What is the initial management approach for a 17-year-old patient with hypertension?

Initial Management Approach for Hypertension in a 17-Year-Old

The initial management of hypertension in a 17-year-old should include a thorough evaluation with specific routine investigations, followed by lifestyle modifications as first-line therapy, with pharmacological treatment reserved for confirmed hypertension that does not respond to lifestyle changes or presents with target organ damage.

Diagnostic Confirmation

Before initiating any treatment, proper confirmation of hypertension is essential:

• Blood pressure should be measured at least three separate days to confirm hypertension 1
• Use appropriate cuff size with the patient seated and relaxed 1
• Hypertension in adolescents ≥13 years is defined as:
  • Systolic BP ≥130 mmHg or diastolic BP ≥80 mmHg 1
  • Or BP ≥95th percentile for age, sex, and height 1

Initial Evaluation

Perform these routine investigations for all hypertensive adolescents:

• Urine strip test for blood and protein
• Blood electrolytes and creatinine
• Blood glucose
• Lipid profile (total:HDL cholesterol ratio)
• 12-lead electrocardiograph 1

Consider ambulatory blood pressure monitoring when:

• Clinic blood pressure shows unusual variability
• To diagnose "white coat hypertension" 1

Treatment Approach

Step 1: Lifestyle Modifications

All 17-year-olds with elevated or confirmed hypertension should begin with lifestyle modifications:

• Weight reduction if overweight/obese 1
• Dietary changes:
  • Reduced sodium intake
  • Increased fruit and vegetable consumption
  • Reduced fat intake 1, 2
• Regular physical activity (predominantly dynamic exercise like brisk walking) 1
• Limiting alcohol consumption (if applicable) 1
• Smoking cessation (if applicable) 1

Step 2: Pharmacological Treatment

Pharmacological treatment should be considered in the following circumstances:

• If target BP is not reached within 3-6 months of initiating lifestyle intervention 1
• For confirmed hypertension (systolic BP or diastolic BP consistently ≥95th percentile or ≥140/90 mmHg), pharmacological treatment should be considered as soon as hypertension is confirmed 1

First-line pharmacological therapy:

• ACE inhibitors or angiotensin receptor blockers (ARBs) are recommended as initial pharmacological treatment 1
• Important caveat: Provide reproductive counseling due to potential teratogenic effects of both drug classes in females of childbearing potential 1

Treatment Goals

The goal of treatment is:

• Blood pressure consistently <90th percentile for age, sex, and height or
• <120/80 mmHg in adolescents ≥13 years 1

Special Considerations

• Consider specialist referral for:

  • Urgent treatment (malignant hypertension, impending complications)
  • Investigation of potential underlying causes
  • Therapeutic problems or failures
  • Special circumstances (unusually variable BP, possible white coat hypertension) 1

• For females of childbearing potential who are sexually active, ensure reliable contraception is being used if prescribing ACE inhibitors or ARBs, as these medications are contraindicated in pregnancy 1

This structured approach prioritizes confirmation of hypertension, appropriate evaluation, and lifestyle modifications as first-line therapy, with careful consideration of pharmacological options when necessary.