What are the initial medications and investigations for young individuals with hypertension?

Management of Hypertension in Young Individuals

For young individuals with hypertension, first-line medications include ACE inhibitors (lisinopril), ARBs (losartan), dihydropyridine calcium channel blockers (amlodipine), or thiazide-like diuretics, with initial investigations focusing on identifying secondary causes and assessing target organ damage. 1

Initial Evaluation and Investigations

Blood Pressure Assessment

• For adolescents 13 years and older: Use adult criteria 1
  • Normal BP: <120/80 mmHg
  • Elevated BP: 120-129/<80 mmHg
  • Stage 1 Hypertension: 130-139/80-89 mmHg
  • Stage 2 Hypertension: ≥140/90 mmHg

Essential Investigations

1. Complete blood count
2. Basic metabolic panel (electrolytes, BUN, creatinine)
3. Urinalysis and urine albumin-to-creatinine ratio to assess for kidney disease
4. Lipid profile to evaluate cardiovascular risk
5. Fasting glucose to screen for diabetes
6. Echocardiogram to assess for left ventricular hypertrophy 1, 2
7. Ambulatory Blood Pressure Monitoring (ABPM) to confirm diagnosis and rule out white coat hypertension 1

Secondary Cause Investigations

Young patients have higher likelihood of secondary hypertension, requiring:

• Renal ultrasound to evaluate kidney structure
• Plasma renin activity and aldosterone levels to screen for primary hyperaldosteronism
• Plasma/urine metanephrines if pheochromocytoma suspected
• Renal artery imaging if renovascular hypertension suspected

Treatment Approach

Lifestyle Modifications (First-line for 3-6 months)

• DASH diet with reduced sodium (<2,300 mg/day) and increased potassium intake 1, 2
• Regular physical activity: 30-60 minutes of moderate-to-vigorous exercise 3-5 days/week 1, 2
• Weight management for overweight/obese individuals 1
• Limit alcohol consumption and avoid tobacco products 2

Pharmacological Therapy

First-line Medications

1. ACE inhibitors (e.g., lisinopril) 1, 3

   • Starting dose: 5-10 mg daily
   • Particularly beneficial in patients with proteinuria or diabetes
   • Contraindicated in pregnancy

2. ARBs (e.g., losartan) 1, 4

   • Starting dose: 25-50 mg daily
   • Alternative when ACE inhibitors cause cough
   • Also contraindicated in pregnancy

3. Dihydropyridine calcium channel blockers (e.g., amlodipine) 1, 5

   • Starting dose: 2.5-5 mg daily
   • Good option for females of childbearing potential
   • Effective across different demographic groups

4. Thiazide-like diuretics (e.g., chlorthalidone) 1, 2

   • Particularly effective in African American patients

Special Considerations

• For African American patients: Consider starting with calcium channel blocker or thiazide diuretic 2
• For females of childbearing potential: Avoid ACE inhibitors and ARBs; prefer calcium channel blockers 1, 2
• For patients with kidney disease or proteinuria: ACE inhibitor or ARB preferred 1, 2

Treatment Algorithm

1. Start with lifestyle modifications for 3-6 months
2. If BP remains ≥140/90 mmHg or target organ damage is present:
   • Begin with a single medication at low dose
   • Monitor every 2-4 weeks for response
3. If inadequate response:
   • Increase dose until maximum tolerated or maximum recommended dose
   • If still inadequate, add second agent from a different class
4. For stage 2 hypertension (≥140/90 mmHg):
   • Consider starting with two medications from different classes 2, 1

Follow-up and Monitoring

• Initial follow-up: Every 4-6 weeks until BP is controlled
• Once controlled: Every 3-6 months
• Home BP monitoring: Recommend for all patients to guide treatment adjustments
• Laboratory monitoring: Check electrolytes and kidney function 1-2 weeks after starting ACE inhibitors, ARBs, or diuretics 1, 2

Important Caveats

• Avoid short-acting nifedipine in hypertensive emergencies due to risk of excessive BP reduction 2
• Target BP goal should be <130/80 mmHg for most young adults 1
• White coat hypertension is common in young individuals; confirm with home or ambulatory monitoring before starting medications
• Medication adherence is particularly challenging in young patients; consider once-daily dosing and combination pills when possible

Remember that early identification and proper management of hypertension in young individuals can significantly reduce the long-term risk of cardiovascular disease and mortality.