How should I manage a 30-year-old woman with a blood pressure of 146/90 mm Hg (stage 2 hypertension) and no prior hypertension diagnosis?

Management of Stage 2 Hypertension in a 30-Year-Old Woman

This patient requires immediate initiation of both lifestyle modifications and pharmacological therapy with two antihypertensive agents from different classes, with follow-up in one month. 1

Immediate Actions

Confirm the Diagnosis

• Repeat blood pressure measurement using proper technique (validated automated upper arm cuff, appropriate cuff size, average of 2-3 readings) at this visit or within 1 week 1
• Confirm with out-of-office monitoring (home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg confirms hypertension) before starting treatment if time permits, but do not delay treatment beyond 1 week given the BP level 1, 2
• Measure BP in both arms simultaneously at first visit; use the arm with higher readings for subsequent measurements 1

Assess Cardiovascular Risk and Screen for Secondary Causes

Given her young age (30 years), screen for secondary hypertension which affects 5-10% of hypertensive patients but is more common in young adults: 3

Essential initial laboratory tests:

• Basic metabolic panel (serum sodium, potassium, creatinine, eGFR) 1, 3
• Fasting glucose or HbA1c 1, 3
• Lipid panel 1
• Urinalysis and urinary albumin-to-creatinine ratio 1, 3
• Thyroid-stimulating hormone 3
• 12-lead ECG 1, 3
• Plasma aldosterone-to-renin ratio (the 2024 ESC guidelines now recommend this for all adults with confirmed hypertension, Class IIa recommendation) 1, 3

Clinical clues suggesting secondary hypertension to assess:

• Onset before age 30 is itself a red flag 3
• Symptoms of obstructive sleep apnea (snoring, daytime sleepiness, obesity) 3
• History of urinary tract infections, hematuria, or family history of polycystic kidney disease (renal parenchymal disease) 3
• Episodic symptoms, palpitations, headaches (pheochromocytoma) 3
• Hypokalemia, muscle weakness/cramps (primary aldosteronism) 3
• Medication use (NSAIDs, oral contraceptives, decongestants, stimulants) 3

Calculate 10-year ASCVD risk using ACC/AHA Pooled Cohort Equations (though at age 30, this will likely be <10% unless diabetes or other major risk factors present) 1

Pharmacological Treatment

Initiate combination therapy immediately with two agents from different classes: 1

First-Line Combination Options (choose one):

1. ACE inhibitor (or ARB) + dihydropyridine calcium channel blocker 1, 4

   • Example: Lisinopril 10 mg daily + Amlodipine 5 mg daily 5, 4

2. ACE inhibitor (or ARB) + thiazide-like diuretic 1, 4

   • Example: Lisinopril 10 mg daily + Chlorthalidone 12.5 mg daily 4

Preferred approach: Use a single-pill combination to improve adherence 1

Important considerations:

• For a 30-year-old woman of childbearing potential, counsel about pregnancy planning as ACE inhibitors and ARBs are contraindicated in pregnancy 5
• If pregnancy is planned or possible, consider calcium channel blocker + thiazide-like diuretic combination instead 1
• Assess electrolytes and renal function 2-4 weeks after initiating therapy with ACE inhibitor/ARB or diuretic 1

Why Two Drugs Initially?

• Stage 2 hypertension (≥140/90 mmHg) requires prompt BP reduction 1
• Combination therapy is more effective than monotherapy and achieves BP control faster 1, 2
• Most patients with stage 2 hypertension require ≥2 drugs to reach target 1, 4

Lifestyle Modifications (Start Immediately)

Implement all of the following simultaneously with medication: 1

• Weight management: Target BMI 20-25 kg/m² and waist circumference <80 cm 1
• DASH or Mediterranean diet: High in fruits, vegetables, whole grains, low-fat dairy, limited saturated fat 1, 4
• Sodium restriction: <2 grams sodium (5 grams salt) per day 1, 4
• Potassium supplementation: 3.5-5 grams daily through diet (unless contraindicated by kidney disease or medications) 4
• Physical activity: 150 minutes/week moderate-intensity aerobic exercise plus resistance training 2-3 times/week 1
• Alcohol limitation: <100 grams/week (preferably avoid completely) 1
• Smoking cessation: If applicable 1
• Limit free sugar: Maximum 10% of energy intake, avoid sugar-sweetened beverages 1

Expected BP reduction from lifestyle changes: 4-11 mmHg systolic BP reduction per intervention, with additive effects 4

Blood Pressure Target

Target BP: 120-129/<80 mmHg (if well tolerated) 1

• The 2024 ESC guidelines recommend targeting systolic BP 120-129 mmHg in most adults to reduce CVD risk 1
• If poorly tolerated, use "as low as reasonably achievable" (ALARA principle) 1
• Minimum acceptable target: <130/80 mmHg 1

Follow-Up Schedule

Reassess in 1 month: 1

• Measure BP to assess response to therapy 1
• Check for orthostatic hypotension (especially if symptomatic) 1
• Review medication adherence 1
• Check electrolytes and renal function if on ACE inhibitor/ARB or diuretic 1
• Reinforce lifestyle modifications 1

If BP not at goal after 1 month:

• Increase doses to full therapeutic levels 1
• If still uncontrolled, add a third agent (typically the missing drug from the ACE inhibitor/ARB + calcium channel blocker + thiazide-like diuretic triad) 1, 4

Target: Achieve BP control within 3 months 1

Common Pitfalls to Avoid

• Do not delay treatment waiting for lifestyle modifications alone—stage 2 hypertension requires immediate pharmacological therapy 1
• Do not use monotherapy for stage 2 hypertension; combination therapy is indicated 1
• Do not combine two RAS blockers (ACE inhibitor + ARB)—this is potentially harmful 1
• Do not miss secondary causes in a young patient—age <30 years mandates thorough screening 3
• Do not use beta-blockers as first-line unless specific indications (post-MI, heart failure, angina)—they are less effective and have metabolic side effects 1
• Do not forget contraception counseling if prescribing ACE inhibitors or ARBs to women of childbearing age 5
• Do not use classic thiazides (hydrochlorothiazide)—thiazide-like diuretics (chlorthalidone, indapamide) are preferred for superior cardiovascular outcomes 1, 4