When should hypertension be worked up?

When to Work Up Hypertension

All adults should have blood pressure measured at every routine clinical visit or at least every 6 months, with confirmed hypertension requiring diagnostic confirmation through repeated measurements and evaluation for secondary causes in specific high-risk scenarios. 1

Initial Screening and Diagnosis

Routine Screening Schedule

• Measure blood pressure at every routine clinical visit or at minimum every 6 months for all adults 1
• Screen every 2 years in persons with BP <120/80 mmHg 1
• Screen annually in persons with systolic BP 120-139 mmHg or diastolic BP 80-90 mmHg 1
• Continue routine screening until age 80 years 1

Diagnostic Confirmation Requirements

When office BP is 120-139/70-89 mmHg (elevated BP in high-risk individuals):

• Confirm with out-of-office measurements using ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) 1
• If not feasible, use repeated office measurements on multiple visits 1

When office BP is 140-159/90-99 mmHg (Grade 1 hypertension):

• Diagnosis must be based on out-of-office BP measurement with ABPM and/or HBPM 1
• If these are not logistically feasible, confirm with repeated office measurements on at least 2-3 separate visits 1
• Hypertension is confirmed when home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg 1

When office BP is 160-179/100-109 mmHg (Grade 2 hypertension):

• Confirm as soon as possible (within 1 month) preferably by home or ambulatory BP measurements 1
• Start drug treatment immediately while confirming diagnosis 1

When office BP is ≥180/110 mmHg:

• Exclude hypertensive emergency immediately 1
• Diagnosis can be based on measurements at a single visit if BP is markedly elevated 1

When to Pursue Secondary Hypertension Workup

High-Suspicion Clinical Scenarios

Initiate workup for secondary causes when patients present with: 2

• Age of onset <30 years 2
• Age of onset >55 years 2
• Accelerated or malignant hypertension 2
• Resistant hypertension (uncontrolled despite 3+ medications) 2
• Specific clinical features suggesting secondary causes 2

Essential Baseline Evaluation

All patients with confirmed hypertension require: 1, 2

• Serum creatinine and estimated glomerular filtration rate (eGFR) 1
• Urine albumin-to-creatinine ratio (ACR) 1
• Fasting glucose or HbA1c 2
• Lipid profile 2
• Serum electrolytes (sodium, potassium) 2
• 12-lead ECG for all patients 1

Additional Testing Based on Findings

• Echocardiography: When ECG shows abnormalities or patient has signs/symptoms of cardiac disease 1
• Fundoscopy: When BP >180/110 mmHg to evaluate for hypertensive emergency and malignant hypertension, or in hypertensive patients with diabetes 1
• Repeat renal function tests: At least annually if moderate-to-severe CKD is diagnosed 1

Special Population Considerations

Children and Adolescents

• Measure BP at each routine visit 1
• Confirm elevated BP (≥90th percentile or ≥120/80 mmHg in adolescents ≥13 years) on three separate days 1
• Confirm hypertension (≥95th percentile or ≥130/80 mmHg in adolescents ≥13 years) on three separate days 1

Patients with Diabetes

• Blood pressure should be measured at every routine clinical visit 1
• Confirm hypertension (≥130/80 mmHg) with multiple readings on separate days 1
• These patients are automatically considered high-risk and require comprehensive cardiovascular risk assessment 1

Key Clinical Pitfalls to Avoid

White coat hypertension: Always confirm office readings ≥140/90 mmHg with out-of-office measurements before diagnosing hypertension, as office BP has limited correlation with 24-hour BP and daily life pressures 1

Inadequate confirmation: The diagnosis should be based on at least 2 BP measurements per visit and at least 2-3 visits in most cases, though severe elevations may warrant single-visit diagnosis 1

Missing secondary causes: Normal renal function (normal urinalysis and serum creatinine) makes renal parenchymal disease or renal artery stenosis less likely, but doesn't exclude other secondary causes in high-risk presentations 2

Overlooking cardiovascular risk stratification: The presence of multiple cardiovascular risk factors (obesity, smoking, prediabetes, hypertension) proportionally increases risk of coronary, cerebrovascular, and renal disease, requiring comprehensive risk calculation using validated scales 2