What else to ask when a patient presents with hypertension?

Initial Assessment of a Patient Presenting with High Blood Pressure

When a patient presents with high blood pressure, obtain a comprehensive medical history focusing on BP duration, cardiovascular risk factors, symptoms of secondary hypertension, and target organ damage, followed by a thorough physical examination and baseline laboratory investigations. 1

Medical History Components

Blood Pressure History

• Duration and severity of elevated BP, including previous BP readings and any prior diagnosis of hypertension 1
• Current and previous antihypertensive medications, including over-the-counter medicines that can influence BP 1
• History of medication side effects and adherence to previous antihypertensive treatment 1
• Hypertension during pregnancy or with oral contraceptive use 1

Cardiovascular Risk Factor Assessment

• Personal history of cardiovascular disease: myocardial infarction, heart failure, stroke, transient ischemic attacks 1
• Metabolic conditions: diabetes mellitus, dyslipidemia 1
• Chronic kidney disease 1
• Lifestyle factors: smoking status, diet (particularly sodium and potassium intake), alcohol consumption, physical activity level 1
• Psychosocial factors including history of depression 1
• Family history of hypertension, premature cardiovascular disease (men <55 years, women <65 years), familial hypercholesterolemia, or diabetes 1

Symptoms Suggesting Hypertensive Complications

• Cardiac symptoms: chest pain, shortness of breath, palpitations 1
• Vascular symptoms: claudication, peripheral edema 1
• Neurological symptoms: headaches, blurred vision, dizziness 1
• Renal symptoms: nocturia, hematuria 1

Red Flags for Secondary Hypertension

• Primary aldosteronism: muscle weakness, tetany, cramps, arrhythmias (suggesting hypokalemia) 1
• Renal artery stenosis: flash pulmonary edema 1
• Pheochromocytoma: sweating, palpitations, frequent severe headaches 1
• Obstructive sleep apnea: snoring, daytime sleepiness, neck circumference >40 cm 1
• Thyroid disease: symptoms of hyper- or hypothyroidism 1

Physical Examination

Cardiovascular Assessment

• Pulse rate, rhythm, and character 1
• Blood pressure in both arms (if difference >10 mmHg consistently, use arm with higher reading; if >20 mmHg, consider further vascular investigation) 1
• Standing BP measurements at 1 and 3 minutes in elderly patients, diabetics, or those with symptoms of orthostatic hypotension 1
• Jugular venous pressure, apex beat, extra heart sounds, basal crackles 1
• Peripheral edema 1
• Vascular bruits (carotid, abdominal, femoral) and radio-femoral delay 1

Other Systems

• Enlarged kidneys on abdominal examination 1
• Neck circumference (>40 cm suggests obstructive sleep apnea) 1
• Thyroid enlargement 1
• Body mass index and abdominal obesity (waist circumference: men ≥102 cm, women ≥88 cm) 1

Laboratory Investigations

Core Laboratory Tests

The following tests should be ordered once elevated BP is confirmed 2:

• Fasting blood glucose to screen for diabetes or prediabetes 2
• Complete blood count (CBC) to assess for anemia or hematologic abnormalities 2
• Lipid profile (total cholesterol, LDL, HDL, triglycerides) to evaluate cardiovascular risk 2
• Serum creatinine with estimated glomerular filtration rate (eGFR) to assess kidney function 2
• Serum electrolytes (sodium, potassium, calcium) to detect imbalances 2
• Thyroid-stimulating hormone (TSH) to screen for thyroid disorders 2
• Urinalysis to detect proteinuria, hematuria, or kidney damage 2
• 12-lead electrocardiogram (ECG) to assess for left ventricular hypertrophy or cardiac abnormalities 2

Optional Tests Based on Clinical Context

• Urinary albumin-to-creatinine ratio (ACR) to detect early kidney damage 2
• Uric acid (optional consideration) 2
• Echocardiography when ECG shows abnormalities or there are signs/symptoms of cardiac disease 2

Blood Pressure Confirmation Strategy

Critical Pitfall to Avoid

Never diagnose hypertension based on a single elevated reading 2. The diagnosis requires confirmation with multiple measurements 1.

Confirmation Protocol Based on Initial BP Reading

For BP <130/85 mmHg:

• Remeasure within 3 years (1 year if other risk factors present) 1

For BP 130-159/85-99 mmHg:

• Confirm with out-of-office BP measurement (home or ambulatory monitoring) due to high possibility of white coat or masked hypertension 1
• If out-of-office monitoring unavailable, repeat measurements on multiple visits 1

For BP 160-179/100-109 mmHg:

• Confirm within 1 month, preferably with home or ambulatory BP measurements 1

For BP ≥180/110 mmHg:

• Immediately exclude hypertensive emergency (acute end-organ damage) 1
• If no emergency, confirm within days to weeks (not >1 month) 1
• Consider prompt treatment initiation after confirmation 1

Out-of-Office BP Monitoring

• Home BP monitoring (HBPM) or ambulatory BP monitoring (ABPM) are more reproducible than office measurements and better predict cardiovascular outcomes 1
• These methods identify white coat hypertension (10-30% of patients with elevated office BP) and masked hypertension (10-15% of patients) 1, 2
• White coat hypertension patients are at intermediate cardiovascular risk and may not require drug treatment if total cardiovascular risk is low 1
• Masked hypertension patients are at similar risk as sustained hypertensives and may require drug treatment 1

Cardiovascular Risk Stratification

Use validated risk assessment tools (such as SCORE2 or SCORE2-OP in Europe, or tools recommended by local guidelines) to calculate 10-year cardiovascular disease risk 1, 2. This assessment should incorporate:

• Age and sex 1
• Smoking status 1
• Lipid levels 1
• Diabetes status 1
• Evidence of target organ damage 1

Special Considerations

Screening for Primary Aldosteronism

Consider screening all adults with confirmed hypertension (BP ≥140/90 mmHg) with renin and aldosterone measurements, as this is a common and treatable cause of secondary hypertension 1.

Chronic Kidney Disease Monitoring

If moderate-to-severe CKD is diagnosed, repeat measurements of serum creatinine, eGFR, and urine ACR at least annually 1, 2.

Resistant Hypertension

Patients with apparent resistant hypertension should be considered for referral to specialized hypertension centers for further evaluation, including objective assessment of medication adherence 1.