What questions and assessments should I perform at a follow‑up hypertension visit, including patient age, sex, race/ethnicity, comorbidities (diabetes, chronic kidney disease, coronary artery disease, heart failure, stroke), home blood‑pressure readings, medication adherence and side effects, lifestyle factors, and physical exam?

Follow-Up Hypertension Visit: Essential Questions and Assessments

At every follow-up visit for hypertension, systematically assess blood pressure control, medication adherence, adverse effects, lifestyle modifications, and screen for target organ damage through focused history, physical examination, and laboratory testing. 1

Blood Pressure Assessment

Office and Out-of-Office Measurements

• Measure office BP using proper technique with a validated automated device, appropriate cuff size, and obtain at least 2-3 readings during the visit 1
• Review home blood pressure monitoring (HBPM) data systematically to assess response to therapy, detect white coat effect, masked hypertension, or masked uncontrolled hypertension 1
• Home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg confirms uncontrolled hypertension requiring treatment adjustment 2
• Check for orthostatic hypotension by measuring BP supine and after 1-3 minutes of standing, particularly in elderly patients, those with diabetes, or on multiple antihypertensive agents 1

BP Control Status

• Determine if BP is at goal: <130/80 mmHg for most adults, or minimum <140/90 mmHg 1
• If BP remains >20/10 mmHg above target, medication adjustment is warranted rather than waiting 1

Medication Assessment

Adherence Evaluation

• Directly ask about medication adherence using non-judgmental, open-ended questions—non-adherence is the most common cause of apparent treatment resistance 1, 3, 4
• Verify prescription refill patterns and identify barriers to adherence (cost, side effects, complexity of regimen, forgetfulness) 1, 4
• Consider fixed-dose single-pill combinations to improve adherence when multiple agents are needed 1, 2

Adverse Effects Screening

• Systematically inquire about medication side effects specific to each drug class 1:
  • ACE inhibitors: dry cough, angioedema
  • ARBs: dizziness, hyperkalemia
  • Calcium channel blockers: peripheral edema, constipation, headache
  • Thiazide diuretics: hypokalemia, hyperuricemia, glucose intolerance
  • Beta-blockers: fatigue, bradycardia, bronchospasm, erectile dysfunction

Current Regimen Review

• Document all current antihypertensive medications with doses and frequency 1
• Identify if the patient is on optimal doses before adding additional agents 1, 5
• Screen for interfering substances: NSAIDs, decongestants, oral contraceptives, systemic corticosteroids, stimulants, herbal supplements (ephedra, St. John's wort, licorice) 5, 6, 3

Comorbidity Assessment

Cardiovascular Disease

• Ask about symptoms of coronary artery disease: chest pain, dyspnea on exertion, palpitations 1, 7
• Screen for heart failure symptoms: orthopnea, paroxysmal nocturnal dyspnea, lower extremity edema, exercise intolerance 1
• Inquire about history of stroke or TIA: focal neurologic symptoms, cognitive changes 1
• Ask about peripheral arterial disease: claudication, rest pain 1

Metabolic Conditions

• Assess diabetes status: polyuria, polydipsia, recent glucose or HbA1c values 1, 2, 8
• Screen for chronic kidney disease: changes in urination, history of proteinuria, known GFR 1
• Evaluate for metabolic syndrome features: central obesity, dyslipidemia 1, 8

Secondary Hypertension Screening

When BP is severely elevated (≥180/110 mmHg) or resistant to triple therapy, screen for 5, 6, 3:

• Primary aldosteronism: unprovoked hypokalemia, muscle weakness
• Obstructive sleep apnea: loud snoring, witnessed apneas, daytime somnolence
• Renal artery stenosis: abdominal bruit, flash pulmonary edema, asymmetric kidney size
• Pheochromocytoma: episodic headaches, palpitations, diaphoresis

Lifestyle Modification Assessment

Dietary Habits

• Quantify sodium intake: aim for <2 g/day (approximately 5 g salt), which yields 5-10 mmHg systolic reduction 5, 2, 6
• Assess DASH diet adherence: high intake of fruits, vegetables, whole grains, low-fat dairy; low saturated fat 5, 2, 6
• Evaluate potassium intake: target 3500-5000 mg/day from dietary sources 2

Physical Activity

• Document exercise frequency and duration: goal ≥30 minutes most days (≥150 minutes/week moderate intensity), which reduces BP by approximately 4/3 mmHg 5, 2, 6

Weight Management

• Measure current weight and calculate BMI: target BMI 20-25 kg/m²; 10 kg weight loss reduces BP by approximately 6.0/4.6 mmHg 5, 2, 6

Alcohol and Tobacco

• Quantify alcohol consumption: limit to ≤2 drinks/day for men, ≤1 drink/day for women 5, 2, 6
• Assess smoking status and offer cessation resources 2

Physical Examination

Cardiovascular Examination

• Auscultate heart sounds for S3 (heart failure), S4 (left ventricular hypertrophy), murmurs 1
• Palpate peripheral pulses to assess for peripheral arterial disease 1
• Examine for jugular venous distension and hepatojugular reflux 1

Volume Status

• Assess for lower extremity edema (heart failure, calcium channel blocker effect, volume overload) 1
• Auscultate lungs for crackles suggesting heart failure 1

Target Organ Damage

• Perform fundoscopic examination when feasible to detect hypertensive retinopathy 1
• Palpate thyroid to exclude thyroid disease as secondary cause 1

Laboratory Testing

Routine Monitoring

• Check serum electrolytes and renal function (sodium, potassium, creatinine, eGFR) at each visit when on diuretics, ACE inhibitors, or ARBs 1
• Specifically monitor 2-4 weeks after initiating or uptitrating these agents 1, 5, 6

Annual Assessments

• Urinalysis for proteinuria annually to detect kidney damage 1
• Fasting lipid panel if not recently checked 1
• Fasting glucose or HbA1c to screen for diabetes 2, 8

Additional Testing When Indicated

• Echocardiography to reassess left ventricular hypertrophy if previously present, or if new heart failure symptoms develop 1
• Aldosterone-to-renin ratio if resistant hypertension or unprovoked hypokalemia 5, 6, 3

Demographic and Risk Stratification

Patient Characteristics

• Document age, sex, and race/ethnicity as these influence medication selection (e.g., calcium channel blockers or thiazide diuretics preferred as initial therapy in Black patients) 5, 2, 6
• Calculate 10-year ASCVD risk using the ACC/AHA Pooled Cohort Equations to guide BP targets and intensity of therapy 1

Follow-Up Timing

Active Titration Phase

• Schedule monthly visits until BP control is achieved when initiating or adjusting medications 1
• Reassess within 2-4 weeks after any medication change 5, 2, 6

Maintenance Phase

• Extend to every 3-6 months once BP is stable at goal 1, 2
• For lifestyle modification alone, follow-up every 3-6 months to reinforce adherence and reassess need for pharmacotherapy 1

Common Pitfalls to Avoid

• Do not assume treatment failure without first confirming medication adherence and excluding white-coat hypertension 1, 5, 6
• Do not delay treatment intensification when BP remains significantly above goal (>20/10 mmHg); adjust therapy within 2-4 weeks 1, 5
• Do not overlook interfering substances (especially NSAIDs) that can negate antihypertensive effects 5, 6, 3
• Do not forget to check electrolytes and renal function when using RAS blockers or diuretics, as hyperkalemia and acute kidney injury can occur 1, 5