What diagnostic work‑up is recommended for an asymptomatic 25‑year‑old with a blood pressure of 130/90 mm Hg and a resting heart rate of 140 bpm?

Diagnostic Work-Up for an Asymptomatic 25-Year-Old with BP 130/90 and Pulse 140

Immediate Priority: Evaluate the Tachycardia

The resting heart rate of 140 bpm is markedly abnormal and requires urgent evaluation before focusing on the borderline blood pressure. 1

Essential Initial Tests for Tachycardia

• Obtain a 12-lead ECG immediately to identify arrhythmias (atrial fibrillation, atrial flutter, supraventricular tachycardia, ventricular tachycardia), assess for structural abnormalities, and detect left ventricular hypertrophy. 2

• Measure thyroid-stimulating hormone (TSH) because hyperthyroidism commonly causes both tachycardia and elevated blood pressure in young adults. 2

• Review all medications and substances including NSAIDs, decongestants, oral contraceptives, stimulants (prescription or recreational), caffeine intake, energy drinks, and herbal supplements (ephedra, guarana). 2

• If the ECG and TSH are normal, assess for common triggers such as excessive caffeine, alcohol, stress, anxiety, sleep deprivation, and dehydration. 2

• Consider 24-hour Holter monitoring if palpitations are frequent or if the ECG does not capture the rhythm during tachycardia, to characterize the arrhythmia and guide treatment. 2

Blood Pressure Assessment Strategy

Confirm True Hypertension with Out-of-Office Monitoring

Do not diagnose hypertension or initiate lifelong antihypertensive therapy based solely on a single office reading of 130/90 mmHg in a 25-year-old. 1, 2

• Arrange home blood pressure monitoring (HBPM) or 24-hour ambulatory blood pressure monitoring (ABPM) to rule out white-coat hypertension before any treatment decision. 1, 2

• White-coat hypertension occurs in 15–20% of individuals with stage 1 hypertension and carries cardiovascular risk comparable to normotension rather than true hypertension. 2

• HBPM technique: Use a validated upper-arm oscillometric device, measure twice daily (morning before breakfast/medication and evening) for at least 3 days (ideally 7 days), take 2 readings 1–2 minutes apart each session, and average all readings. 1

• HBPM diagnostic threshold: ≥135/85 mmHg confirms hypertension (equivalent to office BP ≥140/90 mmHg). 1

• ABPM diagnostic threshold: 24-hour average ≥130/80 mmHg, daytime average ≥135/85 mmHg, or nighttime average ≥120/70 mmHg confirms hypertension. 1

Proper Office Blood Pressure Measurement Technique

• Ensure accurate BP measurement technique to avoid false elevations: empty bladder, quiet environment, appropriate cuff size, arm at heart level, supported back and feet, no conversation, 5 minutes of rest before measurement. 2

• Repeat office BP measurements on at least 2 separate occasions before confirming hypertension diagnosis. 1, 3

Baseline Laboratory and Clinical Evaluation

Screen for Secondary Hypertension

In patients <40 years at onset, actively screen for secondary causes of hypertension, which are more common in young adults than in older populations. 2

• Obtain baseline laboratory tests: fasting glucose and HbA1c, complete blood count, lipid profile, serum creatinine and estimated glomerular filtration rate (eGFR), urinalysis, TSH, and consider urine albumin-to-creatinine ratio if diabetes or chronic kidney disease is suspected. 2

• Evaluate for specific secondary causes:

  • Obstructive sleep apnea: Ask about snoring, witnessed apneas, daytime somnolence, morning headaches
  • Renal artery stenosis: Consider if abdominal bruit present or resistant hypertension develops
  • Primary aldosteronism: Screen with plasma aldosterone-to-renin ratio if hypokalemia or resistant hypertension
  • Pheochromocytoma: Consider if episodic symptoms (headache, palpitations, sweating) or family history
  • Coarctation of the aorta: Check for upper-lower extremity BP differential and delayed femoral pulses 2

Assess for Target Organ Damage

• 12-lead ECG to screen for left ventricular hypertrophy, conduction abnormalities, or ischemic changes. 2

• Urinalysis to detect proteinuria or hematuria suggesting renal involvement. 2

Management Algorithm Based on Out-of-Office BP Results

If Out-of-Office BP Confirms Hypertension (≥135/85 mmHg home or ≥130/80 mmHg ambulatory)

• Begin intensive lifestyle modifications for 3–6 months before considering drug therapy in a 25-year-old with stage 1 hypertension and no high-risk features. 2

• Initiate pharmacologic therapy immediately if any of the following are present: 10-year ASCVD risk ≥10%, diabetes, chronic kidney disease, or evidence of target-organ damage. 2

• Lifestyle interventions include: sodium restriction to <2 g/day, DASH dietary pattern, weight management (target BMI 20–25 kg/m²), regular aerobic exercise (≥30 minutes most days), and alcohol limitation (≤1 drink/day for women, ≤2 drinks/day for men). 2

• Re-measure BP in 3 months: If BP remains ≥130/80 mmHg without high-risk features after lifestyle modifications, start antihypertensive medication. 2

If Out-of-Office BP Is Normal (<135/85 mmHg home or <130/80 mmHg ambulatory)

• Diagnose white-coat hypertension and do NOT initiate antihypertensive medication. 2

• Continue intensive lifestyle modifications to prevent progression to true hypertension. 2

• Re-measure BP in 3–6 months with repeat home or ambulatory monitoring to ensure sustained control. 2

Management of Tachycardia

If Arrhythmia Is Detected

• Treat according to the specific rhythm: Beta-blockers are appropriate for rate control in atrial fibrillation or supraventricular tachycardia, but are not first-line for uncomplicated hypertension in this age group. 2

• Reassure the patient when benign premature atrial or ventricular contractions are identified and no other pathology is present. 2

If No Arrhythmia but Persistent Sinus Tachycardia

• Address underlying causes: anxiety, deconditioning, anemia, hyperthyroidism, medication/substance effects. 2

• Consider cardiology referral if unexplained persistent tachycardia after excluding reversible causes.

Common Pitfalls to Avoid

• Do not prescribe antihypertensives based solely on clinic readings when home BP is borderline or normal—this leads to overdiagnosis and overtreatment. 2

• Do not overlook secondary hypertension in a young adult—systematic screening for sleep apnea, renal artery stenosis, primary aldosteronism, and pheochromocytoma is warranted when BP is difficult to control. 2

• Do not ignore medication- or substance-induced hypertension—review use of NSAIDs, decongestants, stimulants, oral contraceptives, and herbal supplements. 2

• Do not skip lifestyle modifications—they remain first-line therapy and enhance the effectiveness of any future pharmacologic treatment. 2

• Do not dismiss the tachycardia—a resting heart rate of 140 bpm is never normal and requires thorough evaluation before attributing symptoms to anxiety alone.

Follow-Up Timeline

• Within 2–4 weeks: Re-check home BP or arrange 24-hour ambulatory monitoring after the initial assessment. 2

• At 3 months: Reassess BP if lifestyle modifications are underway. 2

• When medication is started: Re-evaluate BP within 2–4 weeks and titrate to achieve target BP within 3 months. 2