What is the workup for persistent hypertension?

From the Guidelines

The workup for persistent hypertension should begin with confirming the diagnosis through multiple blood pressure measurements on separate occasions, followed by a comprehensive history and physical examination, and basic laboratory tests to assess for target organ damage and secondary causes. Initial evaluation should include a complete blood count, basic metabolic panel, lipid profile, urinalysis, and a 12-lead electrocardiogram 1. Laboratory testing should also assess for serum creatinine, estimated glomerular filtration rate, electrolytes, fasting glucose, and urinary albumin-to-creatinine ratio to identify potential secondary causes of hypertension.

Key Components of the Workup

• Comprehensive history and physical examination to identify contributing lifestyle factors and potential secondary causes of hypertension
• Basic laboratory tests, including complete blood count, basic metabolic panel, lipid profile, and urinalysis
• Assessment of target organ damage, including serum creatinine, estimated glomerular filtration rate, electrolytes, fasting glucose, and urinary albumin-to-creatinine ratio
• Additional tests, such as thyroid-stimulating hormone, plasma aldosterone-to-renin ratio, and 24-hour urine collection for metanephrines, may be indicated in certain cases
• Imaging studies, such as renal ultrasound, may be necessary if renovascular hypertension is suspected

Importance of Recent Guidelines

The 2020 International Society of Hypertension global hypertension practice guidelines provide a framework for the management of hypertension, including the use of lifestyle interventions and drug treatment 1. The guidelines recommend starting drug treatment immediately for patients with grade 2 hypertension (≥160/100mmHg) and considering lifestyle interventions and drug treatment for patients with grade 1 hypertension (140-159/90-99mmHg).

Tailoring the Workup to the Patient

The workup for persistent hypertension should be tailored to the patient's age, risk factors, and clinical presentation, with younger patients and those with severe or sudden-onset hypertension requiring more thorough investigation for secondary causes 1. Home blood pressure monitoring or 24-hour ambulatory blood pressure monitoring can help distinguish white-coat hypertension from true persistent hypertension. For patients with resistant hypertension, more extensive evaluation for secondary causes is warranted, including maximization of diuretic therapy and referral to a hypertension specialist if necessary 1.

From the FDA Drug Label

Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake. The workup for persistent hypertension is not explicitly stated in the provided drug labels. However, it is mentioned that control of high blood pressure should be part of comprehensive cardiovascular risk management, which may include:

• Lipid control
• Diabetes management
• Antithrombotic therapy
• Smoking cessation
• Exercise
• Limited sodium intake 2

From the Research

Workup for Persistent Hypertension

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

• Lifestyle modifications are recommended as the first-line treatment for hypertension, and include:
  • Diet adaptation, such as the Dietary Approaches to Stop Hypertension (DASH) diet 3, 4, 5, 6
  • Sodium reduction 3, 4, 5, 6
  • Alcohol restriction 3, 4, 5, 6
  • Physical exercise 3, 4, 5, 6
  • Weight reduction 3, 4, 5, 6
• Pharmacological interventions may be necessary for patients who do not respond to lifestyle modifications, and include:
  • Thiazide or thiazide-like diuretics 4, 7
  • Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers 4, 7
  • Calcium channel blockers 4, 7

Approach to Treatment

The approach to treatment of hypertension involves:

• Assessing the level of blood pressure and the presence of high atherosclerotic cardiovascular disease risk 4
• Setting a blood pressure target of less than 130/80 mmHg for adults under 65 years, and less than 130 mmHg for adults over 65 years 4
• Continuously monitoring and adjusting treatment as needed to achieve the target blood pressure 4, 6

Special Considerations

Special considerations for the treatment of hypertension include:

• Patients with chronic kidney disease, who may require a blood pressure goal of less than 140/90 mmHg 7
• Patients with diabetes mellitus, who may require a blood pressure goal of less than 140/90 mmHg 7
• Black patients, who may prefer thiazide diuretics and calcium channel blockers as initial therapy 7