What to do for a 16-year-old with a blood pressure (BP) of 124/84?

Management of Blood Pressure 124/84 in a 16-Year-Old

For a 16-year-old with BP 124/84 mmHg, this represents Stage 1 hypertension requiring confirmation on three separate days, followed by intensive lifestyle modifications for 3-6 months before considering pharmacologic therapy. 1, 2

Initial Diagnostic Steps

Confirm the diagnosis by measuring 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. 1, 2 This is critical because a single elevated reading is insufficient for diagnosis.

For adolescents ≥13 years old, hypertension classification is:

• Stage 1 Hypertension: 130-139/80-89 mmHg (this patient falls into this category with 124/84 mmHg if systolic is elevated on repeat measurements) 1
• Stage 2 Hypertension: ≥140/90 mmHg 1

Determine Height Percentile Context

While the BP 124/84 mmHg appears elevated for a 16-year-old, you must also determine the patient's height percentile. According to normative data, the 95th percentile for systolic BP in 16-year-old boys ranges from 125-140 mmHg depending on height percentile, and for girls 119-130 mmHg. 3 The diastolic reading of 84 mmHg is definitively elevated for this age group regardless of height or sex. 3

Evaluation for Secondary Causes

Obtain a focused history and targeted screening tests to evaluate for secondary causes, particularly if there are clinical red flags such as:

• Severe BP elevation
• Lack of family history of hypertension
• Symptoms suggesting endocrine disorders
• History of kidney disease 1, 2

Perform urinalysis to detect proteinuria or hematuria suggesting renal parenchymal disease. 1 Additional evaluation should be guided by clinical suspicion but is not routinely required for mild Stage 1 hypertension with positive family history and obesity. 3

First-Line Treatment: Intensive Lifestyle Modifications

Initiate lifestyle modifications for 3-6 months before considering pharmacologic therapy unless there is Stage 2 hypertension, symptomatic hypertension, or evidence of target organ damage. 1, 2

Specific Lifestyle Interventions:

• Dietary modification with sodium restriction: Recommend moderation in salt intake, as the average American adolescent consumes far more sodium than required. 3

• DASH dietary pattern: Emphasize fruits, vegetables, whole grains, and low-fat dairy products. 1

• Weight management: If the patient is overweight or obese, institute weight control measures as weight loss has been demonstrated to lower BP in hypertensive adolescents. 3, 2

• Increased physical activity: Prescribe regular exercise, as improved cardiovascular conditioning lowers BP in this age group. 3, 2

When to Consider Pharmacologic Therapy

Pharmacologic treatment should be initiated if:

• Target BP is not reached within 3-6 months of lifestyle intervention 3, 1
• Stage 2 hypertension is confirmed (≥140/90 mmHg) 1
• Evidence of target organ damage (such as left ventricular hypertrophy) is present 3, 4
• Patient has diabetes or chronic kidney disease 3, 2

First-Line Pharmacologic Agents:

ACE inhibitors or ARBs are the preferred initial agents (e.g., lisinopril, enalapril, candesartan). 1, 2 Alternative first-line options include long-acting calcium channel blockers (e.g., amlodipine) and thiazide diuretics (e.g., hydrochlorothiazide, chlorthalidone). 1

Critical caveat: Reproductive counseling is essential before initiating ACE inhibitors or ARBs due to potential teratogenic effects. 3, 2

Treatment Goal

Target blood pressure should be <130/80 mmHg for adolescents ≥13 years, or consistently <90th percentile for age, sex, and height. 1, 2 Regular monitoring is essential to assess treatment efficacy. 2

Common Pitfalls to Avoid

• Do not diagnose hypertension based on a single measurement – always confirm on three separate days. 1, 2
• Do not use adult-sized cuffs – inappropriate cuff size leads to inaccurate readings. 3
• Do not rush to pharmacotherapy – lifestyle modifications should be given adequate trial (3-6 months) unless there are specific indications for immediate treatment. 1, 2
• Do not forget reproductive counseling when prescribing ACE inhibitors or ARBs to adolescents of childbearing potential. 3, 2