What is the recommended treatment for a 20-year-old with elevated blood pressure (Hypertension) readings of 140/90 and 142/86?

Management of Elevated Blood Pressure in a 20-Year-Old

For a 20-year-old with confirmed hypertension (BP 140/90 and 142/86), comprehensive screening for secondary causes of hypertension is mandatory before initiating treatment, followed by immediate lifestyle modifications and pharmacological therapy with combination treatment (RAS blocker plus calcium channel blocker or diuretic) as first-line therapy. 1

Critical First Step: Screen for Secondary Hypertension

• Comprehensive screening for secondary hypertension is required in all adults diagnosed with hypertension before age 40, except in obese young adults where obstructive sleep apnea evaluation should be prioritized first 1
• Screening for primary aldosteronism by measuring renin and aldosterone levels should be considered in all adults with confirmed BP ≥140/90 mmHg 1
• This step is crucial because secondary causes are more prevalent in young adults, and treating the underlying cause may resolve hypertension entirely 1

Confirm the Diagnosis

• Blood pressure should be confirmed on separate days with proper measurement technique: seated position, feet on floor, arm supported at heart level, after 5 minutes of rest 1
• Consider home blood pressure monitoring (HBPM) or 24-hour ambulatory blood pressure monitoring (ABPM) to exclude white-coat hypertension, which is common in young patients 1
• Home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg confirms true hypertension 2

Immediate Lifestyle Modifications (Start Immediately)

All patients with confirmed BP ≥140/90 mmHg require both lifestyle measures AND pharmacological treatment initiated promptly, regardless of cardiovascular risk 1

Specific lifestyle interventions to implement:

• Weight management: Achieve and maintain body mass index of 20-25 kg/m² 1, 3
• Sodium restriction: Limit intake to <2 g/day (approximately 5 g salt/day) 1, 3
• DASH dietary pattern: Emphasize fruits, vegetables, low-fat dairy products, reduced saturated fat and cholesterol 1, 4, 5
• Potassium supplementation: Increase intake by 0.5-1.0 g/day through potassium-enriched salt (75% sodium chloride/25% potassium chloride) or fruits and vegetables 1
• Physical activity: Regular aerobic exercise 3, 5, 6
• Alcohol limitation: Maximum 2 standard drinks/day (14/week for men, 9/week for women) 1, 3, 6
• Restrict free sugar consumption: Maximum 10% of energy intake, discourage sugar-sweetened beverages 1

Pharmacological Treatment (Start Promptly)

Combination BP-lowering treatment is recommended as initial therapy for most patients with confirmed hypertension (BP ≥140/90 mmHg), as it provides more effective BP control than monotherapy 1

First-line combination options:

• Preferred combination: RAS blocker (ACE inhibitor OR ARB) PLUS dihydropyridine calcium channel blocker 1, 3
• Alternative combination: RAS blocker (ACE inhibitor OR ARB) PLUS thiazide/thiazide-like diuretic 1, 3
• Fixed-dose single-pill combination is strongly recommended to improve adherence 1

Specific medication examples:

• ACE inhibitor: Lisinopril 10-40 mg daily or enalapril 7, 3
• ARB: Candesartan or olmesartan 3
• Calcium channel blocker: Amlodipine 5-10 mg daily (extended-release preferred) 1, 3
• Thiazide-like diuretic: Chlorthalidone 12.5-25 mg daily (preferred over hydrochlorothiazide due to longer duration of action) 1, 3

Important considerations for young patients:

• For younger patients like this 20-year-old, lower systolic targets (<130 mmHg) and diastolic targets (<80 mmHg) may be appropriate if achievable without undue treatment burden 1
• The 2024 ESC guidelines recommend targeting systolic BP of 120-129 mmHg in most adults if well tolerated 1
• Medications should be taken at the most convenient time of day to establish habitual patterns and improve adherence 1

If BP Not Controlled with Two-Drug Combination

• Increase to three-drug combination: RAS blocker + dihydropyridine calcium channel blocker + thiazide/thiazide-like diuretic, preferably as single-pill combination 1
• Never combine two RAS blockers (ACE inhibitor + ARB) as this increases adverse events without additional benefit 1

Monitoring and Follow-up

• Reassess within 2-4 weeks after initiating or adjusting therapy 2
• Goal is to achieve target BP within 3 months of initiating or modifying therapy 2
• Monitor serum creatinine/eGFR and potassium levels when using ACE inhibitors, ARBs, or diuretics 1
• Once BP is controlled and stable, at least yearly follow-up for BP and other cardiovascular risk factors 1

Common Pitfalls to Avoid

• Do not delay pharmacological treatment in favor of lifestyle modification alone—this 20-year-old with BP ≥140/90 mmHg requires both immediately 1
• Do not start with monotherapy when BP is ≥140/90 mmHg—combination therapy is more effective 1
• Do not skip secondary hypertension screening in young adults—this is a critical step that could identify a curable cause 1
• Do not use beta-blockers as first-line therapy unless there are compelling indications (angina, post-MI, heart failure, heart rate control) 1
• Maintain BP-lowering treatment lifelong if well tolerated—hypertension is a chronic condition requiring sustained management 1