Lifestyle modification is the most appropriate next step in management for this 73-year-old patient with likely stage 1 hypertension based on consistently elevated blood pressure determinations. He has no evidence of end-organ manifestations on history or physical examination. Therefore, lifestyle modifications, including a low sodium diet; a diet such as DASH (Dietary Approaches to Stop Hypertension) that emphasizes vegetables, fruits, whole grains, legumes, and low-fat dairy products and limits sweets, red meat, and saturated/total fat; weight loss irrespective of diet; and exercise, are the most appropriate initial management strategies. The most effective lifestyle modification is salt restriction to 1500 mg/d, which lowers blood pressure by an average of 7/3 mm Hg. The eighth report of the Joint National Committee (JNC 8) recommends a blood pressure goal of <150/90 mm Hg for those ≥60 years of age. Because his blood pressure measurements have been around 155/85 mm Hg, salt restriction alone as part of lifestyle modifications may be enough to avoid the use of medications to achieve the treatment goal for this 73-year-old patient.

Although the α-blocker doxazosin may be considered for its dual blood pressure–lowering effect and its effect on urinary frequency, its use as first-line therapy for persistent hypertension following lifestyle modification should be decided while considering its adverse effect profile (such as orthostatic hypotension) and its increased incidence of heart failure that was noted in the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).

This patient may ultimately require medical treatment; because he has gout, the angiotensin receptor blocker (ARB) losartan may be preferred not only for its benefits in lowering blood pressure but also for its uricosuric effect. This is in contrast to thiazide diuretics such as hydrochlorothiazide, which increases serum urate.

β-Blockers such as metoprolol are no longer recommended as primary initial therapy for hypertension given their side-effect profiles, which includes higher cardiovascular-related events and mortality compared with ARBs.

Because this patient has evidence of persistently elevated blood pressures and likely stage 1 hypertension, a 6-month follow-up of his blood pressures without intervention is not appropriate.