What is the appropriate workup for a patient with hypertension?

Appropriate Workup for Hypertension

The appropriate workup for hypertension should include a comprehensive evaluation of blood pressure measurements, medical history, physical examination, laboratory tests, and additional diagnostic investigations to assess for target organ damage and secondary causes of hypertension. 1, 2

Initial Blood Pressure Assessment

• Confirm hypertension with multiple BP measurements on separate occasions
• Classification based on BP readings:
  • Normal: <120/80 mmHg
  • Elevated: 120-129/<80 mmHg
  • Stage 1: 130-139/80-89 mmHg
  • Stage 2: ≥140/≥90 mmHg 2

Medical History

• Duration and severity of hypertension
• Previous treatments and response
• Medication adherence issues
• Family history of hypertension and cardiovascular disease
• Lifestyle factors:
  • Dietary sodium intake
  • Alcohol consumption
  • Physical activity levels
  • Smoking status
• Symptoms suggesting secondary causes or target organ damage:
  • Headaches, visual disturbances
  • Chest pain, dyspnea
  • Neurologic symptoms
  • Dizziness 1

Physical Examination

• Accurate BP measurement in both arms
• Body mass index (BMI) calculation
• Cardiovascular assessment:
  • Heart rate and rhythm
  • Heart sounds (murmurs, gallops)
  • Peripheral pulses
• Fundoscopic examination (retinal changes)
• Neurological assessment
• Abdominal examination (renal bruits, enlarged kidneys)
• Signs of end-organ damage 1

Laboratory Testing

• Basic metabolic panel:
  • Serum creatinine and estimated GFR
  • Electrolytes (sodium, potassium)
• Fasting blood glucose or HbA1c
• Lipid profile
• Complete blood count
• Urinalysis for protein and sediment
• Additional tests when indicated:
  • Serum uric acid
  • Liver function tests
  • Thyroid function tests 1, 2

Cardiovascular Risk Assessment

• 12-lead ECG to assess for left ventricular hypertrophy
• Transthoracic echocardiogram (when indicated) to evaluate:
  • Left ventricular mass
  • Systolic and diastolic function
  • Valvular abnormalities 1

Screening for Secondary Hypertension

Secondary causes should be considered in patients with:

• Resistant hypertension (BP >140/90 mmHg despite optimal triple therapy)
• Sudden onset of hypertension
• Age <30 years without risk factors
• Severe hypertension (>180/120 mmHg)

Common secondary causes to evaluate:

• Primary aldosteronism (plasma aldosterone/renin ratio)
• Renal artery stenosis (duplex ultrasound, CT angiography)
• Chronic kidney disease (eGFR, urinalysis)
• Obstructive sleep apnea (sleep study if symptoms present)
• Pheochromocytoma (plasma or urinary metanephrines)
• Cushing's syndrome (overnight dexamethasone suppression test)
• Thyroid disorders (TSH) 1, 2

Additional Imaging When Indicated

• Renal ultrasound
• CT or MRI of brain (for neurological symptoms)
• CT angiography of thorax/abdomen (for suspected aortic disease)
• Chest X-ray (for suspected pulmonary congestion) 1

Special Considerations

• For suspected hypertensive emergency (BP >180/120 mmHg with acute target organ damage):

  • Immediate hospitalization and parenteral antihypertensive therapy
  • More extensive workup for acute organ damage
  • Careful BP reduction to avoid hypoperfusion 1

• For resistant hypertension:

  • Confirm medication adherence
  • 24-hour ambulatory BP monitoring
  • More extensive evaluation for secondary causes 2

The thoroughness of the workup should be guided by the patient's clinical presentation, age, severity of hypertension, and presence of comorbidities. Early identification of target organ damage and secondary causes is crucial for optimizing treatment and preventing complications.