Work-Up for Newly Diagnosed Hypertension
Confirm the Diagnosis Before Initiating Treatment
Do not diagnose hypertension based on a single office reading—always confirm with out-of-office measurements using home blood pressure monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) before starting therapy. 1
- Measure BP with a validated automated upper-arm cuff sized to encircle ≥80% of the arm circumference. 1
- Have the patient sit quietly with back supported, feet flat on the floor, arm at heart level for 5 minutes before measurement. 1
- Take at least two readings at 1-minute intervals and average them. 1
- Measure both arms simultaneously at the first visit; use the arm with the higher reading for all subsequent measurements. 1
- For office BP 140–159/90–99 mmHg (Grade 1), defer treatment until confirmation with home or ambulatory monitoring. 1
- For office BP ≥160/100 mmHg (Grade 2), obtain confirmation within 1 month, preferably using home or ambulatory measurements. 1
- For office BP ≥180/110 mmHg, immediately exclude hypertensive emergency (acute end-organ damage such as encephalopathy, acute coronary syndrome, acute heart failure, aortic dissection, or acute kidney injury). 1, 2
Common pitfall: White-coat hypertension affects 15–30% of patients and can result in office readings that are on average 18.9 mmHg higher than ambulatory systolic pressure. 1 Relying solely on office readings leads to overdiagnosis and unnecessary treatment.
Baseline Laboratory Evaluation (Mandatory for All Patients)
Obtain the following tests to assess cardiovascular risk, detect hypertension-mediated organ damage (HMOD), and screen for secondary causes:
- Serum creatinine and estimated glomerular filtration rate (eGFR) to assess renal function. 1
- Urine dipstick for proteinuria; if positive or eGFR <60 mL/min/1.73 m², obtain urine albumin-to-creatinine ratio. 1
- Serum electrolytes (sodium, potassium) to detect hypokalemia (suggests primary aldosteronism) or hyperkalemia (renal dysfunction). 1
- Fasting glucose to screen for diabetes, which is present in 15–20% of hypertensive patients. 1
- Full lipid profile (total cholesterol, LDL-C, HDL-C, triglycerides); elevated lipids are present in ~30% of hypertensive individuals. 1
- 12-lead electrocardiogram to detect atrial fibrillation, left-ventricular hypertrophy, or ischemic heart disease. 1
If eGFR <60 mL/min/1.73 m² (moderate-to-severe CKD), repeat creatinine, eGFR, and urine albumin-to-creatinine ratio at least annually. 1
Cardiovascular Risk Stratification
- Calculate 10-year cardiovascular risk using validated tools (SCORE2 for ages 40–69; SCORE2-OP for ≥70 years). 1
- Patients with SCORE2 or SCORE2-OP ≥10% are considered at increased CVD risk. 1
Additional risk enhancers to document:
- Age >65 years, male sex, resting heart rate >80 bpm. 1
- Diabetes (~15–20% prevalence in hypertensive patients). 1
- Overweight/obesity (
40%), hyperuricemia (25%), metabolic syndrome (~40%). 1 - Positive family history of CVD or early-onset hypertension. 1
- Smoking, high alcohol intake, sedentary lifestyle. 1
Screening for Hypertension-Mediated Organ Damage (HMOD)
Cardiac Evaluation
- Echocardiography is indicated when: 1
- ECG shows abnormalities (e.g., left-ventricular hypertrophy, Q waves, ST-T changes).
- Patient has cardiac signs/symptoms (dyspnea, chest pain, edema, murmur).
- Suspicion of left-ventricular hypertrophy, systolic/diastolic dysfunction, or atrial dilation.
Ocular Evaluation
- Fundoscopy is recommended for BP >180/110 mmHg to assess for hypertensive retinopathy (hemorrhages, exudates, papilledema) or in patients with diabetes. 1
Vascular & Renal Imaging (When Clinically Indicated)
- Carotid ultrasound to detect plaques or stenosis. 1
- Renal/renal-artery imaging (ultrasound, CT/MR angiography) if suspected renal parenchymal disease, renal-artery stenosis, or adrenal lesions. 1
- Brain CT/MRI if suspected ischemic or hemorrhagic brain injury. 1
- Ankle-brachial index to detect peripheral artery disease. 1
Screening for Secondary Hypertension (When Clinically Indicated)
Secondary hypertension accounts for <10% of cases but is often curable. 3 Screen when:
- Young age (<30 years) with severe hypertension. 2
- Sudden onset or rapid progression of hypertension. 2
- Resistant hypertension (uncontrolled on ≥3 medications). 2
- Severe or labile hypertension with paroxysmal symptoms. 4
| Potential Cause | Key Clinical Clues | Recommended Test(s) |
|---|---|---|
| Primary aldosteronism | Severe or resistant hypertension, hypokalemia | Aldosterone-renin ratio [1] |
| Obstructive sleep apnea | Daytime sleepiness, loud snoring, witnessed apnea, obesity | Sleep study (polysomnography) [1] |
| Renal-artery stenosis | Young female, known atherosclerotic disease, worsening renal function on ACE-I/ARB | Duplex ultrasound or CT/MR angiography [1] |
| Pheochromocytoma | Paroxysmal hypertension with palpitations, diaphoresis, headache | Plasma free metanephrines [1] |
| Cushing's syndrome | Moon facies, central obesity, abdominal striae, interscapular fat | Late-night salivary cortisol [1] |
| Aortic coarctation | Differential brachial vs. femoral pulses, systolic bruit | MRI/CT or echocardiography [1] |
| Medication-induced | Use of NSAIDs, decongestants, oral contraceptives, systemic steroids, stimulants, licorice | Review medication list and discontinue offending agents [1] |
Common pitfall: Non-adherence to antihypertensive medications is the most frequent cause of apparent treatment resistance. 4 Verify adherence through non-judgmental questioning and family input before pursuing extensive secondary hypertension workup. 4
Additional Investigations
- Urinary albumin-to-creatinine ratio for more precise assessment of renal damage. 1
- Serum uric acid (elevated in ~25% of hypertensive patients). 1
- Liver function tests as part of baseline metabolic assessment. 1
Key Pitfalls to Avoid
- Do not diagnose hypertension based on a single office reading; confirm with home or ambulatory monitoring. 1
- Do not overlook medication adherence; non-adherence is the most common cause of apparent treatment resistance. 4
- Do not miss secondary hypertension, which accounts for <10% of cases but is often curable. 3
- Do not delay confirmation of diagnosis; one-third of patients with diastolic BP >95 mmHg on initial ED visit normalize before follow-up. 5