What is the appropriate work‑up and initial management for hypertension in a 55‑year‑old man?

Initial Management of Hypertension in a 55-Year-Old Man

Diagnostic Confirmation and Assessment

Before initiating treatment, confirm the diagnosis with multiple blood pressure measurements taken on separate occasions, ideally using home blood pressure monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) to exclude white-coat hypertension. 1

Essential Baseline Evaluation

• Measure blood pressure at every visit using proper technique—seated position, appropriate cuff size, and averaging 2-3 readings 1
• Assess for orthostatic hypotension to detect autonomic neuropathy 1
• Calculate 10-year cardiovascular disease risk using validated tools (ASCVD risk calculator) 1
• Screen for target organ damage: check serum creatinine and eGFR, urinalysis for proteinuria/albuminuria, ECG for left ventricular hypertrophy 1
• Obtain fasting lipid panel and glucose to identify metabolic risk factors 2
• Evaluate for secondary causes if blood pressure is severely elevated (≥180/110 mmHg), patient is young (<40 years), or hypertension is resistant to treatment—consider primary aldosteronism, renal artery stenosis, pheochromocytoma, and obstructive sleep apnea 1, 3

Blood Pressure Thresholds and Treatment Initiation

Stage 1 Hypertension (130-139/80-89 mmHg)

• For patients with 10-year ASCVD risk ≥10% or established cardiovascular disease, initiate pharmacologic therapy immediately alongside lifestyle modifications to achieve target <130/80 mmHg. 1
• For lower-risk patients (ASCVD risk <10%), implement intensive lifestyle modifications for up to 3 months; if blood pressure remains ≥130/80 mmHg, add pharmacologic therapy 1, 4

Stage 2 Hypertension (≥140/90 mmHg)

• Initiate combination therapy with two first-line agents from different classes immediately—either as separate agents or preferably as a fixed-dose combination—to achieve blood pressure reduction of at least 20/10 mmHg from baseline. 1, 4
• Single-pill combinations are strongly preferred because they significantly improve medication adherence and persistence 4

First-Line Pharmacologic Therapy

Initial Monotherapy (Stage 1, Lower Risk)

For non-Black patients under 55 years: start with an ACE inhibitor (e.g., lisinopril 10 mg daily) or ARB (e.g., losartan 50 mg daily). 1

For patients ≥55 years or Black patients of any age: start with a calcium channel blocker (e.g., amlodipine 5 mg daily) or thiazide-like diuretic (chlorthalidone 12.5-25 mg daily preferred over hydrochlorothiazide). 1, 4

Initial Combination Therapy (Stage 2)

The preferred two-drug regimen for non-Black patients is an ACE inhibitor or ARB plus either a calcium channel blocker or thiazide-like diuretic. 4

For Black patients, the preferred combination is a calcium channel blocker plus a thiazide-like diuretic, as ACE inhibitors and ARBs are less effective as monotherapy in this population. 4

• Chlorthalidone is preferred over hydrochlorothiazide because it provides superior 24-hour blood pressure control, has a longer half-life (24-72 hours vs 6-12 hours), and has stronger cardiovascular outcome data from the ALLHAT trial 4, 2
• Fixed-dose combinations produce greater blood pressure reduction at lower doses of component agents, resulting in fewer side effects 4

Blood Pressure Targets

Target blood pressure is <130/80 mmHg for most adults, particularly those with established cardiovascular disease or 10-year ASCVD risk ≥10%. 1, 4

• Minimum acceptable target is <140/90 mmHg for lower-risk patients 1
• For adults <65 years, aim for systolic blood pressure of 120-129 mmHg if well tolerated 1, 4
• For adults ≥65 years, target systolic <130 mmHg 1, 2

Lifestyle Modifications (Essential Adjunct to Pharmacotherapy)

Comprehensive lifestyle interventions can lower systolic/diastolic blood pressure by 10-20 mmHg and enhance the efficacy of all antihypertensive medications. 1, 4

Specific Interventions with Proven Efficacy

• Sodium restriction to <2 g/day (approximately 5 g salt): reduces systolic blood pressure by 5-10 mmHg 1, 4
• DASH or Mediterranean dietary pattern: reduces blood pressure by approximately 11.4/5.5 mmHg (systolic/diastolic) 1, 4
• Weight loss for BMI ≥25 kg/m²: losing 10 kg reduces blood pressure by approximately 6.0/4.6 mmHg 1, 4
• Regular aerobic exercise (≥150 minutes/week moderate intensity plus resistance training 2-3 times/week): reduces blood pressure by approximately 4/3 mmHg 1, 4
• Alcohol limitation to ≤2 drinks/day for men, ≤1 drink/day for women 1, 4
• Tobacco cessation is mandatory 4

Monitoring and Follow-Up

Reassess blood pressure within 1 month after initiating or adjusting therapy to evaluate response and medication adherence. 1

• Check serum potassium and creatinine 2-4 weeks after starting an ACE inhibitor, ARB, or diuretic to detect hyperkalemia, hypokalemia, or renal function changes 1, 4
• Aim to achieve target blood pressure within 3 months of treatment initiation 1, 4
• Consider home blood pressure monitoring or 24-hour ambulatory monitoring to confirm office readings and detect white-coat or masked hypertension 1

Treatment Escalation Algorithm

If Blood Pressure Remains Uncontrolled on Dual Therapy

Add a third agent from the remaining class to create triple therapy (ACE inhibitor or ARB + calcium channel blocker + thiazide-like diuretic), which achieves control in >80% of patients. 4

Resistant Hypertension (Uncontrolled on Triple Therapy)

• Before adding a fourth agent, verify medication adherence (the most common cause of apparent treatment resistance), confirm true hypertension with home or ambulatory monitoring, review for interfering substances (NSAIDs, decongestants, oral contraceptives, systemic corticosteroids), and screen for secondary causes. 4, 3
• If blood pressure remains ≥140/90 mmHg despite optimized triple therapy, add spironolactone 25-50 mg daily as the preferred fourth-line agent, which provides additional reductions of approximately 20-25/10-12 mmHg (systolic/diastolic). 4
• Monitor serum potassium closely when adding spironolactone to an ACE inhibitor or ARB due to significant hyperkalemia risk 1, 4

Critical Pitfalls to Avoid

• Do not delay treatment intensification when blood pressure remains ≥140/90 mmHg—prompt action within 2-4 weeks is required to reduce cardiovascular risk. 4
• Do not combine an ACE inhibitor with an ARB (dual renin-angiotensin blockade), as this increases adverse events (hyperkalemia, acute kidney injury) without additional cardiovascular benefit. 1, 4
• Do not add a beta-blocker as initial therapy or as a second/third agent unless there are compelling indications (angina, post-myocardial infarction, heart failure with reduced ejection fraction, atrial fibrillation requiring rate control), as beta-blockers are less effective than other first-line agents for stroke prevention and cardiovascular events. 1, 4
• Do not use non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in patients with heart failure due to negative inotropic effects. 4
• Do not assume treatment failure without first confirming adherence and excluding secondary causes or interfering substances. 4