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

Hypertension Workup

The initial workup for hypertension requires confirmation with out-of-office blood pressure monitoring (home or ambulatory BP), followed by a structured laboratory and clinical assessment to identify cardiovascular risk factors, target organ damage, and secondary causes. 1

Diagnostic Confirmation

Blood Pressure Measurement Strategy

• Use validated automated upper arm cuff devices with appropriate cuff size for the patient 2
• Confirm diagnosis with ambulatory BP monitoring (ABPM) or home BP 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
• Hypertension is confirmed when repeated office BP ≥140/90 mmHg, particularly if home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg 2
• At first visit, measure BP in both arms simultaneously; if there is a consistent difference, use the arm with higher BP for subsequent measurements 2

Essential Initial Laboratory Tests

Metabolic and Renal Assessment

• Serum electrolytes (sodium and potassium) 1
• Serum creatinine and estimated glomerular filtration rate (eGFR) 1
• Fasting glucose and lipid profile 1
• Urinalysis with dipstick urine test 1
• Urine albumin-to-creatinine ratio (UACR) to detect early kidney damage 1
• Serum uric acid levels (treatment recommended if >6 mg/dL with gout symptoms) 1
• Liver function tests 1

Cardiac Evaluation

• 12-lead ECG in all patients to detect atrial fibrillation, left ventricular hypertrophy, and ischemic heart disease 1
• Document heart rate, as >80 beats/min increases cardiovascular risk 1

Anthropometric Measurements

• Body mass index (BMI) and waist circumference, with targets of <94 cm in men and <80 cm in women 1

Physical Examination Findings

Look for specific signs suggesting secondary hypertension: 1

• Enlarged thyroid (thyroid disorders)
• Abdominal bruits (renal artery stenosis)
• Delayed femoral pulses (aortic coarctation)
• Cushingoid features (Cushing syndrome)

Cardiovascular Risk Stratification

High-Risk Features Requiring Immediate Treatment

More than 50% of hypertensive patients have additional cardiovascular risk factors that proportionally increase their risk 1

Identify the following high-risk features: 1

• Established cardiovascular disease
• Stroke
• Diabetes mellitus
• Chronic kidney disease (eGFR <60 mL/min/1.73m²)
• Familial hypercholesterolemia
• Age >65 years
• Male sex
• Family history of premature CVD
• Elevated LDL-cholesterol/triglycerides
• Overweight-obesity
• Hyperuricemia
• Metabolic syndrome

Risk Scoring

• Use SCORE2 for ages 40-69 years or SCORE2-OP for ages ≥70 years to assess 10-year CVD risk 2
• Consider patients with SCORE2 or SCORE2-OP ≥10% as being at increased risk, warranting more aggressive management 2

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 Imaging

• Echocardiography when ECG shows abnormalities or patient has signs/symptoms of cardiac disease to assess left ventricular hypertrophy, systolic/diastolic dysfunction, and 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

Ophthalmologic Examination

• Fundoscopy in patients with BP >180/110 mmHg to detect retinal hemorrhages, papilledema, or signs of malignant hypertension 1
• Fundoscopy in hypertensive patients with diabetes 2

Neurological Assessment

• Brain CT/MRI when neurologic symptoms are 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, 3

Specific Tests for Secondary Causes

Order the following tests when secondary hypertension is suspected: 1

• Aldosterone-renin ratio for primary aldosteronism
• Plasma free metanephrines for pheochromocytoma
• Late-night salivary cortisol or 24-hour urinary free cortisol for Cushing syndrome
• Renal artery imaging (CT/MR angiography or Duplex ultrasound) for renal artery stenosis
• Renal ultrasound when secondary hypertension is suspected to evaluate for renal parenchymal disease, renal artery stenosis, or adrenal lesions

Monitoring Schedule

• Repeat creatinine, eGFR, and UACR at least annually if moderate-to-severe CKD is diagnosed 2
• Achieve target BP within 3 months 2

Treatment Initiation Based on Workup

Grade 1 Hypertension (140-159/90-99 mmHg)

• Start lifestyle interventions immediately 2
• Start drug treatment immediately in high-risk patients (CVD, CKD, diabetes, organ damage, or aged 50-80 years) 2
• For all others, start drug treatment after 3-6 months of lifestyle intervention if BP remains elevated 2

Grade 2 Hypertension (≥160/100 mmHg)

• Start drug treatment immediately along with lifestyle interventions 2

First-Line Drug Therapy

For non-Black patients: 2, 4

1. Low-dose ACEI/ARB
2. Add DHP-CCB
3. Increase to full dose
4. Add thiazide/thiazide-like diuretic
5. Add spironolactone (or alternatives if not tolerated)

For Black patients: 2

1. Low-dose ARB + DHP-CCB or DHP-CCB + thiazide/thiazide-like diuretic
2. Increase to full dose
3. Add diuretic or ARB/ACEI
4. Add spironolactone (or alternatives if not tolerated)

Blood Pressure Targets

• Target BP <130/80 mmHg for most patients 2
• Individualize for elderly based on frailty 2
• Reduce BP by at least 20/10 mmHg as a minimum goal 2

Common Pitfalls to Avoid

• Do not skip out-of-office BP confirmation, as white coat hypertension affects a significant proportion of patients 1
• Do not overlook secondary causes in patients with resistant hypertension, young age (<30 years), or sudden onset of severe hypertension 3, 5
• Do not forget to assess for target organ damage, as its presence changes risk stratification and treatment urgency 1, 6
• Do not use excessive doses of hydrochlorothiazide (>25 mg daily) when combined with other agents, as this increases adverse effects without meaningful additional BP reduction 7