What are the recommendations for managing a patient with hypertension (HTN) who has a coronary artery calcium score of 0, no significant coronary disease, and a large hiatal hernia?

Management Recommendations for Hypertension with Zero Coronary Artery Calcium Score

Continue optimizing blood pressure control with current antihypertensive therapy, targeting <130/80 mmHg, while the hiatal hernia requires no specific intervention unless symptomatic. 1

Blood Pressure Management Strategy

Target Blood Pressure

• Aim for BP <130/80 mmHg in this hypertensive patient 1
• The 2020 International Society of Hypertension guidelines establish this target for all hypertensive patients to reduce cardiovascular morbidity and mortality 1
• If the patient is elderly (>65 years), individualize based on frailty, with acceptable target <140/80 mmHg 1

Medication Optimization

Since the patient has hypertension but zero coronary calcium score (indicating no subclinical atherosclerosis), the cardiovascular risk stratification differs from patients with established coronary disease:

First-line therapy approach: 1, 2

• Start or continue with ACE inhibitor (such as lisinopril) or ARB as initial therapy 1, 2
• If BP remains uncontrolled, add a dihydropyridine calcium channel blocker (such as amlodipine 5-10mg) 1, 3
• Third-line: add thiazide or thiazide-like diuretic if needed 1
• Use single-pill combinations when possible to improve adherence 1

Key consideration: A CAC score of 0 is highly reassuring and indicates very low near-term cardiovascular risk, so aggressive statin therapy or aspirin for primary prevention is not indicated based on this finding alone 4

Lifestyle Modifications (Essential Component)

The following non-pharmacological interventions must be emphasized: 1, 5

• Weight management: Achieve and maintain healthy BMI (18.5-24.9 kg/m²) 1
• Sodium restriction: Limit intake to <2000 mg/day 4, 5
• DASH diet: High in vegetables, fruits, whole grains, and low-fat dairy products 1, 4
• Alcohol moderation: Maximum 14 drinks/week for men, 9 drinks/week for women 5
• Regular exercise: 30-60 minutes of moderate-intensity aerobic activity on most days, preferably daily 1, 4

Hiatal Hernia Management

No Intervention Required Unless Symptomatic

• The large hiatal hernia noted incidentally requires no specific treatment if the patient is asymptomatic 6
• Hiatal hernias are common incidental findings and do not affect cardiovascular risk or hypertension management 6, 7

Monitor for Symptoms

Evaluate the patient for: 6

• Gastroesophageal reflux symptoms (heartburn, regurgitation)
• Dysphagia or chest discomfort
• Respiratory symptoms (chronic cough, aspiration)

If symptomatic: Refer to gastroenterology for consideration of medical management (proton pump inhibitors) or surgical repair if severe 6

Follow-Up Monitoring

Short-term (1-3 months): 1

• Reassess BP to ensure target <130/80 mmHg is achieved
• Evaluate medication adherence and tolerability
• Reinforce lifestyle modifications

Long-term (annually): 1

• Continue BP monitoring
• Reassess cardiovascular risk factors
• No need to repeat coronary calcium scoring - a score of 0 has excellent negative predictive value and does not require repeat imaging for at least 5-10 years 4

Common Pitfalls to Avoid

Do not over-treat based on the hiatal hernia: 6, 7

• The hiatal hernia is an incidental finding and should not influence hypertension management
• Avoid unnecessary gastrointestinal workup unless the patient has specific GI symptoms

Do not under-treat the hypertension: 1

• Despite the reassuring CAC score of 0, hypertension itself remains a major cardiovascular risk factor requiring treatment to target
• The absence of coronary calcification does not eliminate the need for BP control

Ensure medication adherence: 1

• Poor adherence is the most common cause of resistant hypertension 1
• Use once-daily dosing and single-pill combinations to improve compliance 1
• Consider home BP monitoring to engage the patient in self-management 1