What is the best course of treatment for a 44-year-old female with uncontrolled hypertension (blood pressure of 159/88 mmHg) and a mild headache, who is not currently on any antihypertensive medication?

Management of a 44-Year-Old Female with Stage 2 Hypertension (159/88 mmHg) and Mild Headache

This patient requires immediate initiation of combination antihypertensive therapy with two medications, not emergency department referral, as she does not have a hypertensive emergency. 1

This is NOT a Hypertensive Emergency

• A hypertensive emergency requires BP ≥180/120 mmHg WITH acute target organ damage (encephalopathy, acute heart failure, acute coronary syndrome, aortic dissection, acute kidney injury, or retinal hemorrhages), not just an elevated BP number 2
• This patient's BP of 159/88 mmHg with mild headache represents Stage 2 hypertension without acute organ damage and should be managed in the outpatient setting 1, 3
• The mild headache is a non-specific symptom that does NOT constitute hypertensive encephalopathy and should be treated symptomatically with acetaminophen while avoiding NSAIDs that can elevate BP 1

Immediate Treatment Strategy

Start combination therapy TODAY with a fixed-dose single-pill combination of two medications: 1

First-Line Combination Options (Choose ONE):

1. ACE inhibitor (e.g., lisinopril 10 mg) + dihydropyridine calcium channel blocker (e.g., amlodipine 5 mg) 1, 4
2. ACE inhibitor (e.g., lisinopril 10 mg) + thiazide-like diuretic (e.g., chlorthalidone 12.5 mg) 1, 4
3. ARB (e.g., candesartan 8 mg) + calcium channel blocker (e.g., amlodipine 5 mg) if ACE inhibitor not tolerated 1, 4

Why Combination Therapy, Not Monotherapy?

• Current guidelines from the European Society of Cardiology recommend initial combination therapy for most patients with BP ≥140/90 mmHg, representing a paradigm shift from older stepwise approaches 1
• Combination therapy achieves target BP faster, improves adherence with single-pill combinations, and reduces cardiovascular events more effectively than sequential monotherapy 1
• The outdated approach of starting with monotherapy and titrating up is no longer recommended for patients with BP in this range 1

Specific Dosing from FDA Label:

• Lisinopril starting dose: 10 mg once daily for hypertension, adjustable to 20-40 mg daily based on response 5
• If adding a diuretic later, reduce lisinopril to 5 mg once daily initially 5

Blood Pressure Target

Target BP <130/80 mmHg for this 44-year-old patient 1, 4

• For adults under 65 years, the American College of Cardiology recommends targeting systolic BP of 120-129 mmHg or <130/80 mmHg to reduce cardiovascular risk 1
• This aggressive target is appropriate given her young age and need to prevent long-term cardiovascular complications 1

Lifestyle Modifications (Initiate Simultaneously)

Prescribe ALL of the following specific interventions: 1, 4

• Sodium restriction to <1,500 mg/day (or at minimum reduce by 1,000 mg/day from current intake) 1, 4
• Increase dietary potassium to 3,500-5,000 mg/day through fruits and vegetables 1, 4
• Weight loss if BMI >25: Target BMI 20-25 kg/m² and waist circumference <80 cm for women 1
• Physical activity: 90-150 minutes/week of aerobic exercise or dynamic resistance training 1, 4
• Alcohol limitation: ≤1 drink per day for women 1, 4
• DASH diet: Rich in fruits, vegetables, whole grains, low-fat dairy, reduced saturated fat 1, 4

Follow-Up Schedule

Recheck BP in 2-4 weeks, then monthly until target achieved: 1

• Schedule first follow-up visit within 2-4 weeks to assess BP response and medication tolerance 1
• Continue monthly visits for medication titration until BP is controlled to target 1
• Use home BP monitoring between visits to guide therapy adjustments 1

Titration Algorithm if BP Remains Uncontrolled

If BP remains >130/80 mmHg after 4-6 weeks on two-drug combination: 1

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

Secondary Hypertension Screening

At age 44 with new-onset hypertension, screen for secondary causes: 2

• Sleep apnea: Ask about snoring, non-restorative sleep, daytime sleepiness (present in ~20% of resistant hypertension) 2
• Primary aldosteronism: Check morning aldosterone-to-renin ratio if unprovoked hypokalemia, refractory hypertension, or diastolic hypertension in older patients 2
• Renal artery stenosis: Consider if abdominal bruit, flash pulmonary edema, or refractory hypertension 2
• Thyroid disease, pheochromocytoma, Cushing's syndrome: Screen based on clinical suspicion 2

Critical Pitfalls to Avoid

DO NOT: 1, 3

• Refer to emergency department – this is NOT a hypertensive emergency and does not require IV medications or ICU admission 1, 3
• Use immediate-release nifedipine – causes unpredictable precipitous BP drops and is contraindicated 2, 1, 3
• Start with monotherapy – combination therapy is now the preferred initial approach for BP ≥140/90 mmHg 1
• Rapidly lower BP to normal within hours – in the absence of acute organ damage, gradual reduction over days to weeks is safer 2, 3
• Prescribe NSAIDs for headache – these elevate BP and interfere with antihypertensive efficacy 1

Addressing the Mild Headache

• Treat symptomatically with acetaminophen while avoiding NSAIDs 1
• The headache should improve as BP is gradually controlled over the next few weeks 1
• If headache worsens or new neurological symptoms develop (vision changes, confusion, severe headache), reassess urgently for hypertensive encephalopathy 2