What is the appropriate work‑up to monitor hypertension and hypercholesterolemia in an adult patient?

Monitoring Work-up for Hypertension and Hypercholesterolemia

Initial Baseline Laboratory Assessment

For all patients with hypertension, obtain serum creatinine with eGFR, serum sodium and potassium, fasting glucose or HbA1c, fasting lipid panel (total cholesterol, LDL-C, HDL-C, triglycerides), urinalysis with albumin-to-creatinine ratio, thyroid-stimulating hormone, and a 12-lead ECG. 1 This comprehensive panel identifies target organ damage, cardiovascular risk factors, and potential secondary causes of hypertension.

• Serum electrolytes (sodium and potassium) are essential because spontaneous or diuretic-induced hypokalemia strongly suggests primary aldosteronism, which accounts for 8–20% of resistant hypertension cases. 1, 2
• Serum creatinine and eGFR assess kidney function and detect chronic kidney disease, a major cardiovascular risk factor. 1
• Urinary albumin-to-creatinine ratio (not just dipstick) identifies early kidney damage and serves as an independent cardiovascular risk marker. 1, 2
• Fasting glucose or HbA1c uncovers diabetes mellitus, which significantly elevates cardiovascular risk and lowers blood pressure treatment thresholds. 1, 3
• Fasting lipid profile is mandatory for cardiovascular risk stratification in all hypertensive patients. 1, 4
• Thyroid-stimulating hormone screens for thyroid disorders that can affect blood pressure. 1, 2, 3
• 12-lead ECG detects left ventricular hypertrophy, atrial fibrillation, and ischemic heart disease. 1, 3, 5

Frequency of Follow-up Monitoring

During Treatment Titration Phase

Check basic metabolic panel (electrolytes, creatinine, eGFR) within 2–4 weeks after initiating or titrating medications that affect kidney function or electrolytes (ACE inhibitors, ARBs, diuretics, spironolactone). 1 This timing is critical to detect hyperkalemia, hypokalemia, or acute kidney injury before serious complications develop.

• Schedule clinic visits every 6–8 weeks until blood pressure goal (<130/80 mmHg) is safely achieved. 1
• Use home blood pressure monitoring (HBPM) during uptitration to avoid hypotension (SBP <110 mmHg) and detect white coat effects. 1
• Instruct patients to hold or reduce antihypertensive doses during volume depletion (vomiting, diarrhea, decreased oral intake) to prevent acute kidney injury. 1

After Blood Pressure is Controlled

Once target blood pressure is achieved and stable, perform laboratory monitoring (metabolic panel, lipid panel, urinary albumin-to-creatinine ratio) and clinic follow-up every 3–6 months. 1 The frequency depends on medication regimen complexity, presence of chronic kidney disease, and patient stability.

• For patients with moderate-to-severe CKD (eGFR <60 mL/min/1.73 m²), measure serum creatinine, eGFR, and urine albumin-to-creatinine ratio at least annually. 1
• Six-monthly review is sufficient when treatment and blood pressure are stable in patients without significant comorbidities. 1

Out-of-Office Blood Pressure Monitoring

Confirm the diagnosis of hypertension with ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) before initiating treatment in adults with office BP 130–139/80–89 mmHg and elevated cardiovascular risk. 1 This approach detects white coat hypertension (20–30% of apparent hypertension) and masked hypertension, which carry different cardiovascular risks. 1, 2

• For patients already on treatment with office BP at goal but persistent target organ damage or high cardiovascular risk, screen for masked uncontrolled hypertension with HBPM. 1
• If office BP is >5–10 mmHg above goal on ≥3 drugs, use HBPM to detect white coat effect before further intensification. 1
• HBPM should include at least 2 readings 1 minute apart, morning before medications and evening before supper, measured daily for at least 1 week. 1 Base clinical decisions on an average of readings over ≥2 occasions. 1

Additional Cardiac and Vascular Assessment

Obtain echocardiography when ECG shows abnormalities (left ventricular hypertrophy, atrial fibrillation), cardiac murmurs are present, or the patient has cardiac symptoms (dyspnea, chest pain, reduced exercise capacity). 2, 3, 5 Echocardiography detects subclinical left ventricular dysfunction and diastolic abnormalities that predict cardiovascular events even when ECG is normal. 2, 5

• Fundoscopy is essential when BP >180/110 mmHg to evaluate for hypertensive retinopathy, hemorrhages, or papilledema indicating hypertensive emergency. 2, 3
• Coronary artery calcium scoring may be considered in patients with elevated BP when it is likely to change management decisions, particularly for borderline 10-year cardiovascular risk (5% to <10%). 1

Screening for Secondary Hypertension

The 2024 ESC guidelines recommend measuring plasma aldosterone-to-renin ratio (ARR) in all adults with confirmed hypertension (Class IIa recommendation). 1, 2 This represents a paradigm shift from selective screening, recognizing that primary aldosteronism is underdiagnosed and accounts for 8–20% of resistant hypertension. 1, 2

Red Flags Requiring Immediate Secondary Hypertension Work-up

• Age of onset <30 years (or <40 years per ESC 2024) without family history 2
• Resistant hypertension (BP >140/90 mmHg on ≥3 drugs including a diuretic) 1, 2
• Sudden onset or rapid worsening of previously controlled hypertension 1, 2
• Severe hypertension (SBP >180 mmHg or DBP >110 mmHg) or hypertensive emergency 2
• Target organ damage disproportionate to duration or severity of hypertension 2

Cholesterol Monitoring Specifics

Measure fasting lipid panel (total cholesterol, LDL-C, HDL-C, triglycerides) at baseline in all hypertensive patients, as the combined presence of hypertension and hypercholesterolemia markedly increases cardiovascular risk. 1, 4, 6 The prevalence of combined hypertension and hypercholesterolemia is 18% in the general population but reaches 69% in patients with both cardiovascular disease and diabetes. 6

• Treatment goals: Total cholesterol ≤200 mg/dL, LDL-C ≤135 mg/dL (≤100 mg/dL if diabetes or CVD present), triglycerides ≤200 mg/dL. 7
• For secondary prevention (patients with established CVD) or primary prevention with 10-year CVD risk ≥20%, use statins to achieve total cholesterol <5.0 mmol/L or LDL-C <3.0 mmol/L (or 25–30% reduction, whichever is greater). 1
• Recheck lipid panel after initiating or changing lipid-lowering therapy, then monitor according to treatment response and guideline recommendations (typically annually once stable).

Common Pitfalls to Avoid

• Do not rely solely on office blood pressure measurements for diagnosis or treatment decisions—white coat hypertension occurs in 20–30% of cases. 1, 2
• Do not forget to check electrolytes within 2–4 weeks after starting or titrating ACE inhibitors, ARBs, diuretics, or spironolactone—delayed detection of hyperkalemia or acute kidney injury can be life-threatening. 1
• Do not overlook medication non-adherence as a cause of apparent resistant hypertension before pursuing expensive secondary hypertension work-up. 2
• Do not use thiazide diuretics (hydrochlorothiazide) when eGFR <30 mL/min/1.73 m²—switch to loop diuretics. 1, 2
• Do not measure ARR while patients are taking mineralocorticoid receptor antagonists (falsely elevated aldosterone) or beta-blockers (falsely suppressed renin)—these medications interfere with test interpretation. 2