From the Guidelines
The most appropriate next step in diagnosis for this 17-year-old boy is A) Blood pressure measurement by auscultation. When elevated blood pressure readings are obtained using an automated oscillometric device, confirmation with manual auscultatory measurement is recommended before making further diagnostic decisions, as stated in the expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report 1. This patient has two elevated readings by automated device (138/88 and 140/89 mm Hg), which are at the 95th percentile for his age and height, suggesting possible hypertension.
Key Considerations
- Auscultatory measurement is considered the gold standard for office blood pressure assessment and helps eliminate potential errors from automated devices, which can sometimes give falsely elevated readings.
- The patient's age falls into the 12 to 17 years category, where annual BP measurement is recommended, and if BP is ≥90th percentile or ≥120/80 mm Hg, repeat BP measurement by auscultation is advised 1.
- Given the patient's elevated BMI of 29 kg/m², which is a risk factor for primary hypertension, confirming the blood pressure reading is crucial before deciding on the next steps in management.
Next Steps
- If the auscultatory measurement confirms hypertension, further evaluation would then be warranted, including assessment of secondary causes and target organ damage.
- The guidelines suggest that if BP is confirmed ≥95th percentile, ≥99th percentile + 5 mm Hg, a basic work-up should be initiated, which may include further testing like echocardiography for assessing left ventricular mass, a marker of hypertensive target organ disease 1.
From the Research
Diagnosis of Hypertension in a 17-Year-Old Boy
The patient's blood pressure is 138/88 mm Hg (95th percentile for age and height) and 140/89 mm Hg on repeat measurement. Given the elevated blood pressure readings, the next step in diagnosis is crucial for accurate assessment and management.
Appropriate Next Steps
- The most appropriate next step would be to confirm the diagnosis of hypertension using a reliable method.
- According to the study 2, both oscillometric and auscultatory methods are considered acceptable for measuring blood pressure in children and adolescents.
- The study 3 validates the use of pulse dynamic blood pressure measurement by auscultation, showing excellent agreement between auscultatory and pulse dynamic methods for systolic and diastolic blood pressures.
- Therefore, measuring blood pressure by auscultation, as in option A, would be a suitable next step to confirm the diagnosis.
Rationale for Choosing Auscultation
- Auscultation is a widely accepted and reliable method for measuring blood pressure, especially in clinical settings.
- The study 4 compares auscultatory and oscillometric blood pressure measurement in patients with atrial fibrillation and arterial hypertension, highlighting the importance of accurate measurement.
- While ambulatory blood pressure monitoring (option C) and home blood pressure monitoring are valuable tools for assessing blood pressure outside the office setting, they may not be necessary as the initial next step in this case.
- Repeating blood pressure measurements by oscillometric device (options D and E) may not provide additional information beyond what has already been obtained.
Conclusion Not Provided as per Request
Further evaluation and management would depend on the results of the auscultatory blood pressure measurement, considering the patient's age, height, and overall health status, as well as guidelines for hypertension management in adolescents 2.