From the Guidelines
The workup for a 49-year-old female with severe hypertension should include a thorough cardiovascular and neurological assessment, as well as laboratory tests such as haemoglobin, platelet count, creatinine, sodium, potassium, and lactic dehydrogenase (LDH), and quantitative urinalysis to detect signs of organ damage 1.
Key Diagnostic Tests
- ECG to detect ischemia, arrhythmias, and left ventricular hypertrophy
- Fundoscopy to assess for malignant hypertension
- Chest X-ray or point of care ultrasonography to discriminate cardiac from non-cardiac dyspnea
- Transthoracic echocardiogram to assess left ventricular structure and function
Additional Tests as Indicated
- Troponin-T, CK, CK-MB to detect cardiac damage
- Peripheral blood smear to assess for schistocytes
- CT (or MRI)-brain to detect intracranial hemorrhage
- CT-angiography of thorax and abdomen to detect acute aortic disease
- Renal ultrasound to detect postrenal obstruction or kidney damage It is essential to measure blood pressure according to current guidelines in both arms and at the lower limb to detect pressure differences caused by aortic dissection, and to repeat measurements over time to assess for changes in blood pressure 1. The diagnostic workup should be tailored to the individual patient's clinical presentation and suspected underlying causes of hypertension.
From the Research
Workup for Severe Hypertension
The workup for a 49-year-old female with severe hypertension may involve several steps, including:
- Evaluating for signs of end-organ damage, such as cardiac, renal, or cerebral involvement 2
- Conducting a thorough medical history and physical examination to identify potential secondary causes of hypertension
- Ordering laboratory tests, such as:
- Urinalysis to check for proteinuria or hematuria
- Chemistry panel to evaluate renal function and electrolyte levels
- Lipid panel to assess cardiovascular risk
- Renal ultrasound to evaluate kidney size and structure
- Considering further testing, such as:
- Echocardiogram to evaluate cardiac function and structure
- Cardiac catheterization to assess coronary artery disease or pulmonary hypertension
- Vasodilatory testing to evaluate responsiveness to certain medications
Specific Considerations
In patients with severe hypertension, it is essential to consider potential underlying causes, such as:
- Pulmonary arterial hypertension (PAH), which may require specific therapies, such as bosentan, tadalafil, or beraprost 3
- Hypertrophic obstructive cardiomyopathy (HOCM), which may require careful management with medications, such as metoprolol, and potentially invasive procedures, such as alcohol septal ablation 4
- Factitious or induced hypertension, which may require a high index of suspicion and careful observation to diagnose 5
Diagnostic Approach
A stepwise approach to diagnosis and management is crucial in patients with severe hypertension, involving:
- Initial evaluation and stabilization
- Identification of potential underlying causes
- Selection of appropriate therapies, such as antihypertensive medications, diuretics, or PAH-specific treatments
- Ongoing monitoring and adjustment of therapies as needed to achieve optimal blood pressure control and prevent end-organ damage 2, 3, 4