How is end-organ damage evaluated and managed in patients with hypertension?

Evaluation of End-Organ Damage in Hypertension

The comprehensive assessment of end-organ damage in hypertensive patients should include cardiac, renal, cerebrovascular, vascular, and retinal examinations through targeted clinical evaluation and specific diagnostic tests.

Initial Assessment and Routine Tests

• A focused history and physical examination should evaluate for subtle signs of end-organ damage including vision changes, confusion, dyspnea on exertion, and oliguria in patients with hypertension 1
• Routine laboratory tests should include fasting blood glucose, serum lipids, blood sodium, potassium, calcium, TSH, creatinine, eGFR, urinalysis, and urinary albumin-to-creatinine ratio 2
• A 12-lead ECG is essential for all hypertensive patients to detect left ventricular hypertrophy using criteria such as Sokolow-Lyon index (SV1+RV5 ≥35 mm) or Cornell index (SV3+RaVL >28 mm for men or >20 mm for women) 2
• Repeated blood pressure measurements are necessary as a single elevated reading may not accurately reflect the patient's true BP status 1

Organ-Specific Evaluation

Cardiac Assessment

• Echocardiography should be performed when ECG is abnormal, cardiac murmurs are detected, or cardiac symptoms are present 2
• Echocardiography is more sensitive than ECG for detecting LVH (left ventricular mass index: men >115 g/m²; women >95 g/m²) and evaluating LV geometry, left atrial volume, and systolic/diastolic function 2, 1
• Consider measuring high-sensitivity cardiac troponin and/or NT-proBNP to assess hypertension-mediated organ damage 2

Renal Assessment

• Measure serum creatinine, eGFR, and urinary albumin-to-creatinine ratio to assess kidney function 2
• A negative urine dipstick test for both protein and hematuria has high sensitivity (100%) for ruling out acute renal damage 2, 1
• Consider renal ultrasound in patients with evidence of kidney dysfunction to assess kidney structure and exclude renoparenchymal and renovascular hypertension 2

Cerebrovascular Assessment

• Perform a thorough neurological examination to detect subtle neurologic deficits 1
• Brain MRI is most sensitive for detecting early subclinical changes but should be considered only in patients with neurologic disturbances, cognitive decline, or memory loss 2, 1
• Early subclinical changes detectable by MRI include white matter lesions, silent microinfarcts, microbleeds, and brain atrophy 2

Vascular Assessment

• Consider carotid ultrasound to detect vascular hypertrophy or asymptomatic atherosclerosis 2
• Pulse wave velocity measurement can assess large artery stiffening 2
• Ankle-brachial index can signal advanced peripheral artery disease 2

Retinal Assessment

• Fundoscopic examination is essential to detect hypertensive retinopathy, particularly in severe hypertension 2, 1
• Look for flame-shaped hemorrhages, cotton wool spots (exudates), and papilledema, which are associated with increased cardiovascular risk 2
• Fundoscopy is particularly important when diagnosing hypertensive emergencies or malignant hypertension 2, 1

Extended Evaluation

• For patients with suspected secondary hypertension, additional tests may include measurements of renin, aldosterone, corticosteroids, and catecholamines in plasma and/or urine 2
• Consider arteriography, renal and adrenal ultrasound, CT, or MRI when clinical findings suggest secondary causes of hypertension 2
• Abdominal ultrasound may be useful to assess for abdominal aortic aneurysm 2

Management Implications

• Detection of end-organ damage should guide the urgency and intensity of antihypertensive treatment 3
• Patients with hypertensive emergencies (severe hypertension with acute end-organ damage) require immediate BP reduction with short-acting titratable intravenous antihypertensive medications in an intensive care setting 2, 4
• Patients with hypertensive urgencies (severe hypertension with no or minimal end-organ damage) may generally be treated with oral antihypertensives as outpatients 2, 4
• Blockade of the renin-angiotensin-aldosterone system is an essential part of treatment for early end-organ damage 5

Risk Factors and Special Considerations

• Age >60 years, history of diabetes, ischemic heart disease, and previous cerebrovascular events are significantly associated with higher risk of end-organ damage in patients with severe hypertension 6
• The prevalence of end-organ damage may be higher in low-middle-income countries, suggesting a lower threshold for screening may be appropriate in these settings 6
• Rapidly lowering blood pressure in asymptomatic patients may be harmful and should be avoided 2, 1
• Visualizing hypertension-mediated organ damage can help motivate patients toward risk-reducing changes and overcome physician inertia in achieving intensive BP treatment targets 2