Evaluation and Treatment of Medication Adherence: Look Out for "White Coat" Hypertension

A 68-year-old Caucasian woman presents with blood pressure (BP) 170/90 mm Hg and a history of medication intolerance. She is very hesitant to take any medication for BP due to the side effects. Most of the side effects revolve around lightheadedness, faintness, and some episodes of falling, as well as occasional headaches. Upon further questioning, she states that her home BP is 125-135 mm Hg when she wakes up and is highly variable from 11 a.m. on, going as high as 170 mm Hg at times. It gets better with some medication over 10-15 min. Her review of systems is negative except she does not sleep well. She has difficulty getting and staying asleep, with a mean of 4-5 hours of sleep per night. A sleep study was done, showing no sleep apnea. Her physical examination is unremarkable, with no murmurs, edema, or fourth heart sound. She is not taking any medications.

Further evaluation includes 24-hour ambulatory BP monitoring, which shows overall BP 132/78 mm Hg and heart rate 72 bpm; however, when tested in the office, her BP is 162/90 mm Hg. There was no nocturnal dipping and no periods when BP spikes occurred in the early afternoon. Pheochromocytoma workup is negative.

Which one of the following is the most appropriate approach for this person with "white coat" hypertension?

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