What is the initial workup and treatment for hypertension in a 54-year-old woman?

Initial Workup and Treatment for Hypertension in a 54-Year-Old Woman

The initial workup for hypertension in a 54-year-old woman should include blood pressure confirmation, cardiovascular risk assessment, and evaluation for secondary causes, followed by prompt initiation of lifestyle modifications and pharmacological therapy with an ACE inhibitor/ARB, calcium channel blocker, or thiazide-like diuretic based on her specific characteristics.

Diagnostic Workup

Blood Pressure Confirmation

• Confirm hypertension using validated automated upper arm cuff device with appropriate cuff size
• Measure BP in both arms simultaneously at first visit; use arm with higher BP for subsequent measurements 1
• Confirm elevated office readings (≥130/85 mmHg) with home BP monitoring (target <135/85 mmHg) or 24-hour ambulatory BP monitoring (target <130/80 mmHg) 1, 2

Basic Laboratory and Diagnostic Tests

• Complete blood count
• Basic metabolic panel (electrolytes, renal function)
• Fasting blood glucose and HbA1c
• Lipid profile
• Urinalysis with urine albumin-to-creatinine ratio
• 12-lead ECG
• Consider additional tests if secondary hypertension is suspected 2

Secondary Hypertension Evaluation

• Consider comprehensive screening for secondary causes, especially if:
  • Poor response to therapy
  • Sudden onset or worsening of hypertension
  • Clinical features suggesting secondary causes (e.g., hypokalemia, abdominal bruit)
  • Family history of endocrine disorders 2

Initial Treatment Approach

Lifestyle Modifications

• Implement immediately for all patients with elevated BP 1, 2
• Key components:
  • Weight reduction if overweight/obese (target BMI 20-25 kg/m²) 2
  • DASH diet rich in fruits, vegetables, and low-fat dairy products 2, 3
  • Sodium restriction (<5 g/day) 2
  • Regular physical activity (150 minutes moderate-intensity or 75 minutes vigorous-intensity weekly) 2
  • Moderation of alcohol consumption (≤10 g/day for women) 2
  • Smoking cessation 2, 3

Pharmacological Therapy

When to Initiate Medication

• Start drug treatment promptly if BP ≥140/90 mmHg, regardless of cardiovascular risk level 1
• For BP 130-139/80-89 mmHg:
  • Start medication if high cardiovascular risk
  • Consider 3-6 months of lifestyle modification first if low-moderate risk 1, 2

First-Line Medication Options

• Four main classes recommended as first-line therapy:
  1. ACE inhibitors (e.g., lisinopril starting at 10 mg daily) 4
  2. Angiotensin II receptor blockers (e.g., losartan starting at 50 mg daily) 5
  3. Calcium channel blockers (dihydropyridine type)
  4. Thiazide or thiazide-like diuretics 2, 6

Medication Selection Based on Patient Characteristics

• For non-Black patients: Start with low-dose ACE inhibitor/ARB 1, 2
• For Black patients: Start with ARB + dihydropyridine CCB or dihydropyridine CCB + thiazide-like diuretic 1, 2
• With albuminuria (UACR ≥30 mg/g): ACE inhibitor or ARB preferred 1
• With diabetes or chronic kidney disease: ACE inhibitor or ARB preferred 1

Combination Therapy

• For BP significantly above target (>20/10 mmHg above goal): Consider initiating with two-drug combination 2
• If BP not controlled with monotherapy: Add second agent from a different class 1
• If BP not controlled with two drugs: Progress to three-drug combination (RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic), preferably as a single-pill combination 1, 2

Treatment Goals and Follow-up

Blood Pressure Targets

• Target BP <130/80 mmHg for most adults 1, 2
• Systolic BP 120-129 mmHg if tolerated 1, 2

Monitoring and Follow-up

• Follow-up within 2-4 weeks after starting or changing medications 2
• Monitor for adverse effects, particularly with ACE inhibitors/ARBs:
  • Check serum creatinine and potassium 7-14 days after initiation or dose change 1, 2
  • Annual monitoring of renal function and electrolytes 1
• Once BP controlled, follow-up every 3-5 months 2

Important Considerations and Pitfalls

• Do not combine ACE inhibitors with ARBs as this increases adverse effects without additional benefit 1, 2
• Fixed-dose combinations improve medication adherence 2
• Beta-blockers are not recommended as first-line unless specifically indicated (e.g., coronary artery disease, heart failure) 1, 2
• For women of childbearing potential, avoid ACE inhibitors and ARBs due to teratogenic potential 1
• Consider medication cost and insurance coverage to improve adherence
• Monitor for orthostatic hypotension, especially in older patients 1

By following this structured approach to hypertension management in a 54-year-old woman, you can effectively reduce cardiovascular risk and prevent target organ damage while minimizing adverse effects.