What diagnostic tests and treatment approach are recommended for a patient with a new hypertension diagnosis?

Initial Diagnostic Testing for New Hypertension

All patients with newly diagnosed hypertension should receive a standardized panel of basic laboratory tests including serum electrolytes (sodium, potassium, calcium), creatinine with eGFR, fasting glucose, lipid profile, urinalysis, and a 12-lead ECG. 1

Essential Basic Laboratory Tests

The following tests are mandatory for every patient with new hypertension:

Blood Tests

• Serum electrolytes: Sodium, potassium, and calcium to detect abnormalities that may indicate secondary causes (hypokalemia suggests primary aldosteronism) or guide medication selection 1
• Serum creatinine with eGFR: Essential to establish baseline kidney function and identify chronic kidney disease, which affects treatment targets and medication choices 1
• Fasting glucose or HbA1c: Identifies diabetes or prediabetes, which lowers BP treatment thresholds to <130/80 mmHg and significantly increases cardiovascular risk 1, 2
• Lipid profile: Assesses total cardiovascular risk, as 30% of hypertensive patients have dyslipidemia requiring concurrent treatment 1

Urine Tests

• Dipstick urinalysis: Screens for proteinuria and hematuria, which indicate kidney damage and independently predict cardiovascular events 1
• Urinary albumin-to-creatinine ratio: Detects early kidney damage and serves as an independent cardiovascular risk factor, particularly important in diabetic patients 1, 3

Cardiac Assessment

• 12-lead ECG: Detects left ventricular hypertrophy, atrial fibrillation, and ischemic heart disease—all of which influence treatment intensity and medication selection 1, 3

Clinical Impact of Baseline Testing

Recent evidence demonstrates that complete baseline laboratory workup significantly improves blood pressure control. Patients receiving complete testing achieved systolic BP of 129.9 mmHg at 12 months versus 142.8 mmHg in those with partial testing (P = 0.003). 2

Common abnormalities detected include: 54% with LDL >100 mg/dL, 36% with creatinine >0.8 mg/dL, 8% with fasting glucose >125 mg/dL, and 8% with eGFR <60 mL/min/1.73m². 2 These findings directly alter treatment decisions and cardiovascular risk stratification.

Optional Tests Based on Clinical Suspicion

When to Order Additional Testing

Echocardiography is indicated when: 1, 4

• ECG shows abnormalities (LVH, poor R-wave progression, Q waves)
• Cardiac murmurs are present on examination
• Patient has symptoms or signs of heart failure
• Detection of LVH would change treatment decisions

Thyroid-stimulating hormone (TSH) should be checked to exclude thyroid disorders as secondary causes of hypertension. 1, 5

Serum uric acid may be considered as hyperuricemia is present in 25% of hypertensive patients and may influence medication choices. 1

Screening for Secondary Hypertension

Additional targeted testing is warranted only when clinical features suggest specific secondary causes: 1, 3

• Aldosterone-renin ratio: For hypokalemia, muscle weakness, or resistant hypertension (suggests primary aldosteronism)
• Plasma free metanephrines: For episodic hypertension with palpitations, sweating, and headaches (suggests pheochromocytoma)
• Late-night salivary cortisol: For moon facies, central obesity, and abdominal striae (suggests Cushing syndrome)
• Renal artery imaging (ultrasound/CT/MR angiography): For young females, flash pulmonary edema, or worsening renal function with ACE inhibitors (suggests renal artery stenosis)
• Sleep study: For snoring, daytime sleepiness, and neck circumference >40 cm (suggests obstructive sleep apnea)

Physical Examination Findings That Guide Testing

The physical examination should specifically assess for: 1

• Cardiovascular: Pulse rate/rhythm, jugular venous pressure, apex beat displacement, extra heart sounds, peripheral edema, carotid/abdominal/femoral bruits, radio-femoral delay
• Body habitus: BMI, waist circumference, neck circumference >40 cm, fatty deposits, colored striae
• Other systems: Enlarged kidneys on palpation, thyroid enlargement

Common Pitfalls to Avoid

Do not diagnose hypertension based on a single office reading. Confirm elevated BP with repeated measurements on multiple visits or with out-of-office monitoring (home BP or 24-hour ambulatory monitoring) to exclude white coat hypertension, which affects 10-30% of patients. 1, 5

Do not order extensive imaging or specialized testing routinely. Reserve echocardiography, carotid ultrasound, renal imaging, and fundoscopy for patients with specific clinical indications rather than as universal screening. 1, 3

Do not skip the basic laboratory panel. More than 50% of hypertensive patients have additional cardiovascular risk factors that proportionally increase their risk of coronary, cerebrovascular, and renal disease—these must be identified to guide treatment intensity. 1, 3