A 52-year-old woman comes to the office to follow up elevated blood pressure, which was 140/100 mm Hg during a routine preventive visit 4 weeks ago. The patient feels well and has experienced no recent weight changes, headaches, chest pain, palpitations, or polyuria. Medical history is notable only for gastroesophageal reflux disease managed with dietary modification, and she takes no medications. Screening colonoscopy at age 50 was normal. She drinks 1 or 2 glasses of wine most days and does not use tobacco or illicit drugs. The patient is an only child, and her parents have no unusual health history. Blood pressure is 138/100 mm Hg and pulse is 72/min. BMI is 27 kg/m². The patient appears mildly overweight but comfortable. Physical examination is otherwise unremarkable. Laboratory results are as follows: Urinalysis is normal. ECG shows normal sinus rhythm with no significant abnormalities. Which of the following additional studies is most appropriate for this patient?

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11ec193a_97d4_dd21_853d_0b2e5a66cc43_MD0002_00 This patient has a new diagnosis of hypertension. The initial evaluation of hypertension is oriented toward the following objectives: Detecting end-organ damage that may require more aggressive managementAssessing other cardiovascular risk factorsScreening for common secondary causes of hypertension if indicated (eg, abrupt onset, onset at age <30, unexplained hypokalemia)Identifying concurrent conditions and metabolic abnormalities that could influence the choice of antihypertensive therapy Detecting end-organ damage that may require more aggressive management Detecting end-organ damage that may require more aggressive management Assessing other cardiovascular risk factors Assessing other cardiovascular risk factors Screening for common secondary causes of hypertension if indicated (eg, abrupt onset, onset at age <30, unexplained hypokalemia) Screening for common secondary causes of hypertension if indicated (eg, abrupt onset, onset at age <30, unexplained hypokalemia) Identifying concurrent conditions and metabolic abnormalities that could influence the choice of antihypertensive therapy Identifying concurrent conditions and metabolic abnormalities that could influence the choice of antihypertensive therapy Both hypothyroidism and hyperthyroidism can raise blood pressure: Hyperthyroidism causes increased systolic and pulse pressure, whereas hypothyroidism typically causes increased diastolic pressure with decreased pulse pressure; thyroid disease can also lead to lipid abnormalities. Untreated thyroid disease can impair the response to antihypertensive management, but treatment of the underlying thyroid condition can often normalize blood pressure without additional antihypertensive therapy. Therefore, according to American College of Cardiology/American Heart Association guidelines, patients with hypertension warrant screening for thyroid disease with a serum TSH as part of the initial laboratory evaluation (regardless of symptoms) and if they have clinical features of thyroid disease (eg, heat/cold intolerance, weight loss/gain, warm/cold skin). (Choice A) Renal ultrasonography is useful to evaluate hypertension in patients with diffuse atherosclerosis or evidence of renovascular hypertension (eg, atrophic kidney, recurrent flash pulmonary edema, abdominal bruit, onset of severe hypertension at age >55) but is not needed in patients with uncomplicated hypertension. (Choice B) This patient has a normal serum calcium level, making hyperparathyroidism less likely. Although hypertension has been associated with hyperparathyroidism (including normocalcemic hyperparathyroidism) in some studies, this is an inconsistent observation. (Choices C and D) Testing for primary hyperaldosteronism with a plasma aldosterone to plasma renin activity ratio is appropriate for patients with resistant hypertension (ie, uncontrolled despite an appropriate multidrug regimen) or hypertension with significant hypokalemia. Screening for pheochromocytoma with plasma fractionated metanephrines is appropriate for patients with severe, labile, or resistant hypertension. These tests are not needed for routine evaluation of uncomplicated hypertension. Educational objective: Both hyperthyroidism and hypothyroidism can raise blood pressure. Untreated thyroid disease can impair the response to antihypertensive management, but many patients experience normalization of blood pressure when the underlying thyroid disorder is treated. Patients with hypertension warrant screening for thyroid disease in the initial laboratory evaluation. __________ References: Thyroid and the heart. (http://www.ncbi.nlm.nih.gov/pubmed/24662620)

A 52-Year-Old Woman Comes to the Office to Follow Up