Workup for Persistent Hypertension
For patients with persistent hypertension, confirm the diagnosis with out-of-office blood pressure monitoring (ABPM or HBPM), then perform basic laboratory testing including serum creatinine, eGFR, urine albumin-to-creatinine ratio, and a 12-lead ECG, while screening for secondary causes only when clinically indicated by suggestive features. 1
Confirming the Diagnosis
Blood Pressure Measurement Strategy
When screening office BP is 120-139/70-89 mmHg in patients with increased CVD risk, measure BP out-of-office using ABPM and/or HBPM, or if not feasible, make repeated office measurements on multiple visits 1
When screening office BP is 140-159/90-99 mmHg, base the diagnosis on out-of-office BP measurement with ABPM and/or HBPM; if these are not logistically or economically feasible, use repeated office measurements on multiple visits 1
When screening BP is 160-179/100-109 mmHg, confirm as soon as possible (within 1 month) preferably by home or ambulatory BP measurements 1
When BP is ≥180/110 mmHg, immediately exclude hypertensive emergency 1
Diagnostic Thresholds
- Home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg confirms true hypertension requiring treatment 2
Essential Laboratory Workup
Mandatory Tests for All Patients
Serum creatinine, eGFR, and urine albumin-to-creatinine ratio (ACR) are recommended in all patients with hypertension 1
If moderate-to-severe CKD is diagnosed, repeat measurements of serum creatinine, eGFR, and urine ACR at least annually 1
12-lead ECG is recommended for all patients with hypertension 1
Additional Testing Based on Clinical Findings
Echocardiography is recommended in patients with hypertension and ECG abnormalities, or signs or symptoms of cardiac disease 1
Fundoscopy is recommended if BP >180/110 mmHg in the workup of hypertensive emergency and malignant hypertension, as well as in hypertensive patients with diabetes 1
Cardiovascular Risk Assessment
Risk Stratification Tools
SCORE2 is recommended for assessing 10-year risk of fatal and non-fatal CVD among individuals aged 40-69 years with elevated BP who are not already at increased risk due to moderate or severe CKD, established CVD, HMOD, diabetes mellitus, or familial hypercholesterolemia 1
SCORE2-OP is recommended for individuals aged ≥70 years with elevated BP using the same exclusion criteria 1
Individuals with elevated BP and a SCORE2 or SCORE2-OP CVD risk of ≥10% should be considered at increased risk for CVD, regardless of age 1
Risk Modifiers to Consider
- High-risk ethnicity (e.g., South Asian), family history of premature onset atherosclerotic CVD, socioeconomic deprivation, autoimmune inflammatory disorders, HIV, and severe mental illness should be considered to up-classify individuals with borderline increased 10-year CVD risk (5% to <10% risk) 1
Screening for Secondary Hypertension
When to Screen
Screen for secondary hypertension when patients present with suggestive signs, symptoms, or medical history 1
Secondary causes account for 5-10% of hypertension cases and should be considered in severe or resistant hypertension, age of onset <30 years (especially before puberty), malignant or accelerated hypertension, and acute rise in BP from previously stable readings 3
Primary Aldosteronism Screening
- Screening for primary aldosteronism by renin and aldosterone measurements should be considered in all adults with confirmed hypertension (BP ≥140/90 mmHg) 1
Renovascular Hypertension Red Flags
Consider renovascular hypertension in patients with an increase in serum creatinine of at least 50% occurring within one week of initiating ACE inhibitor or ARB therapy 3
Also consider in patients with severe hypertension and a unilateral smaller kidney or difference in kidney size >1.5 cm, or recurrent flash pulmonary edema 3
Other Secondary Causes
Other underlying causes include obstructive sleep apnea, pheochromocytoma, Cushing syndrome, thyroid disease, coarctation of the aorta, and use of certain medications 3
In adults ≥65 years, atherosclerotic renal artery stenosis, renal failure, and hypothyroidism are common causes 3
Resistant Hypertension Evaluation
Definition and Initial Assessment
Resistant hypertension is defined as BP remaining uncontrolled despite use of 3 or more antihypertensive agents 4
Verify medication adherence first, as non-adherence is the most common cause of apparent treatment resistance, affecting 10-80% of hypertensive patients 5
Objective evaluation of adherence (either directly observed treatment or detecting prescribed drugs in blood or urine samples) should be considered if resources allow 1
Referral Considerations
Patients with resistant hypertension should be considered for referral to clinical centers with expertise in hypertension management for further testing 1
Refer to a hypertension specialist if BP remains ≥160/100 mmHg despite five-drug therapy at optimal doses, or if there are concerning features suggesting secondary hypertension 5
Advanced Testing (When Indicated)
Optional Risk Stratification Tools
After assessing 10-year predicted CVD risk and non-traditional CVD risk modifiers, if a risk-based BP-lowering treatment decision remains uncertain for individuals with borderline increased 10-year CVD risk (5% to <10% risk), measuring CAC score, carotid or femoral plaque using ultrasound, high-sensitivity cardiac troponin or B-type natriuretic peptide biomarkers, or arterial stiffness using pulse wave velocity may be considered after shared decision-making and considering costs 1
Coronary artery calcium scoring may be considered in patients with elevated BP or hypertension when it is likely to change patient management 1
Screening Frequency
Opportunistic Screening Recommendations
At least every 3 years for adults aged <40 years 1
At least annually for adults aged ≥40 years 1
In individuals with elevated BP who do not currently meet risk thresholds for BP-lowering treatment, a repeat BP measurement and risk assessment within 1 year should be considered 1
Critical Pitfalls to Avoid
Do not perform routine genetic testing for patients with hypertension 1
Do not screen for secondary causes indiscriminately; an uncritical approach to laboratory and radiologic evaluation leads to unnecessary expenses 6
Do not rely solely on office BP measurements when values are borderline or when white coat hypertension is suspected 1
Do not delay confirmation of hypertensive emergency when BP is ≥180/110 mmHg 1, 7