressure pattern and is a better predictor of future cardiovascular events and all-cause mortality than are office or home blood pressure measurements. __________ References: Ambulatory blood pressure monitoring in clinical practice: a review. (http://www.ncbi.nlm.nih.gov/pubmed/25107387)

A 35-Year-Old Woman Comes to the Physician for Follow-Up of Hypertension