What is the next management step for an asymptomatic 74-year-old hypertension patient with decreased RBC, Hb, Hct, MCHC and elevated MPV on CBC?

Management of Anemia in an Asymptomatic 74-Year-Old Hypertensive Patient

The next management step for this asymptomatic 74-year-old hypertensive patient with decreased RBC, Hb, Hct, MCHC and elevated MPV should be a thorough evaluation for the underlying cause of anemia, with iron studies being the first specific test to order.

Initial Assessment of Anemia

The patient's CBC shows several abnormalities that indicate anemia:

• Decreased red blood cell (RBC) count
• Decreased hemoglobin (Hb)
• Decreased hematocrit (Hct)
• Decreased mean corpuscular hemoglobin concentration (MCHC)
• Elevated mean platelet volume (MPV)

These findings suggest a microcytic hypochromic anemia pattern, which requires further investigation even though the patient is currently asymptomatic.

Diagnostic Workup

1. Iron studies (first priority):

   • Serum ferritin
   • Serum iron
   • Total iron binding capacity (TIBC)
   • Transferrin saturation

2. Additional laboratory tests:

   • Reticulocyte count to assess bone marrow response 1
   • Peripheral blood smear examination
   • Hemoglobinopathy evaluation if iron deficiency is ruled out
   • Vitamin B12 and folate levels (even though the anemia appears microcytic)
   • Inflammatory markers (CRP, ESR) to assess for anemia of chronic disease

3. Medication review:

   • Assess if the patient is taking medications that could contribute to anemia, particularly ACE inhibitors or ARBs which can cause suppression of red blood cell production 2

Considerations Specific to Hypertensive Patients

• Anemia in hypertensive patients requires special attention as it may affect cardiovascular risk and treatment outcomes
• Hematological parameters including RBC, hemoglobin, and hematocrit have been shown to be altered in hypertensive patients 3
• Consider the possibility of kidney dysfunction as a cause of anemia, as hypertension and CKD often coexist 4
• Evaluate estimated glomerular filtration rate (eGFR) and test for microalbuminuria 4

Gastrointestinal Evaluation

Given the age of the patient (74 years) and the pattern of anemia (microcytic hypochromic):

• Consider referral for gastrointestinal evaluation to rule out occult bleeding
• Fecal occult blood testing should be performed
• Based on results, consider upper endoscopy and/or colonoscopy

Management of Hypertension During Anemia Workup

• Continue current antihypertensive medications while investigating anemia
• Monitor blood pressure closely as anemia correction may affect blood pressure control
• If the patient is on ACE inhibitors or ARBs and severe anemia is present, consider temporarily adjusting these medications while investigating the cause 2

Follow-up Plan

1. Schedule follow-up within 2-4 weeks to review results of initial anemia workup
2. Based on findings, develop a specific treatment plan for the underlying cause
3. Monitor complete blood count during treatment to assess response
4. Reassess cardiovascular risk once anemia is addressed

Common Pitfalls to Avoid

• Assuming iron deficiency without confirmatory testing
• Overlooking potential medication-related causes of anemia
• Failing to investigate for occult blood loss in elderly patients with microcytic anemia
• Not considering the relationship between kidney function and anemia in hypertensive patients
• Treating anemia without identifying the underlying cause

The systematic evaluation of anemia in this elderly hypertensive patient is essential, even though they are currently asymptomatic, as it may reveal important underlying conditions and affect overall cardiovascular risk management.