Should I start treatment or do investigations on a 19-year-old male (YOM) with rare presyncopal episodes and significantly elevated blood pressure readings, including hypertension and orthostatic changes?

From the Guidelines

For a 19-year-old male with rare presyncopal episodes and significantly elevated blood pressure readings, including hypertension and orthostatic changes, you should prioritize investigations before starting treatment. This approach is supported by the 2017 ACC/AHA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1, which emphasizes the importance of identifying secondary causes of hypertension, particularly in younger patients. The guideline suggests that a specific, remediable cause of hypertension can be identified in approximately 10% of adult patients with hypertension, and that all new patients with hypertension should be screened with a history, physical examination, and laboratory investigations before initiation of treatment.

Begin with a comprehensive workup including:

• Basic labs (complete blood count, comprehensive metabolic panel, thyroid function tests, urinalysis)
• Ambulatory blood pressure monitoring to confirm persistent hypertension
• An electrocardiogram Consider specialized tests like:
• Plasma metanephrines
• Aldosterone-to-renin ratio
• Renal artery imaging to rule out secondary causes of hypertension, which are more common in young patients Echocardiography would be valuable to assess for structural heart abnormalities. The combination of hypertension with orthostatic changes and presyncopal episodes in a young male suggests possible secondary hypertension or autonomic dysfunction.

While the investigation is ongoing, recommend lifestyle modifications including:

• Reduced sodium intake
• Regular exercise
• Stress management
• Avoiding excessive alcohol and caffeine. Premature treatment without understanding the underlying cause could mask important diagnostic clues or potentially worsen orthostatic symptoms if the patient has autonomic dysfunction, as noted in the 2021 guideline-driven management of hypertension update 1.

From the FDA Drug Label

Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake Many patients will require more than 1 drug to achieve blood pressure goals. Elevated systolic or diastolic pressure causes increased cardiovascular risk, and the absolute risk increase per mmHg is greater at higher blood pressures, so that even modest reductions of severe hypertension can provide substantial benefit

The patient has significantly elevated blood pressure readings, including hypertension and orthostatic changes, which increases the risk of cardiovascular events. Given the patient's age (19 YOM) and rare presyncopal episodes, it is essential to investigate the cause of the elevated blood pressure before starting treatment. Investigations should be done to determine the underlying cause of the hypertension, such as secondary hypertension due to an underlying medical condition. Treatment should be considered after the investigations are completed, and the patient's condition is fully assessed 2, 3.

From the Research

Assessment of Hypertension in a 19-Year-Old Male

The patient presents with rare presyncopal episodes and significantly elevated blood pressure readings, including a home BP of 199/100 and a triage BP of 145/72. Given the patient's age and otherwise healthy status, these readings are concerning and warrant further investigation.

Diagnostic Approach

• The first step in managing this patient is to confirm the diagnosis of hypertension and rule out any secondary causes of high blood pressure 4.
• Ambulatory blood pressure monitoring (ABPM) is a useful tool in diagnosing hypertension and supervising its treatment 5.
• Home blood pressure monitoring (HBPM) can also be used as a reliable alternative to ABPM in evaluating resistant hypertension 6.
• The diagnostic value of HBPM was assessed by taking ABPM as the reference method, and the results showed that HBPM had a sensitivity of 93% and a specificity of 63% in detecting clinic-resistant hypertension 6.

Treatment Considerations

• The optimal blood pressure target in the treatment of hypertension remains a matter of debate, and the decision to start treatment should be based on individual patient characteristics and risk factors 7, 4.
• In patients with evidence of renal disease or at greater risk of developing renal disease, renin-angiotensin system (RAS) blocker-based combination therapy is recommended due to its superior renoprotective effects 7.
• The use of angiotensin II receptor blockers (ARBs) is preferred over angiotensin-converting enzyme (ACE) inhibitors due to the lower incidence of side effects such as cough 7.

Investigation of Resistant Hypertension

• Resistant hypertension is defined as blood pressure that remains above target despite the use of three or more antihypertensive agents 8.
• The investigation of resistant hypertension should include the exclusion of pseudoresistant hypertension using ABPM or HBPM, as well as the assessment of patient adherence to therapy and the adequacy of treatment 8.
• Secondary causes of hypertension should also be considered and investigated if necessary 4.