A 65-year-old woman is referred to the cardiology clinic by her primary care provider for management of hypertension. She has a history of hyperlipidemia, hypertension, and asthma. Her medications include simvastatin 40 mg daily, valsartan 320 mg daily, chlorthalidone 25 mg daily, and an albuterol inhaler as needed. Her intake blood pressure (BP) is 167/82 mm Hg and on repeat check is 160/78 mm Hg. She tells you that she is taking her BP medications regularly and that her BPs are consistently higher in the office than at home. Her BP readings at home range from 140/70 to 150/80 mm Hg. You review the rest of her medical history and discover that she has never smoked, has no history of diabetes mellitus, and her recent lipid panel showed total cholesterol 200 mg/dL, high-density lipoprotein cholesterol 60 mg/dL, and low-density lipoprotein cholesterol 140 mg/dL.
Which one of the following is the best strategy to manage her BP?
Show Answer
The correct answer is: B. Start amlodipine.
Answer choice A is an incorrect choice. Ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) are recommended for screening and monitoring for individuals with suspected "white coat" hypertension (elevated office BP but normal readings when measured outside the office). In patients being treated for hypertension with office BP readings not at goal with suggestion of white coat effect on HBPM, ABPM can be useful to confirm. This patient does not meet this criterion, as both her office and home BP readings are above her target BP goal of <130/80 mm Hg. Therefore, she does not have evidence of white coat effect. She requires intensification of antihypertensive therapy.
Answer choice B is the correct choice. The target BP goal for individuals with an estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk of ≥10% is <130/80 mm Hg for the primary prevention of cardiovascular events. She has an estimated 10-year ASCVD risk of 12% based on her risk factors. Both her office and home BP readings are above her target goal. The first step in the management of hypertension above goal is to confirm and optimize adherence to therapy. She is taking her antihypertensive medications regularly. The next step is to intensify therapy. First-line antihypertensive therapy includes thiazide or thiazide-type diuretics, angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers (ARBs), and calcium channel blockers. She is already taking a thiazide diuretic, chlorthalidone, and ARB (valsartan), at maximum doses. Intensification of therapy with the addition of a calcium channel blocker, another first-line antihypertensive therapy, is the appropriate next step.
Answer choice C is an incorrect choice. She warrants intensification of pharmacologic therapy for BP management. Intensification can involve: 1) increasing doses of existing medications; or 2) addition of an alternative pharmacologic agent. She is already on target doses of both chlorthalidone and valsartan. Increasing valsartan beyond a daily dose of 320 mg has minimal effect on further BP lowering and is not recommended in this case. She warrants addition of an additional agent.
Answer choice D is an incorrect choice. She warrants intensification of antihypertensive pharmacologic therapy. She is already on target doses of chlorthalidone and valsartan, so the addition of a third agent is recommended. Beta-blockers are second-line agents, so a first-line antihypertensive medication such as amlodipine is the preferred choice. Furthermore, because she has a history of asthma, nonselective beta-blockers such as propranolol are not the optimal beta-blocker of choice.
Educational grant support provided by: Medtronic To visit the course page for the Overcoming Challenges in Hypertension Management Grant, click here!
References
Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APha/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018;71:e127-e248.
Lloyd-Jones DM, Braun LT, Ndumele CE, et al. Use of risk assessment tools to guide decision-making in the primary prevention of atherosclerotic cardiovascular disease: a special report from the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2019;73:3153-67.
Viera AJ, Hinderliter AL, Kshirsagar AV, Fine J, Dominik R. Reproducibility of masked hypertension in adults with untreated borderline office blood pressure: comparison of ambulatory and home monitoring. Am J Hypertens 2010;23:1190-7.
Carey RM, Wright JT Jr, Taler SJ, Whelton PK. Guideline-driven management of hypertension: an evidence-based update. Circ Res 2021;128:827-46.
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