How to manage a 37-year-old hypertensive woman with uncontrolled blood pressure, dyspnea, palpitations, and elevated cortisol level?

Management of Severe Hypertension in a 37-Year-Old Woman

The patient requires prompt blood pressure reduction with a target systolic BP of 120-129 mmHg, medication optimization, and evaluation for secondary causes of hypertension given her young age and poor control on current therapy. 1

Initial Assessment and Classification

This 37-year-old woman presents with severely elevated blood pressure (208/150 mmHg) with symptoms of headache, shortness of breath, and palpitations. Her current presentation is best classified as a hypertensive urgency rather than emergency, as there is no evidence of acute end-organ damage:

• No papilledema on fundoscopy
• No loss of consciousness
• No chest pain
• Normal renal function (eGFR >60)
• Elevated troponin (7.33) requires repeat testing

Risk Factors and Comorbidities

• Known hypertension on labetalol 200mg BID (recently started)
• Previous adverse reactions to amlodipine and candesartan
• History of gestational diabetes
• Recurrent UTIs
• Obesity
• Elevated morning cortisol (321)
• Elevated glucose (11.5)

Immediate Management

1. Medication adjustment:

   • Continue labetalol but optimize dosing (current dose may be insufficient)
   • The 5mg amlodipine given as a stat dose was appropriate for gradual BP reduction 1, 2

2. Monitoring:

   • Continue close BP monitoring (target reduction of 20-25% in first hour, then to 160/110 over next 2-6 hours) 3
   • Repeat troponin to rule out cardiac damage
   • Monitor for orthostatic hypotension before further medication adjustments 1

Secondary Hypertension Evaluation

The 2024 ESC guidelines strongly recommend comprehensive screening for secondary causes of hypertension in adults diagnosed before age 40 1. This patient requires evaluation for:

1. Endocrine causes:

   • Elevated morning cortisol (321) suggests possible Cushing's syndrome
   • Consider 24-hour urinary free cortisol or overnight dexamethasone suppression test
   • Evaluate for pheochromocytoma given the paroxysmal nature of symptoms (headache, palpitations) 4
   • Complete thyroid function tests (TSH is normal at 1.95)

2. Renal causes:

   • History of recurrent UTIs warrants renal imaging
   • Urinalysis for proteinuria/hematuria
   • Renal artery stenosis evaluation

3. Sleep apnea:

   • Screening indicated given obesity 1

Long-term Management Plan

1. Medication optimization:

   • Target BP: 120-129 mmHg systolic as recommended by 2024 ESC guidelines 1
   • Labetalol can be continued if well-tolerated, but may need dose adjustment 5
   • Consider adding a thiazide diuretic as recommended for combination therapy 2
   • Avoid ACE inhibitors/ARBs given previous adverse reactions
   • Consider adding spironolactone if BP remains uncontrolled 2

2. Lifestyle modifications:

   • Sodium restriction (<2,300 mg/day)
   • DASH diet high in fruits, vegetables, low-fat dairy
   • Regular physical activity (150 minutes/week of moderate exercise)
   • Weight loss with target BMI of 20-25 kg/m²
   • Alcohol moderation 2

3. Follow-up:

   • Close monitoring within 1 week to assess BP control
   • Complete secondary cause workup
   • Monitor for labetalol side effects (fatigue, dizziness, nausea) 5
   • Evaluate glucose control given elevated reading and history of gestational diabetes

Cautions and Considerations

1. Avoid rapid BP reduction which can lead to cerebral hypoperfusion
2. Watch for orthostatic hypotension with labetalol, particularly when adding other agents 1
3. Monitor for side effects of labetalol including fatigue (5%), dizziness (11%), and nausea (6%) 5
4. Evaluate for diabetes given elevated glucose and history of gestational diabetes
5. Consider specialist referral if BP remains uncontrolled or secondary cause is identified 2

This patient's young age, poor BP control despite medication, and elevated cortisol strongly suggest a secondary cause of hypertension that requires thorough investigation while simultaneously achieving better BP control.