What is the best course of action for managing the blood pressure of a 55-year-old male with no cardiac family history, who exercises regularly and has blood pressure readings ranging from hypotension to hypertension?

Management Approach for Variable Blood Pressure Readings

This patient requires confirmation of blood pressure measurements through proper home monitoring technique and office verification before initiating any pharmacologic therapy, as the readings show significant variability and some values are within normal range. 1

Initial Assessment Strategy

Verify Blood Pressure Accuracy

• Ensure proper home BP measurement technique: readings should be taken after 5 minutes of rest, with appropriate cuff size, arm supported at heart level, and no talking during measurement 1
• The pulse variability (46-76 bpm) and BP fluctuations (117/65 to 140/85) suggest possible measurement errors, white coat effect, or situational factors 1
• Obtain multiple office-based measurements on separate occasions to confirm whether hypertension truly exists, as guideline-based treatment decisions require confirmed office BP ≥140/90 mmHg 1

Risk Stratification

• Calculate the patient's 10-year ASCVD risk score to determine treatment intensity 1
• If ASCVD risk is <15%, the BP target should be <140/90 mmHg 1
• If ASCVD risk is ≥15%, a more intensive target of <130/80 mmHg may be reasonable if safely attainable 1
• Given this patient's profile (55-year-old male, no cardiac family history, regular exercise), he likely falls into the lower risk category 1

Treatment Decision Algorithm

If Confirmed BP is 120-139/80-89 mmHg (Elevated/Stage 1)

• Initiate lifestyle interventions only without pharmacologic therapy for low-risk patients 1
• Lifestyle modifications include: 1
  • DASH-style eating pattern with 8-10 servings of fruits/vegetables daily
  • Sodium restriction to <2,300 mg/day
  • Weight loss if overweight (caloric restriction)
  • Increased physical activity (which this patient already does)
  • Alcohol moderation (≤2 drinks/day for men)
• Reassess BP in 3-6 months 1

If Confirmed BP is 140-159/90-99 mmHg

• Begin with single-agent pharmacologic therapy plus lifestyle modifications 1
• First-line options include thiazide diuretic, ACE inhibitor/ARB, or calcium channel blocker 2
• For this active, healthy patient, an ACE inhibitor (e.g., lisinopril 10 mg daily) or thiazide diuretic would be appropriate initial choices 3, 2

If Confirmed BP is ≥160/100 mmHg

• Initiate two-drug combination therapy immediately (or single-pill combination) plus lifestyle modifications 1
• Preferred combinations: thiazide + ACE inhibitor/ARB, or ACE inhibitor/ARB + calcium channel blocker 2

Critical Monitoring Considerations

Address the Low Pulse Readings

• The documented pulse of 46-56 bpm on some readings warrants evaluation for: 1
  • Athletic bradycardia (likely given regular exercise)
  • Underlying conduction abnormalities
  • Medication effects (though patient is asymptomatic)
• Obtain baseline ECG before initiating beta-blockers or certain calcium channel blockers (verapamil/diltiazem) 1
• The 2022 ADA guidelines note that low diastolic BP is not necessarily a contraindication to BP management in otherwise standard care 1

Follow-up Timeline

• Recheck BP within 1 month after any intervention (lifestyle or pharmacologic) 1
• Target BP should be achieved within 3 months of treatment initiation 4
• Monitor for adverse effects including orthostatic hypotension, electrolyte abnormalities, and syncope 1

Common Pitfalls to Avoid

• Do not treat based on isolated home readings without office confirmation, as this can lead to overtreatment 1
• Do not ignore the bradycardia: while likely physiologic in an active patient, it requires documentation and may influence drug selection 1
• Do not assume all readings above 130/80 require immediate pharmacotherapy: treatment thresholds differ from diagnostic thresholds based on cardiovascular risk 1
• Avoid initiating treatment in older adults without careful monitoring, though at age 55 this patient is not yet in the high-risk elderly category 1