What is the recommended workup and treatment for a newly diagnosed adult patient with uncontrolled hypertension and no known underlying medical conditions?

Hypertensive Workup for Newly Diagnosed Uncontrolled Hypertension

For a newly diagnosed adult with uncontrolled hypertension and no known comorbidities, confirm the diagnosis with out-of-office blood pressure monitoring, obtain baseline laboratory tests to identify target organ damage and secondary causes, initiate lifestyle modifications immediately, and start pharmacological therapy with a thiazide diuretic, ACE inhibitor or ARB, and/or calcium channel blocker based on blood pressure level and cardiovascular risk. 1, 2

Initial Diagnostic Confirmation

Blood Pressure Measurement Strategy

• Do not diagnose hypertension based on a single office reading – stage hypertension using readings on at least 2 separate occasions to avoid misdiagnosis 1, 3
• Use home blood pressure monitoring (HBPM) or ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis and exclude white coat hypertension, particularly when untreated SBP is 130-160 mm Hg or DBP is 80-100 mm Hg 1
• HBPM targets differ from office readings: hypertension is confirmed at ≥130/80 mm Hg for HBPM versus ≥130/80 mm Hg for office BP 1

Mandatory Baseline Laboratory Evaluation

Essential Tests to Order

The following tests must be obtained to identify target organ damage, assess cardiovascular risk, and screen for secondary causes 1:

• Serum creatinine and estimated GFR – to detect chronic kidney disease (35.5% of new hypertensives have creatinine >0.8 mg/dL; 7.5% have GFR <60 mL/min/1.73m²) 4
• Serum potassium and sodium – to screen for primary aldosteronism and establish baseline before diuretic therapy (1.9% have hypokalemia at baseline) 4, 1
• Fasting lipid panel – 54.2% of newly diagnosed hypertensives have LDL >100 mg/dL 4
• Fasting glucose and HbA1c – 8.4% have undiagnosed diabetes (glucose >125 mg/dL) and 7.5% have HbA1c >6.5% 4
• Urinalysis with microscopy – to detect proteinuria, hematuria, and casts indicating renal parenchymal disease 1
• 12-lead electrocardiogram – to identify left ventricular hypertrophy, ischemia, or arrhythmias (yet 89% of patients do not receive this mandatory test) 3, 1

Critical finding: Patients who receive complete baseline laboratory workup achieve significantly better blood pressure control at 12 months (129.9 mmHg) compared to those with partial workup (142.8 mmHg, P=0.003). 4

Screening for Secondary Hypertension

When to Screen

Screen for secondary causes when any of the following are present 1:

• Resistant hypertension (BP ≥130/80 mm Hg on 3+ medications including a diuretic) 5
• Hypertension with spontaneous or diuretic-induced hypokalemia 1
• Abrupt onset or worsening of previously controlled hypertension 1
• Age <30 years with hypertension 1
• Severe hypertension (BP ≥180/120 mm Hg) 1
• Abdominal bruit on examination 1

Specific Secondary Causes to Consider

Primary aldosteronism (8-20% prevalence in hypertensives): 1

• Screen with plasma aldosterone/renin ratio under standardized conditions
• Correct hypokalemia and withdraw aldosterone antagonists for 4-6 weeks before testing 1

Renovascular disease (5-34% in resistant hypertension): 1

• Screen with renal duplex Doppler ultrasound
• Look for flash pulmonary edema or systolic-diastolic abdominal bruit 1

Renal parenchymal disease (1-2% prevalence): 1

• Screen with renal ultrasound if elevated creatinine, abnormal urinalysis, or family history of polycystic kidney disease 1

Obstructive sleep apnea (25-50% prevalence in hypertensives): 1

• Consider in patients with resistant hypertension, snoring, or daytime somnolence 1

Lifestyle Modifications (Initiate Immediately)

All patients require intensive lifestyle interventions regardless of whether medications are started: 1, 2

• Sodium restriction to <1500 mg/day or reduce by at least 1000 mg/day 1
• Increase dietary potassium to 3500-5000 mg/day 1
• Weight loss of at least 1 kg if overweight/obese, targeting ideal body weight 1
• Aerobic exercise 90-150 minutes/week or isometric resistance training 3 sessions/week 1
• Alcohol limitation to ≤2 drinks/day in men, ≤1 drink/day in women 1
• DASH diet rich in fruits, vegetables, whole grains, low-fat dairy with reduced saturated fat 1

Pharmacological Therapy Decision Algorithm

When to Initiate Medications

Start antihypertensive drugs immediately if: 1, 2

• BP ≥140/90 mm Hg (confirmed on multiple readings or HBPM) 1
• BP ≥130/80 mm Hg with established cardiovascular disease, diabetes, or 10-year ASCVD risk ≥10% 1

First-Line Drug Selection

Initiate therapy with one or more of the following three drug classes: 2, 1

1. Thiazide or thiazide-like diuretic – chlorthalidone or hydrochlorothiazide 2
2. ACE inhibitor or ARB – enalapril, lisinopril, candesartan, or irbesartan 2
3. Calcium channel blocker – amlodipine or other dihydropyridine 2

For Stage 2 hypertension (BP ≥140/90 mm Hg), initiate two first-line agents simultaneously rather than sequential monotherapy to achieve control faster 2

Drug Selection Based on Comorbidities

Chronic kidney disease: ACE inhibitor or ARB (mandatory if albuminuria present) 1

Diabetes with albuminuria: ACE inhibitor or ARB 1

Heart failure with reduced ejection fraction: Beta-blocker (carvedilol, metoprolol succinate, or bisoprolol) plus ACE inhibitor/ARB; avoid non-dihydropyridine calcium channel blockers 1

Coronary artery disease: Beta-blocker plus ACE inhibitor or ARB 1

Post-stroke: Thiazide diuretic, ACE inhibitor, or ARB 1

Critical Medication Precautions

When using ACE inhibitors (e.g., lisinopril): 6

• Monitor serum potassium and creatinine within 2-4 weeks of initiation
• Risk of hyperkalemia increases with concurrent use of potassium-sparing diuretics, potassium supplements, or salt substitutes 6
• Hyperkalemia can cause fatal arrhythmias 6
• Expect transient increases in creatinine, especially with concurrent diuretic use 6

When using thiazide diuretics: 6

• Monitor for hypokalemia, hyponatremia, and hypochloremic alkalosis 6
• Chlorthalidone is preferred over hydrochlorothiazide for resistant hypertension 1

Blood Pressure Targets

Target BP <130/80 mm Hg for most adults <65 years 2

Target SBP <130 mm Hg for adults ≥65 years 2

In patients with diabetes or chronic kidney disease, target <130/80 mm Hg 1

Follow-Up Strategy

Monitoring Schedule

• Recheck BP every 3-6 months for patients with elevated BP (120-129/<80 mm Hg) not on medications 1
• Monthly follow-up for patients initiating drug therapy until BP is controlled 1
• Use HBPM or ABPM to detect white coat effect in patients on multiple medications with office BP within 10 mm Hg of goal 1

Team-Based Care Approach

• Implement team-based care with delegation of routine BP monitoring to nurses, pharmacists, or community health workers 1
• Use electronic health records to identify patients with uncontrolled hypertension and trigger quality improvement interventions 1
• Consider telehealth strategies for remote BP monitoring 1

Common Pitfalls to Avoid

Do not diagnose hypertension on a single office reading – 85% of physicians make this error, leading to overdiagnosis 3

Do not omit the ECG – 89% of patients do not receive this mandatory test, missing opportunities to detect left ventricular hypertrophy 3

Do not leave patients on monotherapy when BP remains uncontrolled – 40% of patients remain on single-drug therapy at 18 months despite inadequate control 3

Do not use immediate-release nifedipine for acute BP lowering – causes dangerous rapid BP drops 1

Avoid underdosing or undertitrating medications – only 1.7 medications prescribed per patient on average despite need for multiple agents 3