Initiation of a low-dose ACE inhibitor with follow-up in 2 weeks is appropriate for this patient with hypertension. Lower thresholds for the definition of hypertension exist for measurements obtained in the ambulatory setting. In general, blood pressure averages ≥135/85 mm Hg by ambulatory blood pressure monitoring or home monitoring meet most consensus panels' definition of hypertension, and nighttime hypertension is defined by average values >125/75 mm Hg. This is to reflect the typical blood pressure drop from daytime to nighttime (during sleep) of approximately 15%, noted in both normotensive and hypertensive patients. A lack of blood pressure drop of at least 10% (“non-dipping”) is independently associated with left ventricular hypertrophy, cardiovascular events, moderately increased albuminuria (formerly known as microalbuminuria), and a more rapid rate of decline in glomerular filtration rate. This patient has hypertension defined by ambulatory readings and is a non-dipper with nighttime hypertension; therefore, pharmacologic therapy is indicated.

Although it has been shown that melatonin release is diminished in non-dippers and in small studies melatonin can lower nighttime blood pressure, there are no large trials with cardiovascular end points to recommend this therapy.

Observation is appropriate in the setting of prehypertension or white coat hypertension; however, this patient has confirmed hypertension and requires pharmacologic therapy.