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J.S. is a 54-year-old Hispanic woman who presents to her primary-care clinician for follow-up regarding elevated blood pressure. She was last seen 2 weeks prior with a blood pressure of 162/94 mmHg. She has no significant medical history, she is a 1 ppd tobacco user with a history of 25 pack-years, and she has a family history of premature cardiac death.


Her vital signs are as follows: height, 5 ft 4 in.; weight, 188 lb.; pulse, 84 beats/min; blood pressure, 168/98 mmHg; and body mass index, 32.3. As J.S. has been found to be hypertensive (>149/90) on two consecutive office visits, starting an antihypertensive medication is indicated.


What is your initial choice for an antihypertensive medication in this patient? (Support your treatment plan with a discussion of the evidence based guideline you utilized)
Which therapeutic lifestyle change is a priority in helping J.S. achieve blood pressure control?
Which of the following diagnostic tests would you order for J.S. to establish a baseline before starting an anti-hypertensive?

Question 1: What is your initial choice for an antihypertensive medication in this patient? (Support your treatment plan with a discussion of the evidence-based guideline you utilized)

In the case of J.S., a 54-year-old Hispanic woman with hypertension, an appropriate initial choice for antihypertensive medication would depend on various factors, including the presence of comorbidities and individual patient characteristics. However, based on the information provided, the following medication classes are commonly recommended as initial treatment options for hypertension:

Angiotensin-Converting Enzyme Inhibitors (ACE inhibitors): ACE inhibitors, such as lisinopril, are frequently recommended as the first-line therapy for hypertension, especially in patients with comorbid conditions such as diabetes, chronic kidney disease, or heart failure. ACE inhibitors help relax blood vessels, reducing blood pressure.

Angiotensin Receptor Blockers (ARBs): ARBs, such as losartan, are an alternative option to ACE inhibitors. They work by blocking the action of angiotensin II, a hormone that narrows blood vessels. ARBs are often used when ACE inhibitors are not well-tolerated or if patients have specific contraindications to ACE inhibitors.

Thiazide diuretics: Thiazide diuretics, like hydrochlorothiazide, are another commonly prescribed first-line medication for hypertension. They help the kidneys eliminate excess water and salt from the body, reducing fluid volume and lowering blood pressure.

The choice of the initial antihypertensive medication should also consider any contraindications, side effect profiles, and individual patient preferences. It is important to involve the patient in shared decision-making and discuss the potential benefits and risks of each medication class.

To determine the most appropriate medication choice for J.S., it is recommended to consult current evidence-based guidelines, such as the guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA). These guidelines provide comprehensive recommendations based on clinical trial data and expert consensus.

Question 2: Which therapeutic lifestyle change is a priority in helping J.S. achieve blood pressure control?

In addition to pharmacological treatment, lifestyle modifications play a crucial role in managing hypertension. The primary therapeutic lifestyle change that should be prioritized for J.S. to achieve blood pressure control is weight loss.

Obesity and excess weight are significant risk factors for hypertension. In J.S.’s case, her body mass index (BMI) is 32.3, indicating obesity. Weight loss can lead to a reduction in blood pressure and lower the risk of cardiovascular disease. Even a modest weight loss of 5-10% of the initial body weight can have a substantial impact on blood pressure.

To promote weight loss, J.S. should be advised to adopt a comprehensive approach, including the following lifestyle modifications:

Balanced and calorie-controlled diet: Encourage J.S. to follow a balanced diet rich in fruits, vegetables, whole grains, and lean proteins while minimizing the intake of saturated and trans fats, cholesterol, sodium, and added sugars. Caloric intake should be adjusted to achieve weight loss goals.

Regular physical activity: Engaging in regular aerobic exercise, such as brisk walking, cycling, or swimming, for at least 150 minutes per week is recommended. Additionally, incorporating strength training exercises two days per week can be beneficial. Physical activity helps in weight reduction, improves cardiovascular fitness, and contributes to blood pressure control.

Sodium restriction: Encourage J.S. to limit her sodium intake by reducing the consumption of processed and packaged foods, as they often contain high amounts of sodium. Aim for a daily sodium intake of less than 2,300 milligrams (mg) or even lower, depending on individual circumstances

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