What is the appropriate evaluation and management for a 38-year-old man with stage 2 hypertension (blood pressure 157/100 mm Hg), pulse 85 bpm, nonspecific abdominal discomfort, and fatigue?

Evaluation and Management of a 38-Year-Old Male with Stage 2 Hypertension

This patient requires immediate initiation of dual-agent antihypertensive therapy combined with lifestyle modifications, with follow-up within one month to assess blood pressure control and evaluate for secondary causes of hypertension given his young age. 1

Blood Pressure Classification and Risk Assessment

• At 157/100 mmHg, this patient has Stage 2 hypertension (≥140/90 mmHg), which mandates prompt pharmacologic intervention regardless of cardiovascular risk stratification 1
• Calculate 10-year ASCVD risk using the ACC/AHA Pooled Cohort Equations to guide intensity of therapy, though Stage 2 hypertension already qualifies for immediate dual therapy 1
• At age 38, new-onset hypertension warrants screening for secondary causes including sleep apnea, primary aldosteronism, renal artery stenosis, thyroid disease, pheochromocytoma, and Cushing's syndrome 2

Initial Diagnostic Workup

Laboratory evaluation should include:

• Basic metabolic panel (sodium, potassium, creatinine) to assess renal function and electrolytes before initiating RAS inhibitors or diuretics 1
• Urinalysis with albumin-to-creatinine ratio to detect proteinuria and kidney damage 1
• Fasting lipid panel and glucose to assess cardiovascular risk factors 1
• Thyroid-stimulating hormone (TSH) given fatigue symptoms 2
• Electrocardiogram to evaluate for left ventricular hypertrophy 1

Consider additional testing based on clinical suspicion:

• Sleep study if symptoms suggest obstructive sleep apnea (snoring, daytime somnolence, witnessed apneas) 2
• Plasma aldosterone-to-renin ratio if hypokalemia present or resistant hypertension develops 2

Pharmacologic Treatment Strategy

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

For non-Black patients (preferred initial regimen):

• ACE inhibitor or ARB (e.g., losartan 50 mg daily) PLUS thiazide/thiazide-like diuretic (e.g., chlorthalidone 12.5-25 mg daily) 1, 3
• Alternative: ACE inhibitor/ARB PLUS dihydropyridine calcium channel blocker (e.g., amlodipine 5 mg daily) 1

For Black patients:

• Calcium channel blocker PLUS thiazide/thiazide-like diuretic as initial therapy 1
• ARB may be added as third agent if needed 1

Single-pill combination products improve adherence and should be strongly considered 1, 2

Blood Pressure Target

• Target blood pressure is <130/80 mmHg for adults under 65 years to reduce cardiovascular risk 2
• Aim to achieve target within 3 months of initiating therapy 1
• Reduce BP by at least 20/10 mmHg from baseline 1

Lifestyle Modifications (Essential Adjunct to Pharmacotherapy)

Implement all of the following interventions simultaneously with drug therapy: 1

• Sodium restriction: Reduce intake to <1,500 mg/day 2
• DASH diet: Emphasize fruits, vegetables, whole grains, low-fat dairy, and reduced saturated fat 2
• Potassium supplementation: Increase dietary potassium to 3,500-5,000 mg/day (if no contraindication) 2
• Weight loss: If BMI >25 kg/m², target weight reduction 2
• Physical activity: 90-150 minutes per week of moderate-intensity aerobic exercise 2
• Alcohol limitation: ≤1 drink per day 2

Addressing Concurrent Symptoms

Stomach discomfort and fatigue require evaluation:

• Assess whether symptoms preceded hypertension diagnosis or are new-onset 2
• Consider whether symptoms could represent target organ damage (though unlikely at this BP level) 1
• Evaluate for medication side effects once therapy initiated (ACE inhibitors can cause GI upset; fatigue may worsen initially with BP lowering) 3
• Rule out secondary causes that present with these symptoms (thyroid disease, adrenal disorders) 2

Follow-Up Schedule

Schedule follow-up within 1 month of initiating therapy: 1

• Reassess blood pressure to evaluate treatment response 1
• Check electrolytes and renal function 2-4 weeks after starting RAS inhibitor or diuretic 1
• Assess medication adherence and tolerability 1
• Reinforce lifestyle modifications 1
• Screen for orthostatic hypotension, particularly if symptoms of dizziness develop 1

If BP remains uncontrolled at 1 month:

• Uptitrate existing medications to maximum tolerated doses 1
• Add third agent from different class (typically add the missing component of the triple therapy: ACE inhibitor/ARB + CCB + thiazide diuretic) 1, 4

Critical Pitfalls to Avoid

Do not delay pharmacologic therapy: Stage 2 hypertension requires immediate dual-agent treatment, not a trial of lifestyle modification alone 1, 2

Avoid monotherapy: Starting with a single agent in Stage 2 hypertension is inadequate and delays BP control, increasing cardiovascular risk 1, 2

Do not use immediate-release nifedipine: This causes unpredictable precipitous BP drops and is contraindicated 2

Avoid triple RAS blockade: Simultaneous use of ACE inhibitor, ARB, and/or renin inhibitor is potentially harmful 1

Do not treat this as a hypertensive emergency: BP of 157/100 mmHg without acute target organ damage is Stage 2 hypertension managed in the outpatient setting, not an emergency requiring immediate IV therapy 2

Recheck electrolytes after initiating therapy: Failure to monitor potassium and creatinine 2-4 weeks after starting RAS inhibitors or diuretics can miss dangerous hyperkalemia or acute kidney injury 1