What is the recommended workup and treatment for a patient presenting with hypertension?

Workup for Hypertension

All patients with newly diagnosed hypertension require basic laboratory tests (sodium, potassium, creatinine, eGFR, lipid profile, fasting glucose), dipstick urinalysis, and 12-lead ECG as the essential initial workup, with additional testing reserved for those with suspected organ damage or secondary causes. 1

Essential Initial Workup (All Patients)

Blood Pressure Confirmation

• Confirm the diagnosis with out-of-office measurements using ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) when screening office BP is 120-159/70-99 mmHg 1
• For office BP ≥160/100 mmHg, confirm within 1 month using home or ambulatory measurements 1
• When BP ≥180/110 mmHg, immediately exclude hypertensive emergency before proceeding with routine workup 1

Mandatory Laboratory Tests

• Serum electrolytes: sodium, potassium 1
• Renal function: serum creatinine and estimated glomerular filtration rate (eGFR) 1
• Metabolic assessment: fasting glucose and lipid profile 1
• Urinalysis: dipstick urine test initially 1
• Urine albumin-to-creatinine ratio (UACR) to detect early kidney damage 1

Cardiac Assessment

• 12-lead ECG in all patients to detect atrial fibrillation, left ventricular hypertrophy, and ischemic heart disease 1

Physical Examination Findings to Document

• Body mass index (BMI) and waist circumference (target <94 cm in men, <80 cm in women) 1
• Signs suggesting secondary hypertension: enlarged thyroid, abdominal bruits, delayed femoral pulses, cushingoid features (fatty deposits, colored striae) 1
• Heart rate (>80 beats/min increases cardiovascular risk) 1

Cardiovascular Risk Stratification

More than 50% of hypertensive patients have additional cardiovascular risk factors that proportionally increase their risk of coronary, cerebrovascular, and renal disease. 1

High-Risk Features Requiring Immediate Treatment

• Established cardiovascular disease, stroke, diabetes, chronic kidney disease (eGFR <60 mL/min/1.73m²), or familial hypercholesterolemia 1
• Age >65 years, male sex, family history of premature CVD 1
• Elevated LDL-cholesterol/triglycerides, overweight-obesity, hyperuricemia, metabolic syndrome 1

Risk Calculation

• Use SCORE2 for ages 40-69 years or SCORE2-OP for ages ≥70 years to assess 10-year CVD risk 1
• Patients with SCORE2 or SCORE2-OP ≥10% are considered at increased risk and warrant more aggressive management 1

Additional Testing When Indicated

Hypertension-Mediated Organ Damage (HMOD) Assessment

Detection of HMOD is crucial for patients with low-to-moderate overall risk as it reclassifies them to higher risk and guides treatment intensity. 1

Cardiac Evaluation

• Echocardiography when ECG shows abnormalities or patient has signs/symptoms of cardiac disease to assess left ventricular hypertrophy (LVMI: men >115 g/m², women >95 g/m²), systolic/diastolic dysfunction, atrial dilation 1

Vascular Assessment

• Carotid ultrasound to detect atherosclerotic plaques and stenosis when clinically indicated 1
• Ankle-brachial index (ABI) for peripheral artery disease in patients with suspected lower extremity disease 1

Renal Imaging

• Renal ultrasound or renal artery Duplex when secondary hypertension suspected to evaluate for renal parenchymal disease, renal artery stenosis, adrenal lesions 1

Ophthalmologic Examination

• Fundoscopy in patients with BP >180/110 mmHg to detect retinal hemorrhages, papilledema, or signs of malignant hypertension 1
• Also perform fundoscopy in hypertensive patients with diabetes 1

Neurological Assessment

• Brain CT/MRI when neurologic symptoms present to detect ischemic or hemorrhagic brain injury, white matter lesions, or cognitive decline 1

Secondary Hypertension Screening

Screen for secondary causes when clinical features suggest underlying disease, as 20-40% of malignant hypertension cases have identifiable secondary causes. 1, 2

Indications for Secondary Hypertension Workup

• Age <30 years with hypertension 3
• Resistant hypertension (uncontrolled on 3+ medications including a diuretic) 3
• Sudden onset or worsening of previously controlled hypertension 3
• Severe hypertension (≥180/110 mmHg) 3
• Hypokalemia (spontaneous or diuretic-induced) 3

Specific Tests for Secondary Causes

• Aldosterone-renin ratio for primary aldosteronism 1
• Plasma free metanephrines for pheochromocytoma 1
• Late-night salivary cortisol or 24-hour urinary free cortisol for Cushing syndrome 1
• Renal artery imaging (CT/MR angiography or Duplex ultrasound) for renal artery stenosis 1

Additional Laboratory Tests

• Serum uric acid levels (elevated in 25% of hypertensive patients; treat if >6 mg/dL with gout symptoms) 1
• Liver function tests 1
• Repeat creatinine, eGFR, and UACR at least annually if moderate-to-severe CKD diagnosed 1

Common Pitfalls to Avoid

• Do not rely solely on office BP measurements for diagnosis—out-of-office confirmation prevents overdiagnosis of white-coat hypertension 1
• Do not skip ECG—it is mandatory in all patients and may reveal unsuspected atrial fibrillation or left ventricular hypertrophy 1
• Do not order extensive imaging routinely—reserve echocardiography, carotid ultrasound, and renal imaging for patients with clinical indications or suspected HMOD 1
• Do not miss secondary hypertension in young patients or those with resistant hypertension—these populations have higher prevalence of identifiable causes 2, 3
• Do not forget to assess for target organ damage in patients already at high risk (established CVD, diabetes, CKD)—while it may not change immediate management, it guides long-term monitoring 1