What is the next step in managing a 27-year-old with hypertension (high blood pressure), morning average reading of 137/87 mmHg and evening average reading of 147/102 mmHg, according to National Institute for Health and Care Excellence (NICE) guidelines?

Management of a 27-Year-Old with Elevated Home Blood Pressure Readings

You should arrange ambulatory blood pressure monitoring (ABPM) or continue home blood pressure monitoring to confirm the diagnosis of hypertension before initiating treatment, as the patient's readings show significant variability between morning (137/87 mmHg) and evening (147/102 mmHg) measurements.

Diagnostic Confirmation Required

The patient's home readings suggest possible hypertension, but NICE guidelines require proper confirmation before diagnosis:

• Home blood pressure monitoring confirms hypertension when the average is ≥135/85 mmHg, which this patient meets with evening readings of 147/102 mmHg 1
• The morning average of 137/87 mmHg also exceeds the home BP threshold for hypertension (≥135/85 mmHg) 1
• NICE guidelines recommend confirming elevated office readings with either ABPM (preferred) or home BP monitoring over at least 4-7 days, taking two measurements morning and evening 2
• The significant discrepancy between morning (137/87) and evening (147/102) readings warrants 24-hour ABPM to assess the true BP pattern, as ambulatory BP ≥130/80 mmHg confirms hypertension 1

Risk Stratification for This Young Patient

At age 27, this patient requires careful cardiovascular risk assessment before treatment decisions:

• Calculate 10-year ASCVD risk using validated tools (QRISK2 in UK settings), though risk will likely be low given the young age 1
• Screen for secondary causes of hypertension given the young age, including renal disease, endocrine disorders, and obstructive sleep apnea 3
• Assess for target organ damage with urinalysis (proteinuria), serum creatinine/eGFR, ECG (left ventricular hypertrophy), and fundoscopy 1
• Check for metabolic syndrome components: fasting glucose, lipid profile, BMI, and waist circumference 1

Treatment Algorithm Based on Confirmed BP Level

If Confirmed Stage 1 Hypertension (140-159/90-99 mmHg):

Start with intensive lifestyle interventions for 3-6 months before considering drug therapy, unless high-risk features are present 1:

• Lifestyle modifications include: sodium restriction to <2,300 mg/day, DASH-style diet with 8-10 servings of fruits/vegetables daily, weight loss if BMI >25 kg/m², regular aerobic exercise 30-60 minutes most days, and alcohol moderation 1, 2, 4
• Drug treatment is indicated immediately only if: 10-year ASCVD risk ≥10%, diabetes mellitus, chronic kidney disease (eGFR <60 mL/min/1.73m²), or evidence of target organ damage 1
• For a 27-year-old without these high-risk features, continue lifestyle intervention and monitor BP monthly for 3-6 months before initiating pharmacotherapy 1

If Confirmed Stage 2 Hypertension (≥160/100 mmHg):

Start drug treatment immediately alongside lifestyle interventions 1:

• First-line therapy for non-Black patients: low-dose ACE inhibitor (e.g., lisinopril 10 mg daily) or ARB (e.g., candesartan 8 mg daily) 1
• First-line therapy for Black patients: low-dose ARB plus dihydropyridine calcium channel blocker (e.g., amlodipine 5 mg daily) or thiazide-like diuretic 1
• Target BP <140/90 mmHg minimum, ideally <130/80 mmHg for this young patient to prevent long-term cardiovascular complications 1, 3, 4

Immediate Next Steps

1. Confirm the diagnosis with ABPM or continue home BP monitoring for another 3-4 days to establish a reliable baseline 1, 2
2. Perform baseline investigations: urinalysis, serum creatinine/eGFR, fasting glucose, lipid profile, ECG, and consider renal ultrasound given young age 1, 3
3. Initiate aggressive lifestyle modifications immediately regardless of whether drug therapy is started 2, 4
4. Schedule follow-up in 2-4 weeks to review ABPM results, laboratory findings, and response to lifestyle changes 3, 2

Critical Pitfalls to Avoid

• Do not start antihypertensive medication based solely on 5 days of home readings without proper confirmation, as white-coat effect or measurement error could lead to unnecessary lifelong treatment 5
• Do not dismiss elevated readings in a young patient—investigate for secondary causes before attributing to essential hypertension 3
• Do not use immediate-release nifedipine or hydralazine for blood pressure management in this non-emergency setting 6
• Do not delay lifestyle interventions while awaiting confirmatory testing, as these provide cardiovascular benefits regardless of final diagnosis 2, 4