67-year-old woman with a history of achalasia (successfully treated with a Heller myotomy with partial fundoplication) and osteoporosis, currently being treated with a yearly IV infusion of zoledronic acid, is noted to have an elevated blood pressure reading during her current health care maintenance visit. The patient is doing well and is without symptoms or complaints. The patient is a retired registered nurse and states that in the past 6 months, two blood pressure measurements done in the health care setting averaged above 150/90 mm Hg. However, during that same time period, blood pressure measurements obtained at home averaged less than 130/80 mm Hg. She has no other pertinent personal, social or family history. She takes no other medications besides calcium and Vit D supplements. On exam today she has the following vitals:
BMI 19
BP 150/92
HR 70
RR 14
O2 sat 98% on RA
afebrile
The remainder of the physical examination, including ophthalmic exam is normal.
Which of the following is the most appropriate management for this patient?
A) Begin hydrochlorothiazide
B) Obtain a basic metabolic panel and start lisinopril
C) Collect 24-hour urine metanephrines and catecholamines
D) Perform ambulatory blood pressure monitoring
E) Order a magnetic resonance angiography (MRA) of the renal arteries
D) Perform ambulatory blood pressure monitoring
This patient has a story consistent with “white coat hypertension” which refers to elevated blood pressure measured in the office, but normal out-of-office measurements. This patient might have elevated BP according to the ACC/AHA blood pressure guidelines. Therefore, it’s essential to screen for white coat hypertension using ambulatory blood pressure monitoring (ABPM). ABPM works by taking BP readings continually over a 24-hour period. You'll wear a device that is about the same size as a portable radio. The device is attached to a belt or strap worn on your body. It collects information throughout a 24-hour period that will later be transferred to a computer. The main difference between ABPM and home blood pressure monitoring (HBPM) is that ABPM assesses daytime and nighttime blood pressure during routine daily activities typically during one 24-hour period, whereas HBPM assesses blood pressure at specific times during the day and night over a longer period of time while the patient is seated and resting. In patients with white coat hypertension, annual follow-up with out-of-office BP measurements should be considered to determine if conversion to sustained hypertension has occurred. This patient has no indication for renal artery imaging or pheochromocytoma work up. Starting medications such as thiazide diuretics and ACE inhibitors are indicated once HTN is officially diagnosed after the results of the ABPM.
