What is the initial approach to work up a patient with hypertension in the hospital?

Initial Workup of In-Hospital Hypertension

Begin with a focused assessment to distinguish hypertensive emergency (requiring immediate IV therapy) from hypertensive urgency or chronic uncontrolled hypertension (manageable with oral agents), as the presence of acute end-organ damage determines the entire management pathway. 1

Immediate Clinical Assessment

Confirm the Blood Pressure Elevation

• Take at least 2-3 additional measurements using a validated device with appropriate cuff size to confirm the reading is accurate and sustained 1, 2
• Ensure proper technique: patient seated, arm supported at heart level, appropriate cuff size for arm circumference 1

Determine if Hypertensive Emergency Exists

A hypertensive emergency is defined by acute hypertension-mediated organ damage (HMOD), NOT by a specific BP threshold. 1 There is no magic number—patients can have emergencies at 180/110 or urgencies at 220/130 depending on end-organ involvement.

Key symptoms requiring immediate evaluation: 1

• Neurologic: Severe headache, visual disturbances, altered mental status, focal deficits, seizures
• Cardiac: Chest pain, dyspnea, signs of acute heart failure
• Other: Acute renal failure symptoms, signs of aortic dissection

Essential Diagnostic Workup

History (Focused on High-Yield Elements)

Medication and adherence history: 1

• Current antihypertensive regimen and adherence
• Recent medication changes or discontinuation
• Use of BP-elevating substances: NSAIDs, steroids, immunosuppressants, sympathomimetics, cocaine, nasal decongestants, licorice 1

Symptom timeline: 1

• Onset and duration of current symptoms
• Previous hypertensive episodes or known chronic hypertension

Secondary hypertension clues: 1

• Young age (<30 years) with severe hypertension
• Sudden onset or rapid progression
• Resistant hypertension (uncontrolled on ≥3 medications including diuretic)
• Symptoms of pheochromocytoma (episodic headaches, palpitations, sweating)
• Symptoms of Cushing syndrome or thyroid disease

Physical Examination (Target Organ Assessment)

Cardiovascular: 1

• Heart rate (>80 bpm indicates higher risk) and rhythm assessment
• Apical impulse location and character (left ventricular hypertrophy)
• Cardiac auscultation for gallops, murmurs
• Peripheral pulses (all four extremities—diminished/delayed femoral pulses suggest coarctation)
• Signs of heart failure (jugular venous distension, pulmonary rales, peripheral edema)

Neurologic: 1

• Mental status and focal deficits
• Fundoscopy: papilledema, hemorrhages, exudates, arteriovenous nicking 1

Vascular: 1

• Abdominal bruits (renovascular hypertension)
• Carotid bruits
• Precordial/chest murmurs (coarctation, aortic disease)

Endocrine stigmata: 1

• Cushing features (central obesity, striae, moon facies)
• Thyroid enlargement
• Neurofibromatosis skin findings (pheochromocytoma association)

Mandatory Laboratory Investigations

Basic metabolic panel: 1

• Sodium, potassium (hypokalemia suggests primary aldosteronism)
• Serum creatinine and estimated GFR (renal function/damage)

Additional essential tests: 1

• Urinalysis with dipstick (proteinuria, hematuria indicating renal damage)
• 12-lead ECG (left ventricular hypertrophy, atrial fibrillation, ischemia) 1
• Complete blood count (anemia in renal disease, thrombocytopenia in thrombotic microangiopathy) 1

If available and appropriate: 1

• Lipid profile and fasting glucose (cardiovascular risk stratification)
• Serum uric acid (common in hypertension, 25% prevalence) 1

Additional Testing for Suspected Hypertensive Emergency

When acute end-organ damage is suspected: 1

• Cardiac markers (troponin) if chest pain present 1
• Chest X-ray if pulmonary edema or aortic pathology suspected 1
• Echocardiogram for cardiac structure/function assessment 1
• Brain CT/MRI if neurologic symptoms (hemorrhage, stroke, encephalopathy) 1
• CT angiography of chest/abdomen if aortic dissection suspected 1
• Lactate dehydrogenase (LDH) and haptoglobin if thrombotic microangiopathy suspected 1
• Urine sediment examination for active renal disease 1

Secondary Hypertension Workup (When Indicated)

Reserve for specific clinical scenarios: 1

• Young patients (<30 years) with severe hypertension
• Resistant hypertension despite 3+ medications
• Sudden onset or rapid progression
• Suggestive clinical features from history/exam
• Malignant hypertension (20-40% have secondary causes) 1

Specific tests when indicated: 1

• Aldosterone-renin ratio (primary aldosteronism)
• Plasma free metanephrines (pheochromocytoma)
• Late-night salivary cortisol or other cortisol excess screening (Cushing syndrome)
• Renal artery imaging (ultrasound with Doppler, CT/MR angiography) if renovascular disease suspected
• Renal/adrenal ultrasound or CT for structural abnormalities

Common Pitfalls to Avoid

Do not obtain extensive secondary hypertension workup in all patients. 1, 3 This leads to unnecessary expense and patient risk. Most hospitalized patients have essential hypertension with poor control or medication non-adherence. 4

Do not assume high BP alone equals emergency. 5 Patients with BP >180/120 without acute end-organ damage are hypertensive urgencies and can be managed with oral agents, not IV therapy. 1, 5

Do not use immediate-release nifedipine, hydralazine, or nitroglycerin for hypertensive emergencies. 5 These cause unpredictable BP drops.

Do not overlook medication non-adherence, NSAID use, or alcohol as causes of uncontrolled BP. 4 These are far more common than secondary hypertension in resistant cases.

Younger patients and those with negative family history warrant more detailed workup. 1, 4 The threshold for investigating secondary causes should be lower in these populations.