What is the treatment for adolescent hypertension?

Treatment of Adolescent Hypertension

For this 15-year-old with BP 130/80 mmHg (Stage 1 hypertension), initiate intensive lifestyle modifications for 3-6 months before considering pharmacologic therapy, unless there is evidence of target organ damage, symptomatic hypertension, or diabetes. 1

Confirm the Diagnosis First

• Measure blood pressure on three separate days using an appropriately-sized cuff with the adolescent seated and relaxed after 5 minutes of rest, with the right arm supported at heart level 2, 3
• For adolescents ≥13 years, Stage 1 hypertension is defined as systolic BP 130-139 mmHg or diastolic BP 80-89 mmHg 1, 2
• Consider ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis and rule out white coat hypertension 3

Evaluate for Secondary Causes and Target Organ Damage

• Obtain perinatal history, nutritional history, physical activity patterns, psychosocial factors, and family history to identify findings suggestive of secondary hypertension 1
• Perform urinalysis to detect proteinuria or hematuria suggesting renal parenchymal disease 2, 4
• Echocardiography should be performed if considering pharmacologic treatment to assess for left ventricular hypertrophy (defined as LV mass >51 g/m²·⁷) 1

Initial Treatment: Intensive Lifestyle Modifications (3-6 Months)

Implement the following lifestyle interventions immediately: 1, 2

Dietary Modifications

• DASH dietary pattern: 8-10 servings of fruits/vegetables daily, 2-3 servings of low-fat dairy, whole grains 2, 3, 4
• Sodium restriction to <1500 mg/day (eliminate added salt to cooked foods and reduce high-sodium foods) 1, 3
• Increase potassium intake to 3500-5000 mg/day through dietary sources 3
• Limit total fat to 25-30% of calories, saturated fat to <7%, and avoid trans fats 4

Physical Activity

• Prescribe moderate to vigorous aerobic exercise 3-5 days per week, 30-60 minutes per session (or 90-150 minutes per week total) 1, 3

Weight Management

• If overweight or obese, weight loss has a dose-response relationship of approximately 1 mmHg BP reduction per kilogram lost 3

When to Initiate Pharmacologic Treatment

Start medications immediately (without waiting 3-6 months) if: 1, 2

• Stage 2 hypertension (BP ≥140/90 mmHg)
• Symptomatic hypertension (headaches, cognitive changes)
• Left ventricular hypertrophy on echocardiography
• Diabetes mellitus present
• Chronic kidney disease present

Start medications after 3-6 months if: 1

• Target BP not reached with lifestyle modifications alone
• BP remains ≥130/80 mmHg despite adherence to lifestyle changes

First-Line Pharmacologic Agents

Preferred initial medications include: 1, 2

• ACE inhibitors (e.g., lisinopril, enalapril) - most commonly recommended first-line agent 1, 2
• Angiotensin receptor blockers (ARBs) (e.g., candesartan) 1, 2
• Long-acting calcium channel blockers (e.g., amlodipine) 1, 2
• Thiazide diuretics (e.g., hydrochlorothiazide, chlorthalidone) 1, 2

Critical Contraception Counseling

• ACE inhibitors and ARBs are teratogenic and contraindicated during pregnancy 1
• Mandatory reproductive counseling must be provided before prescribing to adolescents of childbearing age 1, 4
• These agents should be avoided in individuals not using reliable contraception 1

Monitoring After Starting ACE Inhibitors/ARBs

• Check serum creatinine and potassium 7-14 days after initiation to monitor for hyperkalemia 4

Treatment Goals

Target blood pressure is <130/80 mmHg for adolescents ≥13 years (or <90th percentile for age, sex, and height, whichever is lower) 1, 2

Follow-Up Schedule

• Monitor every 3-6 months during lifestyle modification period 3
• Blood pressure should be measured at every clinic visit 1
• If pharmacologic treatment is initiated, use ABPM to assess treatment effectiveness 1

Common Pitfalls to Avoid

• Do not delay confirmation with repeat measurements - single elevated readings are insufficient for diagnosis 2, 3
• Do not use electrocardiography for LVH screening - echocardiography is the recommended modality 1
• Do not prescribe ACE inhibitors/ARBs without contraception counseling in females of childbearing age 1, 4
• Do not assume primary hypertension - always evaluate for secondary causes, especially in younger adolescents 1, 2