From the Guidelines
The most appropriate management for this patient is option C: Perform ambulatory blood pressure monitoring. This patient demonstrates a pattern consistent with white coat hypertension, where blood pressure readings are elevated in clinical settings (averaging 150/90 mmHg) but normal outside of healthcare environments (averaging 128/78 mmHg) 1. Since her out-of-office readings are below 130/80 mmHg, and she has no other risk factors or concerning findings, immediate pharmacologic treatment is not warranted. The discrepancy between office and home measurements suggests anxiety in the clinical setting may be contributing to her elevated readings. Key considerations in managing this patient include:
- Lifestyle and diet therapy as recommended by the ACC/AHA hypertension guidelines, including sodium restriction, increased intake of dietary potassium, weight loss if overweight/obese, appropriate physical activity prescription, moderation of alcohol intake, and a healthy DASH-like diet 1
- The potential for white coat hypertension, which may not require immediate pharmacologic intervention
- The importance of accurate blood pressure measurement to guide management decisions Given the patient's normal home readings and lack of other risk factors, ambulatory blood pressure monitoring is a reasonable next step to confirm the diagnosis and guide further management. Starting chlorthalidone would be premature, and there's no indication for renal artery imaging as she lacks clinical features suggesting secondary hypertension. Rechecking blood pressure in the office in 3 months may not provide sufficient information to guide management, as it may not accurately reflect the patient's typical blood pressure. Therefore, ambulatory blood pressure monitoring is the most appropriate management option for this patient.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION Therapy should be initiated with the lowest possible dose. INDICATIONS AND USAGE Diuretics such as chlorthalidone are indicated in the management of hypertension either as the sole therapeutic agent or to enhance the effect of other antihypertensive drugs in the more severe forms of hypertension.
The most appropriate management is to confirm the diagnosis of hypertension. Given the discrepancy between blood pressure measurements in healthcare settings and those obtained outside of healthcare settings, ambulatory blood pressure monitoring would be the most appropriate next step to confirm the diagnosis before initiating any treatment.
- The patient's blood pressure measurements in healthcare settings are elevated, but measurements outside of these settings are within a normal range.
- There is no clear indication for immediate initiation of antihypertensive medication without confirming the diagnosis.
- Ambulatory blood pressure monitoring can provide a more accurate assessment of the patient's blood pressure over a 24-hour period. Therefore, the correct answer is C Perform ambulatory blood pressure monitoring 2 2.
From the Research
Management of Hypertension
The patient's blood pressure measurements vary significantly between healthcare settings and outside settings, suggesting possible white-coat hypertension. The following options are considered for management:
- Ambulatory Blood Pressure Monitoring: This method provides a more accurate picture of the patient's blood pressure levels throughout the day, including during sleep 3, 4, 5, 6, 7.
- Diagnosis and Treatment: Ambulatory blood pressure monitoring can help identify white-coat hypertension, masked hypertension, and other conditions, allowing for more targeted treatment 4, 6, 7.
- Comparison of Options:
- A: Beginning chlorthalidone without further evaluation may not be appropriate, as the patient's blood pressure measurements are inconsistent.
- B: Obtaining renal artery imaging may not be necessary at this stage, as there is no indication of secondary hypertension.
- C: Performing ambulatory blood pressure monitoring is the most appropriate next step, as it can provide a more accurate diagnosis and guide treatment.
- D: Rechecking blood pressure in the office in 3 months may not be sufficient, as it may not capture the patient's true blood pressure levels.
Recommended Course of Action
Based on the evidence, the most appropriate management for this patient would be to perform ambulatory blood pressure monitoring to confirm the diagnosis and guide treatment 3, 4, 5, 6, 7.