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

Young Hypertension Workup

In young patients with hypertension, begin with proper blood pressure confirmation using repeated measurements and ambulatory monitoring, then systematically evaluate for secondary causes through targeted history, physical examination, and laboratory screening, as secondary hypertension is significantly more common in this age group than in older adults.

Initial Blood Pressure Confirmation

• Obtain repeated blood pressure measurements on at least three separate occasions before diagnosing hypertension, discarding the first reading and averaging subsequent readings 1
• Use proper technique with appropriately sized cuff; wrist and forearm measurements should not be used 1
• Consider ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis and exclude white coat hypertension, particularly in high-risk patients 1
• School-based blood pressure readings should not be used for diagnosis 1

History and Physical Examination for Secondary Causes

Focused history should specifically assess for:

• Age of onset - hypertension presenting before age 30 years strongly suggests secondary causes 1, 2
• Abrupt onset or sudden worsening of previously controlled hypertension 1, 2
• Symptoms suggesting specific etiologies:
  • Urinary tract infections, hematuria, nocturia, or family history of polycystic kidney disease (renal parenchymal disease) 2
  • Episodic headaches, palpitations, sweating, or labile blood pressure (pheochromocytoma) 2
  • Muscle cramps, weakness, or hypokalemia (primary aldosteronism) 2
  • Snoring, daytime sleepiness, witnessed apneas (obstructive sleep apnea) 2
• Medication and substance use including oral contraceptives, NSAIDs, decongestants, stimulants, illicit drugs (especially cocaine), alcohol, and tobacco 1, 2
• Family history of early-onset hypertension, which may suggest monogenic hypertension 1

Physical examination should identify:

• Features of Cushing syndrome or neurofibromatosis 2
• Femoral pulse assessment and blood pressure in all four extremities to evaluate for coarctation of the aorta 1
• Palpation for enlarged kidneys (polycystic kidney disease) 2
• Epigastric or upper abdominal bruit suggesting renovascular disease 1, 2
• Signs of obstructive sleep apnea including obesity and large neck circumference 2

Laboratory and Diagnostic Workup

Basic screening for all young hypertensive patients should include 1, 2:

• Complete metabolic panel with serum creatinine, eGFR, sodium, and potassium (hypokalemia suggests primary aldosteronism or renovascular disease)
• Fasting blood glucose or HbA1c
• Lipid panel
• Urinalysis with urine albumin-to-creatinine ratio
• Thyroid-stimulating hormone
• 12-lead ECG to assess for left ventricular hypertrophy

The 2024 European Society of Cardiology guidelines recommend screening ALL young adults with confirmed hypertension for primary aldosteronism using plasma aldosterone-to-renin ratio, given its 5-20% prevalence and treatability 1, 2

Targeted Testing Based on Clinical Suspicion

Suspect renovascular hypertension and obtain renal imaging (ultrasound with Doppler, CT or MR angiography) if 1, 2:

• Stage 2 hypertension with significant diastolic elevation
• Abrupt onset or worsening hypertension
• Flash pulmonary edema
• Discrepant kidney sizes on ultrasound
• Hypokalemia
• Epigastric/abdominal bruit on examination

Suspect primary aldosteronism and obtain confirmatory testing (intravenous saline suppression test, adrenal CT, adrenal vein sampling) if 2:

• Hypokalemia (spontaneous or diuretic-induced)
• Elevated aldosterone-to-renin ratio
• Family history of early-onset hypertension
• Resistant hypertension

Suspect obstructive sleep apnea and obtain polysomnography if 1, 2:

• Snoring, daytime sleepiness, witnessed apneas
• Obesity
• Non-dipping nocturnal blood pressure pattern on ABPM

Suspect pheochromocytoma and obtain 24-hour urinary metanephrines if 2:

• Episodic symptoms (headaches, palpitations, sweating)
• Labile hypertension
• Hypertensive urgency or emergency

What NOT to Do

• Do not routinely measure serum uric acid for evaluation of elevated blood pressure 1
• Do not routinely perform vascular imaging such as carotid intimal-media thickness or pulse wave velocity measurements 1
• Do not perform expensive imaging studies before completing basic laboratory screening 2

Treatment Approach

Lifestyle modifications should be initiated immediately 1:

• Weight loss if obese (particularly important as obesity is strongly associated with hypertension in young patients)
• DASH-type diet with sodium restriction (<1.5 g/day for ages 9-13 years, adjusted for age) 1
• Regular vigorous physical activity 1
• Avoidance of alcohol, tobacco, and illicit drugs 1

Pharmacological therapy indications:

• Stage 2 hypertension regardless of symptoms 1
• Stage 1 hypertension with target organ damage (left ventricular hypertrophy) 1
• Stage 1 hypertension unresponsive to 3-6 months of lifestyle modification 1

First-line antihypertensive agents include thiazide or thiazide-like diuretics, ACE inhibitors or ARBs (such as lisinopril or losartan), and calcium channel blockers (such as amlodipine) 3, 4, 5, 6

Follow-up Monitoring

• Patients on antihypertensive medications should be seen every 4-6 weeks until blood pressure is controlled, then intervals can be extended 1
• Patients treated with lifestyle modification only should be followed every 3-6 months 1
• Target blood pressure is <130/80 mmHg for adults under 65 years 6

Critical Pitfalls to Avoid

• Failing to consider secondary causes in young patients - approximately 10% of all hypertension is secondary, but this percentage is substantially higher in young adults 7, 2
• Missing medication-induced hypertension by not obtaining thorough medication and substance use history 2
• Delaying diagnosis and treatment, which can lead to irreversible vascular remodeling and target organ damage 2
• Not screening for primary aldosteronism, which affects 8-20% of resistant hypertension cases and is highly treatable 1, 2