What is the initial management approach for an 18-year-old man with hypertension?

Initial Management of Hypertension in an 18-Year-Old Man

Begin with 3-6 months of intensive lifestyle modifications before starting medication, unless blood pressure is ≥140/90 mmHg, in which case initiate pharmacological therapy immediately alongside lifestyle changes. 1, 2

Confirm the Diagnosis

• Measure blood pressure on three separate visits using an appropriately sized cuff with the patient seated and relaxed 1, 2
• For an 18-year-old, hypertension is defined as BP ≥130/80 mmHg or BP ≥95th percentile for age, sex, and height 1
• Elevated blood pressure (prehypertension) is BP 120-129/<80 mmHg or BP ≥90th percentile 1
• Consider ambulatory blood pressure monitoring if there is unusual variability or suspected white coat hypertension 1

Evaluate for Secondary Causes

At age 18, secondary hypertension is more likely than in older adults and must be ruled out before committing to lifelong therapy 1:

• Check for renal disease: serum creatinine, urinalysis for protein and blood 1
• Screen for endocrine causes: serum electrolytes (hypokalemia suggests hyperaldosteronism), blood glucose 1
• Assess for coarctation of aorta: check femoral pulses, measure blood pressure in legs 1
• Consider sleep apnea if overweight with daytime somnolence 1
• Obtain 12-lead ECG to assess for left ventricular hypertrophy 1

Implement Lifestyle Modifications (All Patients)

Dietary Changes

• Adopt the DASH diet: 8-10 servings/day of fruits and vegetables, 2-3 servings/day of low-fat dairy products 1, 2
• Restrict sodium to <2,300 mg/day (ideally <1,500 mg/day), which lowers BP by approximately 5 mmHg 1, 2
• Increase dietary potassium to 3,500-5,000 mg/day through food sources, which lowers BP by approximately 5 mmHg 1, 2
• Limit total fat to 25-30% of calories, saturated fat to <7%, eliminate trans fats 1, 2

Weight and Exercise

• Achieve and maintain ideal body weight (BMI 20-25 kg/m²); expect 1 mmHg BP reduction per 1 kg weight loss 1
• Prescribe 150 minutes/week of moderate-intensity aerobic exercise (brisk walking 30-60 minutes, 5-7 times/week), which lowers BP by approximately 5 mmHg 1, 2
• Add resistance training 2-3 times/week for additional BP reduction of 2-4 mmHg 1

Substance Use

• Limit alcohol to ≤2 standard drinks/day for men (maximum 14/week), which lowers BP by approximately 4 mmHg 1
• Counsel on smoking cessation if applicable, as smoking increases cardiovascular risk more than mild hypertension 1

Pharmacological Therapy Decision Algorithm

If BP is 120-139/70-89 mmHg (Elevated/Stage 1):

• Continue lifestyle modifications alone for 3-6 months 1, 2
• Reassess BP monthly during this period 1
• If BP remains elevated after 3-6 months, initiate medication 1, 2

If BP is ≥140/90 mmHg (Stage 2):

• Initiate pharmacological therapy immediately in addition to lifestyle modifications 1, 2

First-Line Medication Selection

Start with an ACE inhibitor as the preferred initial agent 1, 2:

• Lisinopril 5-10 mg once daily is the recommended starting dose 2, 3
• ACE inhibitors are first-line for adolescents and young adults with hypertension 1, 2
• Provide reproductive counseling before prescribing due to teratogenic effects; ACE inhibitors are contraindicated in pregnancy 1, 2

Alternative First-Line Options:

• Angiotensin receptor blocker (ARB) if ACE inhibitor causes intolerable cough 1, 2
• Thiazide-like diuretic (chlorthalidone or indapamide preferred over hydrochlorothiazide) 1, 4
• Calcium channel blocker (long-acting amlodipine) 1

Common pitfall: Avoid using beta-blockers as first-line therapy in young patients without specific indications (e.g., coronary disease, heart failure), as they are less effective at reducing cardiovascular events in this population 1, 4.

Monitoring and Titration

• Check serum creatinine and potassium 7-14 days after initiating ACE inhibitor or ARB 1, 2
• Monitor for hyperkalemia with ACE inhibitors/ARBs or hypokalemia with diuretics 1, 2
• Reassess BP within 2-4 weeks of medication initiation 2
• Schedule monthly visits until BP target is achieved 1

Blood Pressure Targets

Target BP is <120/80 mmHg or <90th percentile for age, sex, and height 1, 2:

• The 2024 ESC guidelines recommend systolic BP 120-129 mmHg for most adults if well tolerated 1
• The 2025 ADA guidelines recommend <120/80 mmHg for adults <65 years 1
• If target cannot be achieved due to intolerance, aim for "as low as reasonably achievable" 1

Escalation Strategy

If BP goal is not achieved after 4 weeks on monotherapy:

• Increase dose of initial medication 2, 3
• Or add a second agent from a different class (preferably as a fixed-dose combination) 1
• Preferred two-drug combinations: ACE inhibitor + calcium channel blocker, ACE inhibitor + thiazide diuretic, or ARB + calcium channel blocker 1

Key principle: Use fixed-dose single-pill combinations when possible to improve adherence 1.