What is the appropriate workup for hypertension in a 24-year-old patient with a Body Mass Index (BMI) of 26?

From the Guidelines

The workup for hypertension in a 24-year-old with a BMI of 26 should begin with confirming the diagnosis through multiple blood pressure measurements on separate occasions, as young adults can have white coat hypertension. Initial evaluation should include a comprehensive history focusing on lifestyle factors, such as diet, exercise, alcohol, tobacco, and drug use, as well as family history of hypertension and medication use, including over-the-counter drugs and supplements 1. Physical examination should assess for signs of secondary causes, such as abdominal bruits, cushingoid features, or thyroid abnormalities. Laboratory testing should include:

• Basic metabolic panel
• Complete blood count
• Urinalysis
• Lipid profile
• Fasting glucose
• Thyroid function tests An electrocardiogram is recommended to assess for left ventricular hypertrophy. Given the young age, secondary causes of hypertension should be strongly considered, with screening tests including plasma aldosterone-to-renin ratio for primary aldosteronism, 24-hour urine collection for catecholamines to rule out pheochromocytoma, and renal ultrasound to evaluate for renal artery stenosis or other kidney abnormalities. Lifestyle modifications, such as weight loss, adoption of the Dietary Approaches to Stop Hypertension (DASH) eating plan, reducing dietary sodium to no more than 100 mmol per day, engaging in regular aerobic physical activity, and limiting alcohol intake, should be emphasized as the first line of management 1. If pharmacotherapy is needed, first-line options for a young adult typically include ACE inhibitors, ARBs, or calcium channel blockers, with medication choice individualized based on comorbidities and potential side effects.

From the Research

Workup Hypertension in 24-Year-Old with BMI 26

• The patient's blood pressure should be measured and monitored to confirm the diagnosis of hypertension, defined as a systolic blood pressure of at least 130 mm Hg or a diastolic blood pressure of at least 80 mm Hg 2.
• The patient's medical history, lifestyle, and physical activity level should be assessed to identify potential risk factors and comorbidities, such as obesity, which is defined as a BMI of 30 or higher, but in this case, the patient has a BMI of 26, which is considered overweight 3.
• Laboratory tests, such as blood chemistry and urinalysis, may be ordered to rule out underlying conditions that could be contributing to the hypertension 2.

Lifestyle Modifications

• The patient should be advised to make lifestyle modifications, including:
  • Weight loss, aiming for a modest weight loss of 5% to 10% 3.
  • Increasing physical activity, with a goal of at least 150 to 300 minutes per week of moderate-intensity aerobic physical activity 4, 3.
  • Healthy dietary pattern, including low sodium and high potassium intake 2, 4.
  • Moderation or elimination of alcohol consumption 2.

Pharmacologic Therapy

• If lifestyle modifications are not sufficient to control the patient's blood pressure, pharmacologic therapy may be considered, with first-line options including:
  • Thiazide or thiazide-like diuretics, such as hydrochlorothiazide or chlorthalidone 2, 5.
  • Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, such as enalapril or candesartan 2, 6.
  • Calcium channel blockers, such as amlodipine 2, 6, 5.
• The choice of medication should be based on the patient's individual needs and medical history, as well as the presence of any comorbidities or risk factors 2, 6, 5.