What is the most important next step in the care of a 16-year-old girl with hypertension (elevated blood pressure), headaches, chest pain, fatigue, and a systolic murmur?

From the Guidelines

The most important next step in the care of this 16-year-old girl is to obtain blood pressure readings in the upper and lower extremities. This is crucial because the patient's presentation, including hypertension, headaches, chest pain, fatigue, and a systolic murmur, suggests possible coarctation of the aorta, a rare form of hypertension in children and young adults 1. Coarctation of the aorta is characterized by a midsystolic murmur heard over the anterior part of the chest and also over the back, and it often presents with hypertension in the upper extremities concomitantly with low or unmeasurable blood pressure in the legs 1.

Key points to consider in the diagnosis and management of this patient include:

• The presence of a systolic murmur in the left infraclavicular area and under the left scapula, which is consistent with coarctation of the aorta 1
• The importance of measuring blood pressure in all four extremities to identify any potential gradient between the upper and lower limbs, a hallmark of coarctation of the aorta 1
• The need for a comprehensive cardiac evaluation, including an echocardiogram, to confirm the diagnosis and guide management
• The potential for persistent hypertension after repair or stenting, especially in adults, highlighting the importance of long-term follow-up and management 1

Given the potential for coarctation of the aorta or other structural heart disease, obtaining blood pressure readings in the upper and lower extremities is the most critical next step, as it can provide immediate clues to the underlying diagnosis and guide further evaluation and management 1.

From the Research

Diagnosis and Next Steps

The patient presents with hypertension, headaches, chest pain, fatigue, and a systolic murmur, which are indicative of a potential underlying cardiovascular issue. Given the symptoms and physical examination findings, the most important next step in care is to investigate the cause of the hypertension and the systolic murmur.

Potential Causes

• Coarctation of the aorta is a possible cause of the patient's symptoms, as it is an important and treatable cause of secondary hypertension 2.
• Renal artery stenosis is another potential cause of hypertension in this patient, especially given the association with neurofibromatosis type 1 (NF1) 3.
• Other potential causes of hypertension, such as pheochromocytoma, should also be considered and ruled out.

Diagnostic Tests

• Obtaining blood pressure readings in the upper and lower extremities is crucial to diagnose coarctation of the aorta, as a significant difference in blood pressure between the arms and legs may indicate aortic coarctation 2, 4.
• Doppler ultrasound or other imaging studies, such as MR angiography, may be necessary to confirm the diagnosis of coarctation of the aorta or renal artery stenosis 3, 5.
• Laboratory evaluation, including urinary metanephrines, may be necessary to rule out other causes of hypertension, such as pheochromocytoma.

Most Important Next Step

Based on the patient's symptoms and physical examination findings, the most important next step in care is to:

• Obtain blood pressure readings in the upper and lower extremities to assess for a potential difference in blood pressure between the arms and legs, which may indicate coarctation of the aorta 2, 4.