A 50-year-old man comes to the office for a follow-up visit. He has essential hypertension that was diagnosed a year ago. Laboratory results at that time for complete blood cell count, chemistry panel, and urinalysis were normal. At his last office visit 4 weeks ago, the patient's blood pressure was 144/92 mm Hg. He exercises regularly and has been compliant with a low-salt diet. Current medications include a thiazide diuretic and an ACE inhibitor. He quit smoking 2 years ago after a 25-pack-year history. The patient drinks 3 or 4 glasses of wine every day and 6-8 beers on weekend nights with his friends. He does not use illicit drugs. His father died following a stroke at age 60. Today, the patient's blood pressure is 143/88 mm Hg, and pulse is 76/min. The rest of his physical examination is normal. Which of the following is the most appropriate next step in management of this patient's hypertension?

Question

A 50-year-old man comes to the office for a follow-up visit.  He has essential hypertension that was diagnosed a year ago.  Laboratory results at that time for complete blood cell count, chemistry panel, and urinalysis were normal.  At his last office visit 4 weeks ago, the patient's blood pressure was 144/92 mm Hg.  He exercises regularly and has been compliant with a low-salt diet.  Current medications include a thiazide diuretic and an ACE inhibitor.  He quit smoking 2 years ago after a 25-pack-year history.  The patient drinks 3 or 4 glasses of wine every day and 6-8 beers on weekend nights with his friends.  He does not use illicit drugs.  His father died following a stroke at age 60.  Today, the patient's blood pressure is 143/88 mm Hg, and pulse is 76/min.  The rest of his physical examination is normal.  Which of the following is the most appropriate next step in management of this patient's hypertension?

Quizplus · Accepted Answer

This patient with hypertension has a persistently elevated blood pressure (BP) despite taking appropriate antihypertensive medication. Common causes of such persistent BP elevations include medication nonadherence, dietary indiscretion (eg, excessive sodium intake), and concurrent medications (eg, nonsteroidal anti-inflammatory drugs, decongestants, glucocorticoids) that raise BP. In addition, excessive alcohol intake (ie, >2 drinks/day) and binge drinking (ie, ≥5 drinks in a single sitting) are associated with increased incidence of hypertension, higher BP, and failure to respond to appropriate antihypertensive therapy. In contrast, moderate alcohol intake (eg, ≤2 drinks/day for men, ≤1 drink/day for women) is associated with lower BP, decreased incidence of coronary artery disease, and lower cardiovascular mortality. Although adding other agents to control this patient's BP may eventually be necessary, the first step should be counseling regarding his drinking. (Choices B and E) Addition or titration of antihypertensive medication may be considered for this patient later if moderation of alcohol intake is unsuccessful. If a third medication is needed, a calcium channel blocker (eg, amlodipine) is preferred over a beta blocker in the absence of additional specific indications (eg, heart failure, hyperthyroidism). Thiazide diuretics have a nonlinear dose-response curve; the BP-lowering effect is proportionately greater at lower doses, and up-titration often induces greater adverse effects than benefits. (Choices C and D) Screening tests (eg, plasma aldosterone/renin ratio, renal vascular ultrasonography) for secondary causes of hypertension are recommended for patients with treatment-resistant hypertension (ie, BP elevated despite ≥3 appropriate antihypertensive medications). They also are indicated for unusual presentations (eg, young or very old age of onset, sudden onset) and when standard initial tests suggest a secondary cause (eg, hypokalemia). Most patients have primary hypertension; in the absence of specific indications, routine testing for secondary causes is not cost effective and may result in false-positive results. Educational objective: Excessive alcohol intake (ie, >2 drinks/day) and binge drinking (ie, ≥5 drinks in a single sitting) are associated with increased incidence of hypertension, higher blood pressure, and failure to respond to appropriate antihypertensive therapy. In contrast, moderate alcohol intake is associated with lower blood pressure. References: Hypertension. (http://www.ncbi.nlm.nih.gov/pubmed/29565029) Alcohol-induced hypertension: mechanism and prevention. (http://www.ncbi.nlm.nih.gov/pubmed/24891935)

A 50-Year-Old Man Comes to the Office for a Follow-Up