What is the recommended workup for diastolic hypertension?

From the Guidelines

The recommended workup for diastolic hypertension should start with confirming the diagnosis through multiple blood pressure measurements, and then proceed with a comprehensive evaluation including medical history, physical examination, and laboratory tests such as basic metabolic panel, fasting glucose, lipid profile, urinalysis, and an ECG, as these steps are crucial for identifying potential secondary causes and guiding appropriate management. When evaluating diastolic hypertension, it's essential to consider the patient's overall clinical context, including the presence of diabetes mellitus (DM), as the management strategy may differ 1. The goal for diastolic blood pressure (DBP) is to target <80 mmHg, but not <70 mmHg, as indicated by recent guidelines 1. Key components of the workup include:

• A thorough medical history to identify risk factors, family history of hypertension, and use of medications that could be contributing to elevated blood pressure.
• A physical examination to look for signs of end-organ damage, such as left ventricular hypertrophy, or clues to secondary causes of hypertension.
• Laboratory tests:
  • Basic metabolic panel to assess electrolyte balance and renal function.
  • Fasting glucose to evaluate for diabetes or pre-diabetes.
  • Lipid profile to assess cardiovascular risk.
  • Urinalysis to check for proteinuria or hematuria, indicating kidney damage.
  • ECG to evaluate for left ventricular hypertrophy or other cardiac abnormalities.
• Additional tests based on clinical suspicion, such as thyroid function tests if thyroid disease is suspected, or specific tests for primary aldosteronism or pheochromocytoma if these conditions are considered.
• Imaging studies like renal ultrasound if renal artery stenosis is a concern, particularly in younger patients or those with resistant hypertension. Given the importance of blood pressure control in reducing the risk of micro- and macrovascular complications, especially in patients with diabetes 1, a comprehensive workup for diastolic hypertension is critical for guiding treatment decisions and improving patient outcomes.

From the Research

Diastolic Hypertension Workup

The recommended workup for diastolic hypertension involves a combination of lifestyle modifications and pharmacological interventions.

• The first-line treatment for hypertension in adults without diabetes or cardiovascular or renal disease is single-agent therapy with a thiazide diuretic, such as chlortalidone or hydrochlorothiazide 2.
• Thiazide diuretics have been shown to reduce all-cause mortality and the incidence of stroke in hypertensive patients 2.
• The Dietary Approaches to Stop Hypertension (DASH) diet, which is rich in fruits, vegetables, nuts, and low-fat dairy foods, has been found to lower blood pressure substantially and significantly 3, 4.
• Lifestyle modifications, such as weight loss, sodium restriction, and limiting alcohol consumption, are also important components of the initial treatment of hypertensive patients 4.

Pharmacological Interventions

In terms of pharmacological interventions, the following are recommended:

• Thiazide diuretics, such as chlortalidone and hydrochlorothiazide, are effective in reducing blood pressure and preventing cardiovascular complications 2, 5.
• Angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril, are also effective in reducing blood pressure and preventing cardiovascular complications, but may not be as effective as thiazide diuretics in certain patient populations 2, 6.
• Calcium channel blockers, such as amlodipine, may be used as an alternative to thiazide diuretics or ACE inhibitors, but may have a higher risk of certain side effects, such as heart failure 6.

Patient-Specific Considerations

When selecting a treatment for diastolic hypertension, patient-specific considerations should be taken into account, including:

• The presence of certain comorbidities, such as diabetes or cardiovascular disease, which may affect the choice of treatment 2.
• The patient's renal function, which may affect the choice of treatment and the need for dose adjustments 5.
• The patient's lifestyle and preferences, which may affect adherence to treatment and the choice of lifestyle modifications 3, 4.