A 67-year-old woman presents to the physician’s office for a health maintenance visit and is noted to have an elevated blood pressure reading. The patient is doing well and is without symptoms or complaints. She has a history of achalasia which was successfully treated with a Heller myotomy with partial fundoplication and also has osteoporosis. She is currently being treated with a yearly intravenous infusion of zoledronic acid and also takes a daily calcium and vitamin D supplement. 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 mmHg. However, during that same time period, blood pressure measurements obtained at home averaged less than 130/80 mmHg. She has no other pertinent personal, social, or family history. She is afebrile with a blood pressure of 150/92 mmHg, heart rate of 70 beats/min, respirations of 14/min, and oxygen saturation of 98% on room air. Body mass index (BMI) is 19 kg/m2. The physical examination, including ophthalmic examination, is normal.
E) 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 with normal out-of-office measurements. This patient might have elevated blood pressures according to the ACC/AHA blood pressure guidelines. Therefore, it is essential to evaluate for hypertension using ambulatory blood pressure monitoring (ABPM). ABPM works by taking blood pressure readings continually over a 24-hour period. The patient wears a device that 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 established white coat hypertension, annual follow-up with out-of-office blood pressure measurements should be considered to determine if conversion to sustained hypertension has occurred.
Answer choice A: Begin hydrochlorothiazide, is incorrect. Starting medications such as a thiazide diuretic is indicated once a diagnosis of hypertension is established based on the results of the ABPM.
Answer choice B: Collect 24-hour urine metanephrines and catecholamines, is incorrect. This is the correct workup if pheochromocytoma is suspected. However, the patient does not have symptoms related to excess catecholamine secretion such as sustained or paroxysmal hypertension, headaches, palpitations, or diaphoresis.
Answer choice C: Obtain a basic metabolic panel and start lisinopril, is incorrect. Obtaining a basic metabolic panel and starting an angiotensin converting enzyme (ACE) inhibitor may be indicated once a diagnosis of hypertension is established based on the results of the ABPM.
Answer choice D: Order magnetic resonance angiography (MRA) of the renal arteries, is incorrect. This patient has no indication for renal artery imaging such as concern for renal artery stenosis or fibromuscular dysplasia.
Key Learning Point
A diagnosis of white coat hypertension can be evaluated using ambulatory blood pressure monitoring, which takes blood pressure readings continuously over a 24-hour period and can establish whether a patient has hypertension or not.
