Does NICE (National Institute for Health and Care Excellence) Clinical Knowledge Summaries (CKS) recommend an electrocardiogram (ECG) as part of the initial assessment for a patient with newly diagnosed hypertension?

Does NICE CKS Recommend ECG for Newly Diagnosed Hypertension?

While the evidence provided does not include NICE Clinical Knowledge Summaries guidelines specifically, the European Society of Cardiology (ESC) 2024 guidelines—the most recent and authoritative hypertension guidelines available—explicitly recommend a 12-lead ECG as a routine test in the initial work-up of all patients with newly diagnosed hypertension. 1

ECG as a Routine Initial Test

The 2024 ESC guidelines clearly list a 12-lead ECG among the routine tests recommended for initial assessment of hypertensive patients, with the specific clinical utility being "guiding treatment choice." 1 This recommendation is consistent across multiple iterations of European guidelines:

• The 12-lead ECG should be part of the initial routine work-up for all patients with hypertension and should be repeated whenever patients present with an irregular pulse or cardiac symptoms 1
• The ECG should be analyzed specifically for left ventricular hypertrophy (LVH) and atrial fibrillation (AF) 1
• This recommendation applies regardless of age or comorbidities 2

Clinical Rationale for ECG in Hypertension

The ECG serves multiple critical functions in the initial hypertension assessment:

Detection of Left Ventricular Hypertrophy

• While ECG has lower sensitivity than echocardiography for detecting LVH, it remains highly specific 1
• LVH detected by ECG criteria (Sokolow-Lyon index, Cornell voltage, or RaVL criteria) is an independent predictor of cardiovascular events in observational studies and clinical trials 1
• The ECG is particularly valuable in patients over 55 years of age for LVH detection 1

Detection of Arrhythmias

• Early detection of atrial fibrillation facilitates prevention of strokes through appropriate anticoagulant therapy 1
• Atrial fibrillation is a very frequent cause of cardiovascular complications, especially stroke, in hypertensive patients 1

Additional Diagnostic Information

• The ECG can detect patterns of ventricular overload or "strain," which indicates more severe risk 1
• It identifies ischemia, conduction abnormalities, and left atrial dilatation 1

Comparison with Other Initial Tests

The 2024 ESC guidelines categorize tests into "routine" versus "optional":

Routine Tests (Required for All Patients):

• Fasting blood glucose and HbA1c 1
• Serum lipids 1
• Blood sodium, potassium, calcium, TSH 1
• Blood creatinine, eGFR, urinalysis, and urinary albumin-to-creatinine ratio 1
• 12-lead ECG 1

Optional Tests (Clinically Indicated):

• Echocardiography (recommended when ECG is abnormal, murmurs detected, or cardiac symptoms present) 1
• Coronary artery calcium scoring 1
• Carotid/femoral ultrasound 1
• Cardiac biomarkers 1

Important Clinical Caveats

The ECG should trigger further evaluation when abnormal:

• If the ECG shows abnormalities, echocardiography is then recommended to more precisely assess cardiac structure and function 1
• An abnormal ECG finding (such as LVH) can be used to justify more comprehensive cardiac imaging 3
• Twenty-four-hour Holter monitoring is indicated when arrhythmias or ischemic episodes are suspected based on symptoms or ECG findings 1

Documentation considerations:

• The presence of an abnormal ECG (ICD-10 code R94.31) provides additional justification for echocardiography in hypertensive patients 3
• ECG findings should be documented to guide treatment intensity and follow-up frequency 3

Practical Implementation

Based on the most recent ESC guidelines, the algorithmic approach is straightforward:

1. All newly diagnosed hypertensive patients should receive a 12-lead ECG as part of their initial routine work-up 1, 2
2. Analyze the ECG for: LVH (using Sokolow-Lyon, Cornell, or RaVL criteria), atrial fibrillation, conduction abnormalities, and ischemic changes 1
3. If ECG is abnormal: Proceed to echocardiography for more detailed cardiac assessment 1
4. If ECG shows irregular rhythm or AF: Consider 24-hour Holter monitoring 1
5. Repeat ECG: Whenever patients present with irregular pulse, cardiac symptoms, or if hypertension becomes difficult to control 1, 2

While NICE CKS guidelines are not included in the provided evidence, the 2024 ESC guidelines represent the current gold standard for hypertension management and unequivocally recommend ECG as a routine initial test for all hypertensive patients.