A 35-year-old man comes for a new patient evaluation. He takes no medications. His parents both have diabetes mellitus.
On physical examination, blood pressure is 165/104 mm Hg and BMI is 31. The remainder of the examination is unremarkable.
Laboratory studies, including serum electrolyte, blood urea nitrogen, and creatinine levels and urinalysis results, are normal.
Lifestyle modifications are recommended, but blood pressure findings are unchanged on a subsequent visit 2 weeks later.
The most appropriate next step in management for this patient is initiation of lisinopril and hydrochlorothiazide. This patient has stage 2 hypertension (systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥100 mm Hg), and both lifestyle modifications and antihypertensive therapy are indicated. The guidelines proposed by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommend initiating treatment with two medications in patients with stage 2 hypertension or those whose blood pressure is greater than 20 mm Hg systolic or 10 mm Hg diastolic above target. Low-dose hydrochlorothiazide and an angiotensin-converting enzyme (ACE) inhibitor, such as lisinopril, would be reasonable in this patient to ensure adequate blood pressure control. Careful follow-up and monitoring for signs of impaired fasting glucose or glucose intolerance also are recommended.
Monotherapy with hydrochlorothiazide, metoprolol, or terazosin would not be appropriate in a patient with stage 2 hypertension. Furthermore, evidence suggests that β-blockers do not perform as well as comparator drugs, particularly in preventing stroke, and thus they are no longer universally recommended as first-line single agents in the absence of a compelling indication, which may include a history of myocardial infarction and heart failure. Finally, thiazide diuretics appear to be superior to α-blockers (such as terazosin), ACE inhibitors, and calcium channel blockers as initial therapy for reducing cardiovascular and kidney risk in patients with hypertension.
- Current guidelines recommend initiating treatment with two medications in patients with stage 2 hypertension or those whose blood pressure is greater than 20 mm Hg systolic or 10 mm Hg diastolic above target.