What is the initial workup and treatment for a young patient with hypertension?

Initial Workup and Treatment for Young Patients with Hypertension

For young patients with hypertension (under age 40), comprehensive screening for secondary causes of hypertension is strongly recommended, except in obese young adults where evaluation should begin with obstructive sleep apnea assessment. 1

Diagnostic Evaluation

Initial Workup

1. Blood pressure measurement

   • Confirm hypertension with multiple readings on separate days
   • Use proper technique: patient seated quietly for 5 minutes, back supported, feet flat on floor, appropriate cuff size
   • For adolescents ≥13 years: hypertension defined as ≥130/80 mmHg (stage 1) or ≥140/90 mmHg (stage 2) 2
   • For children <13 years: hypertension defined as BP ≥95th percentile for age, sex, and height 2

2. Secondary cause evaluation (essential for patients <40 years)

   • Laboratory tests:
     • Complete blood count
     • Comprehensive metabolic panel (electrolytes, renal function)
     • Urinalysis
     • Thyroid function tests
     • Plasma aldosterone/renin ratio
   • Imaging:
     • Renal ultrasound
     • Echocardiogram to assess for left ventricular hypertrophy
     • Consider renal artery imaging if suspicion for renovascular hypertension

3. Risk factor assessment

   • Family history of hypertension
   • Obesity assessment (BMI, waist circumference)
   • Sleep apnea screening (especially in obese patients)
   • Dietary habits (sodium intake, alcohol consumption)
   • Physical activity level
   • Smoking status

Treatment Approach

1. Lifestyle Modifications (First-line for all patients)

• Weight management: Target BMI 20-25 kg/m² and waist circumference <94 cm (men) and <80 cm (women) 1
• Physical activity: 30-60 minutes of moderate to vigorous exercise 3-5 days/week 2
• Dietary changes:
  • Mediterranean or DASH diet
  • Sodium restriction (<2300 mg/day)
  • Increased fruits and vegetables
  • Reduced processed foods
  • Limited alcohol consumption (<100g/week) 1
• Smoking cessation if applicable

2. Pharmacological Treatment

For non-obese young adults with confirmed hypertension:

• Begin with 3-6 months of lifestyle modifications
• If BP remains ≥140/90 mmHg or if target organ damage is present, initiate pharmacological therapy 1

Initial medication selection:

• First-line options (preferably as single-pill combinations) 1:
  • ACE inhibitor (e.g., lisinopril) or ARB
  • Dihydropyridine calcium channel blocker (e.g., amlodipine)
  • Thiazide/thiazide-like diuretic (preferably chlorthalidone or indapamide)

Treatment algorithm:

1. Start with a two-drug combination (preferably single-pill): RAS blocker (ACE inhibitor/ARB) + CCB or diuretic 1
2. If BP not controlled, advance to three-drug combination: RAS blocker + CCB + thiazide/thiazide-like diuretic 1
3. If still not controlled, consider resistant hypertension and add a fourth agent

Special considerations:

• For women of childbearing potential: Avoid ACE inhibitors/ARBs (contraindicated in pregnancy) 2
• For patients with chronic kidney disease or diabetes: Prefer ACE inhibitors or ARBs 2

Treatment Goals and Follow-up

• BP target: 120-129 mmHg systolic for most adults 1
• Follow-up: Every 4-6 weeks until BP controlled, then every 3-6 months
• Home BP monitoring: Recommended to guide treatment adjustments and improve adherence 1

Important Caveats

1. Never combine two RAS blockers (ACE inhibitor and ARB) due to increased adverse effects without additional benefit 1

2. For obese young adults, start with obstructive sleep apnea evaluation before extensive workup for other secondary causes 1

3. Orthostatic hypotension should be assessed before starting or intensifying treatment, especially in older patients 1

4. Medication adherence is critical - use fixed-dose combinations and once-daily dosing when possible to improve compliance 1

5. Telehealth strategies can augment office-based management and improve BP control 1