What is the initial evaluation and treatment approach for a patient diagnosed with hypertension?

Initial Evaluation and Workup for Hypertension

Confirm the Diagnosis First

Before labeling a patient as hypertensive, confirm the diagnosis with out-of-office blood pressure measurements (ambulatory or home monitoring), especially for readings between 140-159/90-99 mmHg. 1, 2 This prevents overdiagnosis of white-coat hypertension, which occurs in 20-35% of patients with elevated office readings. 1

Proper Blood Pressure Measurement Technique

• Have the patient sit quietly with back supported for 5 minutes before measurement 1, 3
• Use appropriately sized cuff (bladder encircling at least 80% of arm) 1
• Support arm at heart level 1, 3
• Take minimum of 2 readings at 1-minute intervals and average them 1, 3
• Measure both arms initially; use the arm with higher readings for future measurements 1, 3
• Check standing blood pressure in elderly and diabetic patients to detect orthostatic hypotension 1

Out-of-Office Confirmation

• For home monitoring: measure twice daily (morning and evening) for at least 3-7 days, taking 2 readings per session 1-2 minutes apart 3
• Ambulatory monitoring is the gold standard for excluding white-coat hypertension 1

Initial Laboratory and Diagnostic Workup

Routine Tests (Required for All Patients)

Every hypertensive patient needs these baseline investigations: 1, 2, 4

• Urinalysis: strip test for protein and blood 1
• Serum creatinine and estimated GFR: assess kidney function 1
• Urinary albumin-to-creatinine ratio: detect early kidney damage 1
• Serum electrolytes (sodium, potassium): screen for primary aldosteronism 1
• Fasting blood glucose and HbA1c: identify diabetes 1
• Lipid profile: total cholesterol, LDL, HDL, triglycerides 1
• 12-lead ECG: detect left ventricular hypertrophy and arrhythmias 1, 4
• Hemoglobin/hematocrit: screen for polycythemia 1
• Serum calcium and TSH: screen for hyperparathyroidism and thyroid disease 1

Optional Tests for Target Organ Damage Assessment

Consider these when resources allow or clinical suspicion warrants: 1

• Echocardiography: assess left ventricular hypertrophy, diastolic dysfunction, and cardiac structure 1
• Carotid or femoral ultrasound: detect atherosclerotic plaque 1
• Pulse wave velocity: measure arterial stiffness 1
• High-sensitivity troponin and NT-proBNP: assess cardiac stress 1

Screen for Secondary Causes of Hypertension

Approximately 10% of hypertension cases have an identifiable secondary cause that may be curable. 5 Screen systematically based on clinical clues:

History Red Flags

• Obstructive sleep apnea: loud snoring, witnessed apnea, excessive daytime sleepiness 1
• Pheochromocytoma: episodic hypertension with palpitations, diaphoresis, headache 1
• Renal artery stenosis: young female, known atherosclerotic disease, worsening renal function with ACE inhibitors 1
• Drug-induced: NSAIDs, oral contraceptives, steroids, sympathomimetics, decongestants 1
• Primary aldosteronism: muscle weakness, polyuria, hypokalemia 1

Physical Examination Findings

• Cushing's syndrome: moon facies, central obesity, purple abdominal striae, interscapular fat pad 1
• Aortic coarctation: differential between brachial and femoral pulses, systolic bruit, diminished femoral pulses 1
• Renal artery stenosis: abdominal or flank bruit 1
• Hypertensive retinopathy: fundoscopic examination for hemorrhages, exudates, papilledema 1

Specific Testing for Secondary Causes

When clinical suspicion exists: 1

• Primary aldosteronism: elevated aldosterone-to-renin ratio 1
• Renal artery stenosis: duplex ultrasound, MRA, or CT angiography (sensitivity varies by institution) 1
• Pheochromocytoma: plasma or urinary metanephrines 1
• Chronic kidney disease: if creatinine clearance <30 mL/min, consider renal ultrasound 1

Assess Cardiovascular Risk and Target Organ Damage

Calculate 10-Year Cardiovascular Risk

Use validated risk calculators (ASCVD calculator in US, SCORE in Europe) to guide treatment intensity. 2, 4 This determines whether stage 1 hypertension requires immediate pharmacotherapy or lifestyle modification alone.

Document Target Organ Damage

Look for evidence of hypertensive complications: 1

• Cardiac: left ventricular hypertrophy on ECG or echocardiography, prior MI, heart failure 1
• Renal: elevated creatinine, reduced GFR, proteinuria, microalbuminuria 1
• Cerebrovascular: prior stroke or TIA 1
• Vascular: peripheral arterial disease, carotid bruits 1
• Retinal: hypertensive retinopathy 1

Evaluate Medication Adherence

Poor adherence is a major contributor to apparent treatment resistance. 1 Ask directly and nonjudgmentally about:

• Success in taking all prescribed doses 1
• Adverse effects from medications 1
• Out-of-pocket costs 1
• Dosing inconvenience 1
• Use of over-the-counter medications, herbal supplements 1

Family members often provide more objective adherence assessments. 1

Common Pitfalls to Avoid

• Don't diagnose hypertension on a single elevated reading: Confirm with multiple measurements over separate visits or out-of-office monitoring 1, 3
• Don't miss white-coat hypertension: Up to 35% of office hypertension may not be sustained outside the clinic 1
• Don't overlook secondary causes: Especially in young patients, resistant hypertension, or sudden onset/worsening 1, 5
• Don't forget to check standing blood pressure: Orthostatic hypotension affects treatment decisions in elderly and diabetic patients 1
• Don't use improper cuff size: This is a common source of falsely elevated readings 1, 3

When to Refer to a Specialist

Consider referral for: 1, 4

• Suspected secondary hypertension requiring specialized testing 1, 4
• Resistant hypertension (uncontrolled after 6 months of treatment with 3+ medications including a diuretic) 1
• Hypertensive emergency with acute end-organ damage 6
• Unusual blood pressure variability 4
• Young patients (<30 years) with hypertension 1