What are the current guidelines for the workup of hypertension (HTN)?

Current Guidelines for Hypertension Workup

The 2020 International Society of Hypertension guidelines provide a comprehensive, tiered approach to hypertension workup that prioritizes basic laboratory investigations and ECG for all patients, with additional testing reserved for those with suspected organ damage or secondary causes. 1

Essential Initial Workup (All Patients)

History and Physical Examination

Target your history to identify symptoms suggesting secondary hypertension and end-organ damage:

• Secondary hypertension red flags: muscle weakness, tetany, cramps (hypokalemia/primary aldosteronism); flash pulmonary edema (renal artery stenosis); sweating, palpitations, frequent headaches (pheochromocytoma); snoring, daytime sleepiness (obstructive sleep apnea); thyroid symptoms 1
• Organ damage symptoms: chest pain, shortness of breath, claudication, peripheral edema, blurred vision, nocturia, hematuria 1

Physical examination must include:

• Pulse rate/rhythm/character, jugular venous pressure, apex beat, extra heart sounds, basal crackles, peripheral edema, bruits (carotid, abdominal, femoral), radio-femoral delay 1
• Enlarged kidneys, neck circumference >40 cm (obstructive sleep apnea marker), enlarged thyroid, BMI/waist circumference, fatty deposits and colored striae (Cushing syndrome) 1

Mandatory Laboratory Investigations

All hypertensive patients require:

• Blood tests: Sodium, potassium, serum creatinine with eGFR calculation 1
• If available: Lipid profile and fasting glucose 1
• Urine: Dipstick urinalysis 1
• 12-lead ECG: To detect atrial fibrillation, left ventricular hypertrophy, ischemic heart disease 1

Additional Testing (When Indicated)

These investigations are reserved for patients with suspected hypertension-mediated organ damage (HMOD), coexistent diseases, or secondary hypertension:

Imaging Studies

• Echocardiography: For suspected LVH, systolic/diastolic dysfunction, atrial dilation, aortic coarctation 1
• Carotid ultrasound: To assess for atherosclerotic plaques and stenosis 1
• Renal/adrenal imaging: Ultrasound, renal artery Duplex, CT/MR angiography for renal parenchymal disease, renal artery stenosis, adrenal lesions 1
• Fundoscopy: To identify retinal changes, hemorrhages, papilledema, arteriovenous nipping 1
• Brain CT/MRI: When ischemic or hemorrhagic brain injury is suspected 1

Functional and Specialized Laboratory Tests

• Ankle-brachial index: For peripheral artery disease assessment 1
• Secondary hypertension workup (when clinically indicated): Aldosterone-renin ratio, plasma free metanephrines, late-night salivary cortisol or other cortisol excess screening 1
• Urinary albumin/creatinine ratio: For kidney damage assessment 1
• Serum uric acid levels: Common in hypertension (25% prevalence) 1
• Liver function tests: Part of comprehensive assessment 1

Cardiovascular Risk Assessment

More than 50% of hypertensive patients have additional cardiovascular risk factors that must be identified: 1

• Common comorbidities: Diabetes (15-20%), lipid disorders (30%), overweight-obesity (40%), hyperuricemia (25%), metabolic syndrome (40%) 1
• Risk stratification factors: Age >65 years, male sex, heart rate >80 bpm, increased body weight, diabetes, high LDL-C/triglycerides, family history of CVD or hypertension, early-onset menopause, smoking, psychosocial factors 1
• HMOD markers: LVH on ECG, moderate-severe CKD (eGFR <60 ml/min/1.73m²) 1
• Established disease: Prior coronary heart disease, heart failure, stroke, peripheral vascular disease, atrial fibrillation, CKD stage 3+ 1

Clinical Pitfalls to Avoid

Do not order extensive imaging and specialized testing for every hypertensive patient—this is unnecessary and costly. 1 The guidelines clearly distinguish between essential workup (blood tests, urinalysis, ECG) and additional testing that should only be pursued when clinical suspicion exists for organ damage or secondary causes. 1

HMOD detection is most valuable for risk stratification in low-to-moderate risk patients, not those already identified as high risk (established CVD, stroke, diabetes, CKD), where it is unlikely to change management. 1

Cardiovascular risk assessment should be integrated into the diagnostic workup, particularly with family history of CVD, as the presence of additional risk factors proportionally increases coronary, cerebrovascular, and renal disease risk. 1