Components of a Complete Hypertensive Workup
A comprehensive hypertensive workup should include a detailed history, physical examination, laboratory tests, and additional diagnostic studies to identify underlying causes and assess for target organ damage.
Medical History
- Perinatal history: Maternal hypertension, birth weight, gestational age, complications during pregnancy 1
- Duration of hypertension and previous BP readings 2
- Previous treatments and responses to antihypertensive medications 2
- Medication adherence issues 2
- Emergency symptoms: Headache, visual disturbances, chest pain, dyspnea, neurological symptoms, abdominal pain, nausea 1
- Medication use: NSAIDs, steroids, sympathomimetics, cocaine, uterocontractive drugs 1
- Family history: 3-generation history of hypertension, premature cardiovascular disease, sudden cardiac death 2
Risk Factor Assessment
- Nutritional history: Salt intake, high-fat foods, sugary beverages, fruit/vegetable consumption 1, 2
- Physical activity and sedentary behavior patterns 1, 2
- Psychosocial history: Stress, depression, anxiety, bullying, body perception concerns 1
- Substance use: Smoking, alcohol, recreational drugs 1, 2
- Comorbidities: Diabetes, dyslipidemia, chronic kidney disease 2
Physical Examination
- Blood pressure measurement: Using proper technique with appropriate cuff size and patient positioning 2
- Anthropometrics: Height, weight, BMI, waist circumference 1, 2
- Cardiovascular assessment: Pulse rate/rhythm/character, jugular venous pressure, apex beat, heart sounds, peripheral edema, bruits 2
- Fundoscopy: To detect hypertensive retinopathy (hemorrhages, cotton wool spots, papilledema) 1
- Signs of secondary causes: Enlarged kidneys, neck circumference, enlarged thyroid, signs of Cushing syndrome 2
Basic Laboratory Tests
Blood tests:
Urine tests:
Diagnostic Studies
- 12-lead ECG: To detect atrial fibrillation and left ventricular hypertrophy 2
- Echocardiography: For assessment of left ventricular hypertrophy and function 2
- Renal ultrasound: To evaluate for renal parenchymal disease 1
- Carotid ultrasound: If evidence of vascular disease 2
Screening for Secondary Hypertension
Based on clinical suspicion, additional tests may include:
| Suspected Cause | Recommended Screening Test |
|---|---|
| Primary aldosteronism | Aldosterone-to-renin ratio |
| Renovascular hypertension | Renal Doppler ultrasound, CT/MR angiography |
| Pheochromocytoma | Plasma or urinary fractionated metanephrines |
| Obstructive sleep apnea | Overnight polysomnography |
| Cushing's syndrome | 24h urinary free cortisol, dexamethasone suppression |
| Thyroid disease | TSH |
| Coarctation of aorta | Echocardiogram, CT angiogram |
Special Considerations for Hypertensive Emergencies
For patients presenting with severe hypertension and signs of end-organ damage:
- Cardiac assessment: High-sensitivity cardiac troponin, NT-proBNP 1
- Neurological evaluation: Brain CT or MRI if neurological symptoms 1
- Additional testing: Urine drug screen if substance use is suspected 1
Pregnancy-Specific Assessment
For pregnant women with hypertension:
- Fetal assessment: Electronic fetal heart monitoring, ultrasound for fetal growth 1
- Amniotic fluid assessment 1
- Uterine artery Doppler velocimetry 1
- sFlt-1/PlGF ratio to predict pre-eclampsia 1
Pediatric Considerations
For children with hypertension:
- Growth parameters: Poor growth may indicate underlying chronic illness 1
- Assessment for diminished femoral pulses 1
- Evaluation for secondary causes is particularly important as they are more common in children 1
A recent study demonstrated that patients receiving complete laboratory workups at hypertension diagnosis showed better blood pressure control at 12 months compared to those with partial workups 3, highlighting the importance of comprehensive evaluation.