USMLE® Step 2 Question of the Day: High blood pressure
Sep 4, 2024
A 55-year-old woman presents to her primary care physician for a follow-up appointment for elevated blood pressure measurements. Two weeks ago, her blood pressure was 134/81 mmHg. She reports occasional headaches and fatigue and denies chest pain, weight loss, or changes in bowel habits. She has no significant past medical history and does not take any medications. Her family history is notable for dyslipidemia in her father and hypertension in her mother. She has a 20-pack-year smoking history and exercises infrequently. Her BMI is 28 kg/m2. Physical examination is unremarkable. Her 24-hour ambulatory blood pressure monitoring reveals a mean blood pressure of 136/82 mmHg. Laboratory results are unremarkable. Her 10-year ASCVD risk is calculated at 6%. Which of the following is the most appropriate next step in the management of this patient’s blood pressure?
A. DASH diet and increased physical activity
B. Smoking cessation
C. Renal ultrasound
D. ACE inhibitor therapy
E. Beta-blocker therapy
Scroll down for the correct answer!
The correct answer to today's USMLE® Step 2 CK Question is...
A. DASH diet and increased physical activity
Before we get to the Main Explanation, let's see why the answer wasn't B, C, D, or E. Skip to the bottom if you want to see the correct answer right away!
Incorrect answer explanations
Today's incorrect answers are...
B. Smoking cessation
Incorrect: While smoking cessation is important for overall cardiovascular health, it does not directly lower blood pressure. The primary intervention for this patient should be lifestyle changes that directly influence blood pressure, including dietary modifications and increasing physical activity.C. Renal ultrasound
Incorrect: A renal ultrasound may be considered when renal artery stenosis or renal parenchymal disease is suspected. This patient's age, family history of hypertension, and absence of findings associated with kidney disease make a secondary cause of hypertension unlikely.D. ACE inhibitor therapy
Incorrect: ACE inhibitors are the first-line treatment option for the management of stage 1 hypertension in patients with a 10-year ASCVD risk of 10% or more. In this patient with a low ASCVD risk, management consists of lifestyle modifications with dietary modifications and increased physical activity.E. Beta-blocker therapy
Incorrect: Beta-blockers are not first-line for the management of hypertension unless the patient has a specific indication, such as a history of heart failure with reduced ejection fraction, ischemic heart disease, or atrial fibrillation.
Main Explanation
This patient with a family history of hypertension and a sedentary lifestyle presents with occasional headaches and 24-hour ambulatory blood pressure measurements falling within the range of 130-139/80-89 mmHg. Without findings suggestive of a secondary cause of hypertension, this presentation is consistent with stage 1 hypertension. Given that her 10-year ACVSD risk score is <10%, lifestyle interventions including following a DASH diet and increasing her physical activity are the most appropriate next steps in management.
Blood pressure can be classified into:
Normal blood pressure: systolic blood pressure (SBP) <120 mm/Hg and diastolic blood pressure (DPB) <80 mmHg
Elevated blood pressure: systolic blood pressure (SBP) between 120 and 129 mm/Hg and diastolic blood pressure (DPB) <80 mm/Hg
Stage 1 hypertension: SBP between 130 and 139 mm/Hg or DBP between 80 to 89 mmHg
Stage 2 hypertension: SBP ≥140 mm/hg, or DBP ≥90 mm/hg
The initial management of stage 1 hypertension depends on the patient's 10-year risk of atherosclerotic cardiovascular disease (ASCVD). For patients with a 10-year ASCVD risk less than 10%, lifestyle modifications are the primary intervention. This includes adopting a DASH (Dietary Approaches to Stop Hypertension) diet, reducing dietary sodium, enhancing potassium intake, increasing physical activity, and limiting alcohol intake. Smoking cessation is also recommended, but it does not directly influence blood pressure control. Patients with stage 1 hypertension and a 10-year ASCVD risk of 10% or more, known cardiovascular disease, diabetes mellitus, or chronic kidney disease should be treated with antihypertensive medication and lifestyle modification.
Major takeaway
Patients with stage 1 hypertension and a low ASCVD risk (<10%) should have their blood pressure managed with lifestyle modifications including adopting a DASH diet and increasing the amount of physical activity. Pharmacological interventions with anti-hypertensive agents are reserved for patients with a higher ASCVD risk (≥10%) or for those with known cardiovascular disease, diabetes mellitus, or chronic kidney disease.
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: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Hypertension. 2018 Jun;71(6):e136-e139] [published correction appears in Hypertension. 2018 Sep;72(3):e33]. Hypertension. 2018;71(6):1269-1324. doi:10.1161/HYP.0000000000000066
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