What is the initial workup and management for a patient with hypertension?

From the Guidelines

The initial workup for a patient with hypertension should include a thorough history, physical examination, and basic laboratory tests, with management starting with lifestyle modifications and pharmacologic therapy as needed, aiming for a blood pressure target of <130/80 mmHg for most adults, as recommended by the 2017 American College of Cardiology/American Heart Association hypertension guideline 1. The initial evaluation should confirm the diagnosis by measuring blood pressure on at least two separate occasions, using proper technique with the patient seated quietly for 5 minutes before measurement.

• Laboratory evaluation should include:
  • Complete blood count
  • Basic metabolic panel
  • Lipid profile
  • Urinalysis
  • Electrocardiogram to assess for end-organ damage and secondary causes Management begins with lifestyle modifications for all patients, including:
• Weight reduction
• DASH diet (rich in fruits, vegetables, and low-fat dairy with reduced saturated fat)
• Sodium restriction to <2.3g daily
• Regular physical activity (150 minutes/week of moderate-intensity exercise)
• Limiting alcohol consumption For pharmacologic therapy, first-line medications include:
• Thiazide diuretics (hydrochlorothiazide 12.5-25mg daily)
• ACE inhibitors (lisinopril 10-40mg daily)
• ARBs (losartan 50-100mg daily)
• Calcium channel blockers (amlodipine 5-10mg daily) Treatment should start with a single agent at a low dose and titrate upward every 2-4 weeks until target blood pressure is achieved, with the addition of a second agent from a different class if blood pressure remains uncontrolled on a maximum dose of one medication 1. These medications work through different mechanisms—diuretics reduce fluid volume, ACE inhibitors and ARBs block the renin-angiotensin system, and calcium channel blockers relax vascular smooth muscle—providing effective blood pressure control while minimizing side effects through complementary actions. The choice of antihypertensive therapy should follow contemporary guidelines, considering the patient's comorbidities and individual characteristics, as outlined in the 2017 ACC/AHA guideline 1 and supported by other studies 1.

From the FDA Drug Label

For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) The initial workup and management for a patient with hypertension should follow published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) 2.

• Control of high blood pressure should be part of comprehensive cardiovascular risk management, including:
  • Lipid control
  • Diabetes management
  • Antithrombotic therapy
  • Smoking cessation
  • Exercise
  • Limited sodium intake
• Many patients will require more than one drug to achieve blood pressure goals. The FDA drug label does not provide a specific initial workup for hypertension, but it emphasizes the importance of following established guidelines for management 2.

From the Research

Initial Workup for Hypertension

The initial workup for a patient with hypertension involves a comprehensive approach to identify the underlying causes and assess the risk of cardiovascular disease. The following steps are recommended:

• Take a thorough medical history, including questions about lifestyle habits, diet, and physical activity 3, 4, 5
• Perform a physical examination to check for signs of target organ damage, such as left ventricular hypertrophy or retinopathy 4
• Order laboratory tests, including:
  • Electrolyte panel to check for electrolyte imbalances 4
  • Renal function tests to assess kidney function 4
  • Lipid profile to evaluate cardiovascular risk 4
  • Urinalysis to check for proteinuria or hematuria 4
• Assess the patient's blood pressure using office and home measurements to confirm the diagnosis and monitor response to treatment 4, 5

Lifestyle Modifications for Hypertension

Lifestyle modifications are a crucial component of hypertension management and are recommended as first-line therapy for patients with high-normal blood pressure or grade 1 hypertension without high-risk factors 3, 4, 5. The following lifestyle modifications are recommended:

• Weight loss, if overweight or obese 3, 4, 5, 6, 7
• Healthy dietary pattern, including:
  • Low sodium intake 3, 4, 5, 6, 7
  • High potassium intake 3, 4, 5, 7
  • Increased consumption of fruits, vegetables, and whole grains 5
• Regular physical activity, such as aerobic exercise and strength training 3, 4, 5, 6, 7
• Moderation or elimination of alcohol consumption 3, 4, 5, 6, 7
• Stress management techniques, such as meditation or yoga 5, 7
• Smoking cessation, if applicable 3, 5, 6, 7

Management of Hypertension

The management of hypertension involves a stepped-care approach, with lifestyle modifications as the foundation of therapy 3, 4, 5. If lifestyle modifications are insufficient to control blood pressure, antihypertensive medication may be initiated. The choice of medication depends on the patient's individual characteristics, such as comorbidities and risk factors 4. The following medications are recommended as first-line therapy:

• Thiazide or thiazide-like diuretics, such as hydrochlorothiazide or chlorthalidone 4
• Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, such as enalapril or candesartan 4
• Calcium channel blockers, such as amlodipine 4