What are the diagnostic criteria and management approach for a patient with a blood pressure of 150/100 according to the Canadian hypertension guidelines?

Hypertension Diagnosis and Management in This 66-Year-Old Male

Question #1: Diagnostic Criteria for Hypertension

This patient meets diagnostic criteria for hypertension with a single office visit showing BP 150/100 mmHg repeated once, given his multiple cardiovascular risk factors and target organ damage risk. 1

According to the most recent Canadian guidelines:

• For patients WITH macrovascular target organ damage or independent cardiovascular risk factors (which this patient has—smoking, family history of premature CHD, obesity from fast food consumption), hypertension is diagnosed when average systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg. 1

• This patient's BP of 150/100 mmHg clearly exceeds both thresholds 1

• The presence of multiple risk factors (32 pack-year smoking history, strong family history with father having CHD at age 48, sedentary lifestyle, excessive alcohol intake) eliminates the need for prolonged observation periods before diagnosis. 1

• For lower-risk patients without target organ damage or risk factors, more prolonged confirmation over 3-4 weeks would be required, but this does not apply here 2

Key diagnostic point: The bilateral measurement and single repeat confirm this is not a measurement artifact, and his high cardiovascular risk profile justifies immediate diagnosis rather than extended observation. 1

Question #2: Key Components of Physical Examination

The provider must specifically assess for target organ damage and cardiovascular complications, not just perform a routine physical exam.

Cardiovascular System Assessment:

• Examine for left ventricular hypertrophy: palpate for displaced, sustained apical impulse; auscultate for S4 gallop 3
• Assess for heart failure signs: elevated JVP, peripheral edema, pulmonary crackles 3
• Auscultate all major vessels for bruits (carotid, renal, femoral arteries) to detect atherosclerotic disease 3
• Palpate all peripheral pulses to assess for peripheral arterial disease 3

Fundoscopic Examination (already performed but critical):

• Look specifically for hypertensive retinopathy: arteriovenous nicking, copper/silver wiring, hemorrhages, exudates, papilledema 3

Abdominal Examination:

• Palpate for abdominal aortic aneurysm 3
• Auscultate for renal artery bruits (suggests renovascular hypertension) 1

Body Habitus:

• Measure waist circumference (target <102 cm in men)—critical given his fast food consumption 4
• Calculate BMI to quantify obesity 4

Neurological:

• Assess for prior stroke deficits or cognitive impairment 3

Question #3: Preliminary Laboratory Investigations

The following investigations must be ordered immediately upon diagnosis:

Mandatory Baseline Tests:

• Urinalysis (dipstick) for blood and protein to detect renal damage 3
• Serum electrolytes (sodium, potassium) and creatinine to assess renal function and establish baseline before starting ACE inhibitors or diuretics 3
• Fasting blood glucose to screen for diabetes (major risk factor) 3
• Fasting lipid profile (total cholesterol, HDL, LDL, triglycerides) to assess total cardiovascular risk 3, 4
• 12-lead electrocardiogram to detect left ventricular hypertrophy, prior MI, or ischemia 3

Additional Recommended Tests Given His Profile:

• Calculate 10-year cardiovascular risk using validated tools—this patient likely exceeds 15-20% given age, smoking, family history, and hypertension 3, 4
• Consider eGFR calculation from creatinine to detect early chronic kidney disease 4

Optional/Specialized Tests (Not Routine):

• Echocardiography is NOT routine but may be considered if LVH suspected on ECG or physical exam 2
• Home or ambulatory BP monitoring is NOT needed for this straightforward case with clear office hypertension and multiple risk factors 2
• Renovascular screening (renal ultrasound, plasma renin) only if clinical suspicion exists (renal bruit, resistant hypertension, acute rise in creatinine) 1

Critical pitfall to avoid: Do not delay treatment while waiting for optional tests. This patient requires immediate pharmacotherapy given his BP ≥140/90 mmHg with multiple cardiovascular risk factors. 1 The mandatory baseline tests listed above should be ordered but treatment should begin promptly, not after extended observation periods that apply only to lower-risk patients. 1

Treatment threshold met: With BP 150/100 mmHg, smoking history, premature family history of CHD, and sedentary lifestyle with poor diet, this patient has clear indications for both immediate lifestyle modification counseling AND pharmacological therapy. 1 Target BP should be <140/90 mmHg, and initial therapy should include either a thiazide diuretic, ACE inhibitor, ARB, or long-acting calcium channel blocker, with strong consideration for fixed-dose combination therapy given his BP is >10 mmHg above target. 1