A 45 year-old Caucasian woman presents to your office for a health physical. She has a family history of heart disease. Her father had a myocardial infarction (MI) at age 60. She does not smoke. She works at a local bank as a manager and is often stressed with work and her two kids. She tries to exercise regularly by going for a walk with her family, but admits she does not always succeed. She and her husband each have two glasses of wine after dinner regularly. She tries to watch her diet by limiting her saturated fat intake. Upon physical examination, her blood pressure (BP) is 138/87 mm Hg; her weight is 72 kg, and her body mass index (BMI) is 28 kg/m2 (normal, 18.5 to 24.9 kg/m2). No edema or murmur is noted. She does not have an abdominal bruit. Her laboratory work up shows normal range electrolytes. Her creatinine is 0.9 mg/dL (normal, 0.84-1.21 mg/dL), and her low density lipoprotein cholesterol (LDL-C) is 149 mg/dL (desirable, <100 mg/dL). Her BP was 134/86 mm Hg one year ago, according to her chart.
1. In addition to increasing exercise and adhering to the DASH (dietary approaches to stop hypertension) diet, what else do you recommend for your patient?
- Start candesartan 4 mg daily
- Limit alcohol consumption to one drink a day
- Add resistance exercises to her routine
- Initiate chlorthalidone 25 mg daily
- Initiate amlodipine 2.5 mg daily
Correct answer: B) Limit alcohol consumption to one drink a day
Rationale: This patient is in the pre-hypertensive range. The evidence-based Joint National Committee (JNC) 8 guideline does not recommend initiating therapy for patients aged less than 60 unless their blood pressure (BP) is greater than 140 systolic or greater than 90 diastolic. Therefore, options A, D, and E are incorrect. While resistance exercise has been shown to reduce BP modestly, increased arterial stiffness is noted with resistance exercise. Therefore, option C is not the best choice and is not recommended by the American Heart Association unless a good aerobic exercise program is already in place. Studies show that when men consume more than two drinks daily and women consume more than one drink daily of alcohol, there is a dose-related increase in BP. Therefore, this patient should reduce ethanol consumption to one drink a day.