What is the best approach to diagnose and treat a patient with undifferentiated symptoms, possibly including hypertension?

Diagnosing and Treating Patients with Undifferentiated Symptoms Including Hypertension

The best approach to diagnose and treat a patient with undifferentiated symptoms, possibly including hypertension, is to follow a systematic diagnostic protocol with appropriate blood pressure measurement, comprehensive risk assessment, and targeted investigations for organ damage, followed by risk-stratified treatment decisions. 1

Initial Diagnostic Approach

Blood Pressure Assessment

• Obtain accurate blood pressure measurements using standardized technique with the patient seated quietly for 5 minutes, using appropriate cuff size, and taking multiple readings 1
• Consider out-of-office blood pressure measurement using ambulatory blood pressure monitoring (ABPM) and/or home blood pressure monitoring (HBPM) when screening office BP is 120-139/70-89 mmHg, especially in patients with increased cardiovascular disease (CVD) risk 1
• For screening office BP of 140-159/90-99 mmHg, diagnosis should be confirmed with out-of-office measurements or repeated office measurements on more than one visit 1
• For BP ≥160/100 mmHg, confirm as soon as possible (within 1 month) preferably by home or ambulatory BP measurements 1
• For BP ≥180/110 mmHg, exclude hypertensive emergency immediately 1

Essential Laboratory and Diagnostic Tests

• Perform urine strip test for blood and protein 1
• Measure serum creatinine, estimated glomerular filtration rate (eGFR), and urine albumin:creatinine ratio (ACR) 1
• Check blood electrolytes, glucose, and serum total:HDL cholesterol ratio 1
• Obtain 12-lead electrocardiogram (ECG) for all patients with hypertension 1
• Consider echocardiography in patients with ECG abnormalities, cardiac signs, or symptoms 1

Additional Targeted Investigations

• Perform fundoscopy if BP >180/110 mmHg to assess for hypertensive retinopathy, especially in suspected hypertensive emergency 1
• Consider coronary artery calcium (CAC) scoring by cardiac CT or carotid/femoral artery ultrasound to assess for atherosclerotic plaque when it may change patient management 1
• Measure high-sensitivity cardiac troponin and/or NT-proBNP to assess for hypertension-mediated organ damage when appropriate 1
• Consider large artery stiffness assessment (carotid-femoral or brachial-ankle pulse wave velocity) when it may influence management decisions 1

Screening for Secondary Hypertension

• Screen for secondary hypertension in patients with suggestive signs, symptoms, or medical history 1
• Consider screening for primary aldosteronism by measuring renin and aldosterone in all adults with confirmed hypertension (BP ≥140/90 mmHg) 1
• Evaluate for obstructive sleep apnea in patients with symptoms such as snoring, witnessed apnea, or excessive daytime sleepiness 1
• Consider renal artery stenosis in young females, patients with known atherosclerotic disease, or those with worsening renal function 1
• Assess for pheochromocytoma in patients with episodic hypertension, palpitations, diaphoresis, or headache 1
• Evaluate for Cushing's syndrome in patients with characteristic physical features (moon facies, central obesity, abdominal striae) 1

Treatment Approach

Lifestyle Modifications

• Recommend sodium restriction to approximately 2g per day (equivalent to about 5g of salt) for all adults with elevated BP and hypertension 1
• Advise moderate-intensity aerobic exercise of ≥150 min/week plus resistance training (2-3 times/week) 1
• Target a healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 1
• Suggest adopting a healthy diet such as Mediterranean or DASH diets 1
• Recommend limiting alcohol consumption to less than 100g/week of pure alcohol, with complete avoidance being preferable 1
• Advise restriction of free sugar consumption, particularly sugar-sweetened beverages 1
• Strongly encourage smoking cessation with appropriate support 1

Pharmacological Treatment

• For adults with elevated BP and low/medium CVD risk (<10% over 10 years), start with lifestyle measures 1
• For adults with elevated BP and high CVD risk, after 3 months of lifestyle intervention, initiate pharmacological treatment for those with confirmed BP ≥130/80 mmHg 1
• For patients with confirmed BP ≥140/90 mmHg, initiate pharmacological treatment regardless of risk status 1
• First-line medications include ACE inhibitors, ARBs, dihydropyridine calcium channel blockers (CCBs), and thiazide or thiazide-like diuretics 1, 2
• Consider lisinopril (ACE inhibitor) which has demonstrated superior reductions in systolic and diastolic blood pressure compared to hydrochlorothiazide in studies 3
• Alternatively, amlodipine (CCB) has shown effectiveness in reducing blood pressure and preventing hospitalizations for angina 4, 2
• For resistant hypertension (BP uncontrolled despite 3 or more medications), consider adding a mineralocorticoid receptor antagonist as a fourth agent 1, 5

Special Considerations

Hypertensive Urgency and Emergency

• For hypertensive urgency (severe BP elevation without acute organ damage), use oral medications with gradual BP reduction over 24-48 hours 6, 7
• Avoid rapid BP lowering as it can precipitate renal, cerebral, or coronary ischemia 7
• For hypertensive emergency (severe BP with acute organ damage), admit to intensive care unit for immediate BP reduction with short-acting titratable IV antihypertensive medication 1, 8
• Monitor BP frequently during the first hours of treatment, with a target BP reduction of no more than 25% within the first hour 7

Monitoring and Follow-up

• For patients with elevated BP who don't meet thresholds for treatment, repeat BP measurement and risk assessment within 1 year 1
• If moderate-to-severe chronic kidney disease is diagnosed, repeat measurements of serum creatinine, eGFR, and urine ACR at least annually 1
• Consider referral to specialized hypertension centers for patients with resistant hypertension 1
• Recommend taking medications at the most convenient time of day to establish a habitual pattern and improve adherence 1

By following this systematic approach to diagnosis and treatment, clinicians can effectively manage patients with undifferentiated symptoms that may include hypertension, reducing their risk of cardiovascular morbidity and mortality.