What additional testing is recommended for a patient with stage 1 hypertension?

Recommended Additional Testing for Stage 1 Hypertension

For patients with stage 1 hypertension, basic laboratory testing should include fasting blood glucose, complete blood count, lipid profile, serum creatinine with eGFR, serum electrolytes (sodium, potassium, calcium), thyroid-stimulating hormone, urinalysis, and an electrocardiogram. 1

Basic Laboratory Testing (Required)

• Fasting blood glucose - to screen for diabetes or prediabetes, which frequently coexists with hypertension 1
• Complete blood count - to evaluate for anemia or other hematologic abnormalities 1
• Lipid profile - to assess cardiovascular risk; up to 42% of hypertensive patients may have elevated cholesterol levels 1, 2
• Serum creatinine with estimated glomerular filtration rate (eGFR) - to assess kidney function and establish baseline renal status 1
• Serum electrolytes (sodium, potassium, calcium) - to identify electrolyte abnormalities that may suggest secondary causes of hypertension 1
• Thyroid-stimulating hormone - to screen for hypothyroidism or hyperthyroidism, which are remediable causes of hypertension 1
• Urinalysis - to screen for kidney disease 1
• Electrocardiogram - to assess for left ventricular hypertrophy and other cardiac abnormalities 1

Optional Testing (Based on Clinical Indications)

• Echocardiogram - recommended particularly in cases of:

  • Uncontrolled hypertension despite therapy 3
  • Suspected hypertensive heart disease 1, 3
  • When initiating therapy to assess for target organ damage 1, 3
  • Abnormal ECG findings 1, 3

• Urinary albumin-to-creatinine ratio - more sensitive than standard urinalysis for detecting early kidney damage 1

  • KDOQI recommends this over urine dipstick for albuminuria assessment 1
  • Particularly important in patients with diabetes or high cardiovascular risk 1

• Serum uric acid - may provide additional risk stratification information 1

• Ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) - to identify white coat or masked hypertension 1

  • Particularly valuable when office readings are inconsistent 1
  • Can confirm the diagnosis of hypertension 1

Additional Testing Based on Specific Clinical Scenarios

• Renal ultrasound - consider when:

  • Patient is younger than 30 years 1
  • Poor response to standard treatment approaches 1
  • Abnormal kidney function tests 1, 2
  • Suspected secondary hypertension 1

• Advanced cardiovascular imaging - in selected cases:

  • Pulse wave velocity, carotid intima-media thickness, or coronary artery calcium scoring may be considered for further risk stratification, though not routinely recommended 1
  • These provide noninvasive estimates of vascular target organ injury and atherosclerosis 1

Considerations for Special Populations

• For patients with diabetes or chronic kidney disease:

  • Urinary albumin-to-creatinine ratio is strongly recommended 1
  • More comprehensive cardiovascular risk assessment 1

• For patients with resistant hypertension:

  • More extensive evaluation for secondary causes 1
  • Consider sleep study to rule out obstructive sleep apnea 1

Clinical Pitfalls to Avoid

• Relying solely on office BP measurements without confirming with out-of-office measurements can lead to misdiagnosis (white coat or masked hypertension) 1
• Using urine dipstick alone instead of quantitative urinary albumin-to-creatinine ratio may miss early kidney damage 1
• Overlooking the need for echocardiography in patients with uncontrolled hypertension, as ECG has limited sensitivity for detecting left ventricular hypertrophy 3
• Failing to assess standing blood pressure to detect orthostatic hypotension, especially in older adults 1

Remember that the diagnostic evaluation should be tailored based on the severity of hypertension, response to treatment, and presence of target organ damage or clinical clues suggesting secondary causes 1.