Case Scenarios of Hypertension and Corresponding Guidelines-Based Evaluation and Management Recommendations

ScenarioCase StudyaRecommended EvaluationOutcomes of Initial EvaluationBP GoalInitial Treatment (Step 1)Outcomes of Initial TreatmentNext Level Treatment (Step 2)Outcomes of Step 2 TreatmentNext-Level Treatment (Step 3) and Outcome
Stage 1 hypertension with no TOD13-y-old obese boy with 3 BP readings averaging 97th percentile; ABPM, mean, 98%; systolic load, 40%.Basic workup: Medical/family/sleep hx, physical exam, CBC, renal panel, U/A, renal U/S, Echocardiogram, fasting lipids, glucose.Unremarkable history and physical exam except for obesity. Lipid profile reveals elevated triglycerides. Other tests are negative.<95th percentile (<90th percentile according to European guidelines)Lifestyle changes (discourage sugar-sweetened beverage, saturated and trans fats, encourage high dietary fiber consumption, physical activity, appropriate portions, etc)b for up to 6 mo, with monitoring at 3 or 6 moBP remains at 97th percentile; ABPM, mean, 97th percentile; systolic load, 30%. No change in BMI percentile.Continued lifestyle changes. Enalapril, starting at 5 mg/d, titrating up to 20 mg/dBP <95th percentile; normal ABPM. No change in BMI percentile.N/A
Stage 1 HTN with TOD15-y-old girl, obese, with 3 BP readings averaging 99th percentile; ABPM, mean, 99th percentile; systolic load, 50%Basic workupHistory and physical exam unremarkable. Has impaired fasting glucose and dyslipidemia with elevated TG and low HDL. LVM of 52 g/m2 (above adult threshold). Other tests negative.<90th percentileLifestyle changes plus candesartan starting at 8 mg a day, titrating up to 16 mg/day. Monitor BP every 3–6 mo.No improvement in BP after 6 moAggressive encouragement of weight loss. Increase candesartan to maximum of 32 mg/d.BP <90th percentile; normal ABPM; LVM 38 g/m2. Modest weight loss of 8 lbs.N/A
Stage 2 HTN11-y-old boy, modestly overweight with 3 BP readings taken over 2 wk, all slightly >99th percentile. ABPM, mean, 99th percentile; systolic load, 40%.Basic workup plus extended workup or referral to pediatric hypertension expert.cBasic and extended workup negative, except for strong family history of hypertension.<95th percentile; (<90th percentile according to European guidelines which are based on same population data)Lifestyle changes plus amlodipine starting at 2.5mg a day. Monitor BP every 3–6 mo.BP improved but remains between 95 and 99th percentiles; ABPM, mean, 96th percentile; systolic load, 30%. No change in BMI percentile.Amlodipine titrated up to maximum of 10mg daily. Monitor every 3–6 mo.BP improved further on maximum dose but still slightly above 95th percentile; ABPM, no improvement. No change in BMI percentile.Add hydrochlorothiazide 12.5 mg/d. Normal BP and ABPM. No change in BMI percentile.
Secondary HTN9-y-old girl, modestly overweight with 3 BP readings averaging 95th percentile; ABPM, mean, 95th percentile; systolic load, 60%; diastolic load 25%.Basic and extended workup, through pediatric hypertension expert.Bilateral renal artery stenosis; diagnosed with fibromuscular dysplasia.<90th percentileRevascularization through surgery and modest weight loss through lifestyle changes.BP eventually decreased to 80th percentile; ABPM, mean 75%, systolic load, 20%; diastolic load, 5%.N/AN/AN/A
  • CBC, complete blood count; HDL, high density lipoprotein cholesterol; HTN, hypertension; hx, history; N/A, not applicable; TG, triglycerides; TOD, target organ damage; U/A, urinalysis; U/S, ultrasound.

  • a Percentiles refer to whichever is higher of the systolic or diastolic BP.

  • b These are described in more detail in the NHLBI Guidelines

  • c Extended workup according to both NHLBI and European Guidelines includes plasma renin (low rennin suggests mineralocorticoid-related disease), renovascular imaging, plasma and urine steroid levels, plasma and urine catecholamines.