What is the appropriate evaluation and treatment approach for a patient with suspected hypertension and elevated blood pressure?

Diagnosis and Management of Hypertension

Diagnostic Confirmation

Hypertension is diagnosed when repeated office BP measurements average ≥140/90 mmHg, ideally confirmed with home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg. 1

Proper BP Measurement Technique

• Use a validated automated upper arm cuff device with appropriate cuff size (bladder encircling 80% of the arm) 1
• Have the patient rest seated (feet on floor, back supported) for >5 minutes before measurement 1
• Patient should avoid caffeine, exercise, and smoking for at least 30 minutes before measurement 1
• Ensure bladder is empty and neither patient nor observer talks during measurement 1
• At first visit, measure BP in both arms simultaneously and use the arm with higher readings for subsequent measurements 1
• Take an average of ≥2 readings obtained on ≥2 separate occasions 1

Confirmation Strategy Based on Initial Reading

• If office BP <130/85 mmHg: Remeasure after 3 years 1
• If office BP ≥130/85 mmHg: Confirm with home or ambulatory BP monitoring 1
• If home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg: Hypertension is confirmed 1

Ambulatory BP Monitoring Indications

Consider 24-hour ambulatory monitoring for: 1

• Suspected white-coat hypertension (elevated office BP without target organ damage)
• Apparent drug resistance
• Hypotensive symptoms with antihypertensive medications
• Episodic hypertension

Initial Evaluation

Essential History Components

• Duration of known hypertension and previous BP readings 1
• Current and past antihypertensive medications and adherence 1
• Cardiovascular risk factors: diabetes, dyslipidemia, smoking, family history of premature CVD (men <55 years, women <65 years) 1
• Symptoms suggesting secondary hypertension: muscle weakness, palpitations, headaches, sweating episodes 1
• Symptoms of target organ damage: chest pain, dyspnea, visual changes, claudication, TIA/stroke 1

Physical Examination Essentials

• Calculate body mass index (BMI) and measure waist circumference 1
• Funduscopic examination for hypertensive retinopathy 1
• Cardiovascular examination: heart sounds, murmurs, jugular venous distension 1
• Auscultation for carotid, abdominal, and femoral bruits 1
• Palpation of thyroid gland 1
• Palpation of lower extremities for edema and pulses 1
• Neurological assessment 1

Routine Laboratory Investigations

The following tests are sufficient for initial evaluation: 1

• Urinalysis: Dipstick for protein and blood
• Serum creatinine and electrolytes: Assess renal function and exclude secondary causes
• Fasting blood glucose: Screen for diabetes
• Lipid panel: Total cholesterol and HDL cholesterol ratio
• 12-lead electrocardiogram: Detect left ventricular hypertrophy and ischemic changes

More extensive investigations are only warranted if initial evaluation suggests secondary hypertension, target organ damage is present, or patient fails to respond to appropriate treatment. 1, 2

Treatment Approach

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

Start lifestyle interventions immediately in all patients. 1

Initiate drug treatment immediately in high-risk patients: 1

• Established CVD
• Chronic kidney disease (CKD)
• Diabetes mellitus
• Evidence of target organ damage
• Age 50-80 years

For low-moderate risk patients, initiate drug treatment only if BP remains elevated after 3-6 months of lifestyle intervention. 1

Grade 2 Hypertension (≥160/100 mmHg)

Start drug treatment immediately along with lifestyle interventions. 1, 3

Lifestyle Modifications (All Patients)

• Weight reduction: Achieve ideal body weight through reduced fat and total calorie intake 1
• Dietary sodium restriction: Limit to <2.3 g/day; eliminate excessively salty foods 1, 4
• Dietary potassium supplementation: Increase intake through fruits and vegetables 1, 4
• Physical activity: Regular dynamic exercise (brisk walking) rather than isometric (weight training) 1, 4
• Alcohol limitation: <21 units/week for men, <14 units/week for women 1, 4
• Smoking cessation 1

Pharmacologic Treatment Algorithm

Non-Black Patients

Step 1: Start low-dose ACEI (e.g., lisinopril 5-10 mg daily) or ARB (e.g., losartan 50 mg daily) 1, 3, 5

Step 2: Add dihydropyridine calcium channel blocker (DHP-CCB) (e.g., amlodipine 5 mg daily) 1, 6

Step 3: Increase both medications to full dose 1

Step 4: Add thiazide or thiazide-like diuretic (e.g., chlorthalidone 12.5-25 mg daily) 1, 4

Step 5: Add spironolactone 25-50 mg daily; if not tolerated or contraindicated, use amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Black Patients

Step 1: Start low-dose ARB plus DHP-CCB, or DHP-CCB plus thiazide/thiazide-like diuretic 1, 3

Step 2: Increase to full dose 1

Step 3: Add the missing component (diuretic or ARB/ACEI) 1

Step 4: Add spironolactone; if not tolerated or contraindicated, use amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Special Considerations

• Consider monotherapy in low-risk Grade 1 hypertension and in patients aged >80 years or frail 1
• Use once-daily dosing and single-pill combinations to improve adherence 1

Blood Pressure Targets

Target BP <130/80 mmHg for most adults <65 years; individualize for elderly based on frailty. 1, 3

• Initial goal: Reduce BP by at least 20/10 mmHg 1, 3
• Achieve target BP within 3 months 1, 3

Monitoring and Follow-Up

• Initiate home BP monitoring to track progress and improve adherence 3
• Schedule follow-up within 2-4 weeks after initiating or adjusting therapy to assess response and medication adherence 3
• Achieve target BP within 3 months of treatment initiation 1, 3
• Refer to hypertension specialist if BP remains uncontrolled despite appropriate therapy or if secondary hypertension is suspected 1

Critical Pitfalls to Avoid

Do not rapidly lower BP in asymptomatic patients—this is unnecessary and potentially harmful. 1, 3, 7 The American College of Emergency Physicians found no evidence that acute BP management in asymptomatic patients improves outcomes, and rapid reduction may cause harm. 1

Do not use immediate-release nifedipine, hydralazine, or IV medications for asymptomatic hypertension. 1, 8 These agents cause unpredictable, precipitous BP drops.

Do not initiate extensive diagnostic workup for secondary hypertension unless initial evaluation provides specific clues. 1, 2 The yield is low and testing is expensive; focus on the basic evaluation outlined above.

Recognize that up to one-third of patients with elevated office BP will normalize before follow-up. 1 This underscores the importance of confirming the diagnosis with repeated measurements or out-of-office monitoring before committing patients to lifelong therapy.