A 62-year-old woman comes to the office to follow up on elevated blood pressure. Her blood pressure was 152/92 mm Hg a month ago; she has been monitoring it at home since then, with an average blood pressure of 148/88 mm Hg. The patient's only other medical condition is osteoporosis, diagnosed six months ago and treated with vitamin D, calcium, and alendronate. Today in the office her blood pressure is 155/90 mm Hg on the left arm and 150/90 mm Hg on the right arm; pulse is 70/min. Physical examination is normal. Complete blood count, serum creatinine, serum electrolytes, TSH, and urinalysis are normal. ECG is normal. Which of the following is the best next step in management of this patient's blood pressure?

Question

A 62-year-old woman comes to the office to follow up on elevated blood pressure.  Her blood pressure was 152/92 mm Hg a month ago; she has been monitoring it at home since then, with an average blood pressure of 148/88 mm Hg.  The patient's only other medical condition is osteoporosis, diagnosed six months ago and treated with vitamin D, calcium, and alendronate.  Today in the office her blood pressure is 155/90 mm Hg on the left arm and 150/90 mm Hg on the right arm; pulse is 70/min.  Physical examination is normal.  Complete blood count, serum creatinine, serum electrolytes, TSH, and urinalysis are normal.  ECG is normal.  Which of the following is the best next step in management of this patient's blood pressure?

Quizplus · Accepted Answer

11ec25c8_d21a_0448_bc81_c9652a59ec14_MD0003_00 This patient has hypertension, confirmed on multiple occasions in both a health care setting and at home. Although a short-term trial of lifestyle modification only (eg, dietary modification, weight loss) may be considered for low-risk patients with minimal blood pressure elevations, antihypertensive medication should be initiated immediately for those with repeated high blood pressure readings, especially ≥150 mm Hg systolic and/or ≥90 mm Hg diastolic (Choice A). First-line antihypertensive medications include ACE inhibitors (eg, lisinopril), angiotensin receptor blockers (eg, losartan), calcium channel blockers (eg, amlodipine), and thiazide diuretics (eg, chlorthalidone). The choice of drug is largely determined by individual patient factors, including comorbid conditions, concurrent medications, and side-effect profile. For patients with osteoporosis, thiazide diuretics are generally preferred; thiazides increase calcium reabsorption in the distal tubule, reducing renal calcium wasting and slowing the rate of bone loss. increase calcium reabsorption (Choices B and C) Common medications that raise blood pressure include decongestants (eg, pseudoephedrine), stimulants (eg, methylphenidate), some antidepressants (eg, bupropion), erythropoietin, and nonsteroidal anti-inflammatory drugs (NSAIDs). Calcium and alendronate do not generally affect blood pressure. (Choice D) Beta blockers (eg, atenolol) are commonly used for hypertension in patients with comorbid coronary heart disease (with angina or history of myocardial infarction), heart failure with reduced ejection fraction, and atrial fibrillation. Although the benefit of hypertensive treatment is primarily determined by the degree of blood pressure lowering rather than choice of drug, beta blockers appear to not confer the same benefits as other classes, especially in patients age >60. Educational objective: First-line antihypertensive medications include ACE inhibitors, angiotensin receptor blockers, calcium channel blockers, and thiazide diuretics; the choice of drug is largely determined by comorbid conditions, concurrent medications, and side-effect profile. Thiazide diuretics reduce renal calcium wasting and slow the rate of bone loss and are therefore preferred in patients with osteoporosis. References: 2017 ACC/AHA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/29146533) Association between hypertension, antihypertensive drugs, and osteoporosis in postmenopausal Syrian women: a cross-sectional study. (http://www.ncbi.nlm.nih.gov/pubmed/32149161) Long-term thiazide use and risk of low-energy fractures among persons with Alzheimer's disease-nested case-control study (http://www.ncbi.nlm.nih.gov/pubmed/30993395)

A 62-Year-Old Woman Comes to the Office to Follow Up