What is the next step for a 15-year-old patient with persistent hypertension (elevated blood pressure) of 128/75 mmHg for the past year?

Confirm Hypertension with Out-of-Office Blood Pressure Monitoring

For a 15-year-old with persistent blood pressure readings of 128/75 mmHg over the past year, the next step is to confirm the diagnosis with ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM), as office readings alone may overestimate true blood pressure in adolescents. 1

Understanding the Blood Pressure Classification

• In adolescents aged 13 years and older, the 2014 American Heart Association guidelines define elevated blood pressure as 120-129 mmHg systolic with diastolic <80 mmHg, and hypertension as ≥130/80 mmHg. 2

• This patient's reading of 128/75 mmHg falls into the elevated blood pressure category (not yet hypertension), but the persistent elevation over one year warrants further evaluation. 2

• According to the ambulatory blood pressure monitoring reference tables for 15-year-old males, the 90th percentile for 24-hour systolic BP is approximately 122-123 mmHg, meaning this patient's office reading is above the 90th percentile. 1

Diagnostic Confirmation Strategy

Ambulatory or home blood pressure monitoring is essential because:

• White coat hypertension occurs in 10-30% of adolescents with elevated office readings, representing an intermediate cardiovascular risk between normotensives and sustained hypertensives. 1

• Masked hypertension (normal office BP but elevated out-of-office BP) occurs in 10-15% of cases and carries similar cardiovascular risk as sustained hypertension. 1

• For confirmation, home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg indicates true hypertension requiring intervention. 1

Concurrent Evaluation Steps

While arranging ABPM/HBPM, perform the following assessments:

• Medical history: Family history of hypertension or premature cardiovascular disease, symptoms suggesting secondary causes (headaches, palpitations, muscle weakness, snoring/daytime sleepiness), dietary habits (sodium and caffeine intake), physical activity level, and medication/supplement use. 1

• Physical examination: Body mass index and weight status (obesity is the most important correlate of elevated BP in adolescents), neck circumference >40 cm (obstructive sleep apnea), peripheral pulses and radio-femoral delay (coarctation), abdominal bruits (renal artery stenosis), and signs of Cushing syndrome or thyroid disease. 1

• Screening for secondary causes: While primary hypertension is now most common in adolescents (especially those who are overweight/obese with positive family history), secondary causes should be considered if BP is substantially elevated (>99th percentile), there is little family history, or the patient is younger with severe elevation. 1, 2

Management Based on Confirmation Results

If ABPM/HBPM confirms elevated BP but not hypertension (130-139/80-89 mmHg):

• Initiate intensive lifestyle modifications: sodium restriction to <2g/day, weight loss if overweight (BMI >85th percentile), DASH-style diet with increased potassium intake, regular aerobic exercise (≥30 minutes most days), and elimination of energy drinks/excessive caffeine. 1, 3, 4

• Recheck BP every 3-6 months to monitor for progression to hypertension. 1

• Drug treatment is not indicated at this stage unless there is evidence of target organ damage (left ventricular hypertrophy on echocardiography) or other high-risk features. 1, 2

If ABPM/HBPM confirms hypertension (≥130/80 mmHg for adolescents ≥13 years):

• Continue lifestyle modifications as above. 2

• Consider echocardiography to assess for left ventricular hypertrophy, which would indicate target organ damage and necessitate pharmacological therapy. 2

• Initiate antihypertensive medication if: (1) symptomatic hypertension, (2) stage 2 hypertension (≥140/90 mmHg) without modifiable factors like obesity, (3) evidence of left ventricular hypertrophy, (4) hypertension associated with chronic kidney disease or diabetes, or (5) persistent hypertension despite 3-6 months of lifestyle modifications. 1, 2

• First-line medications for adolescents include ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics, all of which are effective, safe, and well-tolerated in this age group. 2, 5

Critical Pitfalls to Avoid

• Do not diagnose hypertension based solely on office readings in adolescents, as this leads to overdiagnosis and unnecessary treatment in those with white coat hypertension. 1

• Do not delay lifestyle interventions while awaiting ABPM results—these should begin immediately regardless of final diagnosis. 1, 3

• Do not initiate pharmacological therapy without first confirming sustained hypertension through out-of-office monitoring and attempting lifestyle modifications (unless there are compelling indications like symptomatic hypertension or target organ damage). 1, 2

• Do not overlook obesity assessment—this is the single most important modifiable risk factor for elevated BP in adolescents and should be the primary target of intervention. 1, 2