What is the appropriate work‑up for a patient with newly diagnosed hypertension?

Hypertension Work-Up

Confirm the Diagnosis

Use out-of-office blood pressure measurements to confirm hypertension before initiating treatment. 1, 2

• Measure BP with a validated automated upper arm cuff device using appropriate cuff size for the patient 1
• Have the patient sit quietly with back supported for 5 minutes before measurement 1
• Take at least 2 readings at 1-minute intervals and average them 1
• Measure BP in both arms simultaneously at first visit; use the arm with higher readings for future measurements 1, 2

Diagnostic thresholds vary by measurement method: 1

• Office BP ≥140/90 mmHg indicates hypertension (ISH guidelines) 1
• Home BP ≥135/85 mmHg confirms hypertension 1, 2
• 24-hour ambulatory BP ≥130/80 mmHg confirms hypertension 1, 2

For office BP 140-159/90-99 mmHg (Grade 1): Confirm with home BP monitoring or 24-hour ambulatory monitoring before starting treatment 1

For office BP ≥160/100 mmHg (Grade 2): Confirm as soon as possible (within 1 month), preferably with home or ambulatory measurements 1

For office BP ≥180/110 mmHg: Exclude hypertensive emergency immediately 1, 3

Essential Laboratory Tests

All patients require these baseline investigations: 1

• Serum creatinine and estimated GFR (eGFR) to assess kidney function 1
• Urine dipstick test for proteinuria 1
• Serum electrolytes (sodium, potassium) 1
• Fasting glucose to screen for diabetes 1
• Lipid profile (total cholesterol, LDL-C, HDL-C, triglycerides) 1
• 12-lead ECG to detect atrial fibrillation, left ventricular hypertrophy, or ischemic heart disease 1

If moderate-to-severe CKD is diagnosed (eGFR <60 ml/min/1.73m²): Repeat creatinine, eGFR, and urine albumin-to-creatinine ratio at least annually 1

Cardiovascular Risk Assessment

Calculate 10-year cardiovascular risk using validated tools: 1

• SCORE2 for individuals aged 40-69 years without established CVD, moderate/severe CKD, diabetes, or familial hypercholesterolemia 1
• SCORE2-OP for individuals aged ≥70 years 1
• Consider patients at increased CVD risk if SCORE2 or SCORE2-OP ≥10% 1

Additional risk factors that increase cardiovascular risk: 1

• Age >65 years, male sex, heart rate >80 bpm 1
• Diabetes (present in 15-20% of hypertensive patients) 1
• Elevated LDL-C or triglycerides (30% of hypertensive patients) 1
• Overweight/obesity (40% of hypertensive patients) 1
• Hyperuricemia (25% of hypertensive patients) 1
• Metabolic syndrome (40% of hypertensive patients) 1
• Family history of CVD or early-onset hypertension 1
• Smoking, high alcohol intake, sedentary lifestyle 1

Screen for Hypertension-Mediated Organ Damage (HMOD)

Echocardiography is recommended if: 1

• ECG shows abnormalities 1
• Patient has signs or symptoms of cardiac disease 1
• Suspicion of left ventricular hypertrophy, systolic/diastolic dysfunction, or atrial dilation 1

Fundoscopy is recommended if: 1

• BP >180/110 mmHg (to evaluate for hypertensive emergency and malignant hypertension) 1
• Patient has diabetes 1

Additional imaging when indicated: 1

• Carotid ultrasound for plaques or stenosis 1
• Kidney/renal artery imaging (ultrasound, CT/MR angiography) if suspecting renal parenchymal disease, renal artery stenosis, or adrenal lesions 1
• Brain CT/MRI if suspecting ischemic or hemorrhagic brain injury 1

Ankle-brachial index to detect peripheral artery disease 1

Screen for Secondary Hypertension

Screen for secondary causes when clinically indicated: 1

Primary aldosteronism: 1

• Check aldosterone-renin ratio if hypertension is severe, resistant, or associated with hypokalemia 1

Obstructive sleep apnea: 1, 4

• Suspect if patient has daytime sleepiness, loud snoring, witnessed apnea, or obesity 1

Renal artery stenosis: 1

• Suspect in young females, patients with known atherosclerotic disease, or worsening renal function 1
• Consider renal artery Duplex ultrasound or CT/MR angiography 1

Pheochromocytoma: 1

• Suspect if episodic hypertension with palpitations, diaphoresis, and headache 1
• Check plasma free metanephrines 1

Cushing's syndrome: 1

• Suspect if moon facies, central obesity, abdominal striae, or interscapular fat deposition 1
• Check late-night salivary cortisol or other screening tests 1

Aortic coarctation: 1

• Suspect if differential in brachial or femoral pulses, or systolic bruit 1

Chronic kidney disease: 1

• Already assessed with creatinine and eGFR 1

Medication-induced hypertension: 1, 4

• Review for NSAIDs, decongestants, oral contraceptives, systemic corticosteroids, herbal supplements (ephedra, St. John's wort) 1, 4

Additional Investigations

Urinary albumin-to-creatinine ratio for more precise assessment of kidney damage 1

Serum uric acid levels (elevated in 25% of hypertensive patients) 1

Liver function tests 1

Common Pitfalls to Avoid

Do not diagnose hypertension based on a single office reading – white coat hypertension affects 15-30% of the general population and is common in elderly patients 1, 5

Do not rely on doctor's office readings alone – they are 18.9 mmHg higher than ambulatory systolic pressure and poorly predict true hypertension (specificity only 26%) 5

Do not delay confirmation with out-of-office measurements – this leads to misdiagnosis and unnecessary treatment in up to 30% of patients 6, 7

Do not overlook medication adherence – non-adherence is the most common cause of apparent treatment resistance 1, 4

Do not miss secondary hypertension – affects <10% of cases but is potentially curable 4