What is the best management approach for a 67-year-old patient with normal blood pressure (BP) at rest (120/80 mmHg) but significant hypertension during activity (160/80 mmHg)?

Management of Exercise-Induced Hypertension in a 67-Year-Old

This patient requires confirmation of blood pressure measurements with home or ambulatory monitoring, followed by initiation of lifestyle modifications and likely pharmacological therapy, as the exercise BP of 160/80 mmHg represents stage 1 hypertension that warrants treatment to reduce cardiovascular risk. 1

Diagnostic Confirmation

Confirm the diagnosis with proper measurement technique:

• Use validated automated upper arm cuff device with appropriate cuff size 1
• Obtain multiple readings over 2-3 office visits, taking the average of 2 readings per visit 1
• Consider home BP monitoring (threshold ≥135/85 mmHg) or 24-hour ambulatory monitoring (threshold ≥130/80 mmHg) to confirm the diagnosis 1
• Measure BP in both arms simultaneously at first visit; use the arm with higher readings for subsequent measurements 1

The exercise BP of 160/80 mmHg meets criteria for Grade 1 hypertension (140-159/90-99 mmHg), even though resting BP is normal. 1 This exaggerated BP response to activity is clinically significant and requires intervention. 1

Risk Stratification

At age 67, this patient is automatically considered high-risk for cardiovascular disease, which influences treatment decisions: 1, 2

• Calculate 10-year atherosclerotic CVD risk using validated tools (ASCVD calculator, QRISK2, or SCORE) 1
• Screen for target organ damage (ECG, echocardiogram if indicated, urinalysis for proteinuria, serum creatinine/eGFR) 1
• Assess for diabetes, chronic kidney disease, or existing cardiovascular disease 1, 2

Lifestyle Modifications (Initiate Immediately)

All patients with elevated BP should begin comprehensive lifestyle interventions: 1, 3

• Dietary modifications:

  • Sodium restriction to <1500 mg/day or reduction by at least 1000 mg/day 2, 3
  • Increase potassium intake to 3500-5000 mg/day 2, 4
  • Follow DASH diet emphasizing fruits, vegetables, whole grains, and low-fat dairy products with reduced saturated fat 2, 4

• Physical activity:

  • 90-150 minutes per week of aerobic or dynamic resistance exercise 2, 4
  • 30-60 minutes of aerobic exercise 4-7 days per week 5

• Weight management:

  • Maintain healthy body weight (BMI 18.5-24.9 kg/m²) and waist circumference (<102 cm for men, <88 cm for women) 5

• Alcohol moderation:

  • Limit to ≤14 standard drinks per week for men, ≤9 for women 5

• Smoking cessation:

  • Refer to cessation programs, as tobacco use independently causes CVD and mortality 1

Pharmacological Treatment Decision

Given the patient's age (67 years) and exercise BP of 160/80 mmHg, immediate pharmacological therapy is recommended alongside lifestyle modifications: 1

The 2024 ESC guidelines recommend prompt initiation of BP-lowering medication for confirmed BP ≥140/90 mmHg, irrespective of CVD risk. 1 The patient's age alone places them in a high-risk category that warrants immediate treatment rather than waiting 3-6 months for lifestyle intervention alone. 1, 2

First-Line Pharmacological Therapy

For this patient, initiate combination therapy with a RAS blocker plus either a dihydropyridine calcium channel blocker or thiazide diuretic: 1

Preferred initial regimen (assuming non-Black patient):

• Low-dose ACE inhibitor (e.g., lisinopril 10 mg daily) 1, 2, 6 OR ARB
• PLUS dihydropyridine calcium channel blocker (e.g., amlodipine 5 mg daily) 1, 3
• Use fixed-dose single-pill combination when possible to improve adherence 1

Alternative initial regimen:

• Low-dose ACE inhibitor/ARB PLUS thiazide/thiazide-like diuretic (chlorthalidone or indapamide preferred over hydrochlorothiazide) 1, 3

For Black patients, modify approach:

• Start with ARB plus dihydropyridine calcium channel blocker OR calcium channel blocker plus thiazide diuretic 1, 2
• ACE inhibitors are less effective as monotherapy in Black patients 6, 3

Important caveat: Consider monotherapy only if the patient is >80 years, frail, or has symptomatic orthostatic hypotension. 1 At age 67 without these features, combination therapy is preferred. 1

Blood Pressure Targets

Target systolic BP of 120-129 mmHg for this patient, provided treatment is well tolerated: 1, 2

• This represents the most recent (2024) ESC guideline recommendation for most adults 1
• Aim to reduce BP by at least 20/10 mmHg from baseline 1, 2
• Achieve target within 3 months of treatment initiation 1, 2

If the 120-129 mmHg target is poorly tolerated:

• Apply the ALARA principle (as low as reasonably achievable) 1
• Minimum acceptable target is <140/90 mmHg 1

Monitoring and Titration

Reassess BP within 2-4 weeks after initiating therapy: 7

• Use both office and home BP measurements for monitoring 1, 2
• Verify medication adherence and proper BP measurement technique before dose adjustments 7

If BP remains uncontrolled after 4-6 weeks on dual therapy:

• Increase to three-drug combination: RAS blocker + dihydropyridine calcium channel blocker + thiazide/thiazide-like diuretic 1, 7
• Preferably use single-pill combination for the three-drug regimen 1

If BP remains uncontrolled on three-drug combination:

• Add spironolactone as fourth-line agent 1
• If spironolactone contraindicated or not tolerated, consider amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Common Pitfalls to Avoid

• Do not combine two RAS blockers (ACE inhibitor + ARB) - this is not recommended and increases adverse effects without additional benefit 1
• Do not use beta-blockers as first-line therapy unless there are compelling indications (angina, post-MI, heart failure, or rate control needed) 1
• Do not discontinue medications once BP is controlled - maintain lifelong treatment, even beyond age 85 if well tolerated 1
• Do not ignore the exercise BP elevation - this represents true hypertension requiring treatment, not just "white coat" effect 1

Long-Term Management

Continue BP-lowering medication lifelong: 1

• Maintain treatment even beyond age 85 years if well tolerated 1
• Take medications at the most convenient time of day to establish habitual pattern and improve adherence 1
• Screen fasting lipids and treat dyslipidemia according to guidelines 5
• Consider statin and/or aspirin therapy based on overall cardiovascular risk 5

Expected benefit: A 10 mmHg reduction in systolic BP decreases cardiovascular events by approximately 20-30%. 3

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