What is the initial work‑up for a newly diagnosed hypertensive patient?

Initial Work-Up for Newly Diagnosed Hypertension

All newly diagnosed hypertensive patients require a standardized initial work-up consisting of basic laboratory tests, ECG, and cardiovascular risk stratification to guide treatment decisions and detect secondary causes. 1, 2

Confirm the Diagnosis First

Before proceeding with any work-up, confirm that hypertension is sustained and not a single elevated reading 1, 2, 3:

• For office BP 120-159/70-99 mmHg: Confirm with out-of-office measurements (ambulatory or home BP monitoring) 1, 2
• For office BP ≥160/100 mmHg: Confirm within 1 month using home or ambulatory measurements 1, 2
• For BP ≥180/110 mmHg: Immediately exclude hypertensive emergency before routine work-up 1, 2, 3
• Use validated automated devices with appropriate cuff size; take at least 2-3 measurements 4, 3

Mandatory Basic Laboratory Tests

Every newly diagnosed hypertensive patient requires these tests 1, 2:

Core Metabolic Panel

• Serum electrolytes (sodium and potassium) 1, 2
• Serum creatinine with estimated GFR to assess renal function 1, 2
• Fasting blood glucose to detect diabetes 1, 2

Additional Essential Tests

• Complete lipid profile (total cholesterol, LDL, HDL, triglycerides) 1, 2
• Urinalysis (dipstick) 1, 2
• Urine albumin-to-creatinine ratio (UACR) to detect early kidney damage 1, 2
• Complete blood count 1, 4
• Thyroid-stimulating hormone to detect thyroid disorders 1
• 12-lead ECG to detect left ventricular hypertrophy, atrial fibrillation, and ischemic heart disease 1, 2

Essential Clinical Assessment

History Taking

Focus on these specific elements 1, 4:

• Medication review: Current antihypertensives, adherence patterns, NSAIDs, steroids, sympathomimetics, cocaine, amphetamines 1, 4
• Duration and severity: When hypertension was first detected, previous BP readings 1, 4
• Symptoms suggesting secondary causes: Muscle cramps/weakness (hypokalemia from aldosteronism), palpitations/heat intolerance (hyperthyroidism), weight loss, frequent urination, easy bruising (Cushing's) 1, 4
• Family history: Premature cardiovascular disease (men <55 years, women <65 years), hypertension, kidney disease 1
• Cardiovascular risk factors: Smoking, diabetes, dyslipidemia, obesity 1

Physical Examination

Perform these specific assessments 1, 4:

• BP measurement in both arms: Difference >10 mmHg suggests vascular disease 1
• Orthostatic BP: Measure at 1 and 3 minutes after standing (abnormal if SBP drops ≥20 mmHg or DBP ≥10 mmHg) 1
• Heart rate: Resting HR >80 bpm independently predicts cardiovascular events 1, 2
• BMI and waist circumference: Target <94 cm in men, <80 cm in women 2
• Cardiovascular exam: Apical impulse location (LVH), cardiac auscultation, peripheral pulses 4
• Vascular exam: Abdominal bruits (renovascular disease), carotid bruits, delayed femoral pulses (coarctation) 1, 4
• Endocrine stigmata: Cushingoid features, thyroid enlargement, neurofibromatosis 4
• Fundoscopy: Especially if BP >180/110 mmHg to detect retinal hemorrhages or papilledema 1, 2

Cardiovascular Risk Stratification

Risk stratification determines treatment intensity and urgency 1, 2:

High-Risk Features Requiring Immediate Treatment

• Established cardiovascular disease (prior MI, stroke, peripheral artery disease) 2
• Diabetes mellitus 2
• Chronic kidney disease (eGFR <60 mL/min/1.73m²) 2
• Familial hypercholesterolemia 2

Additional Risk Factors to Document

• Age: Men ≥55 years, women ≥65 years 1, 2
• Male sex 1, 2
• Dyslipidemia: Total cholesterol >190 mg/dL, LDL >115 mg/dL, HDL <40 mg/dL (men) or <46 mg/dL (women), triglycerides >150 mg/dL 1
• Obesity: BMI ≥30 kg/m² or abdominal obesity (waist ≥102 cm men, ≥88 cm women) 1
• Family history of premature CVD 1, 2

Risk Calculation

• Use SCORE2 for ages 40-69 years or SCORE2-OP for ages ≥70 years 2
• SCORE2/SCORE2-OP ≥10% indicates high risk requiring aggressive management 2

Optional Tests for Specific Indications

When to Assess for Hypertension-Mediated Organ Damage (HMOD)

Consider these tests in patients with low-to-moderate risk to reclassify risk level 2:

• Echocardiography: When ECG shows abnormalities or cardiac symptoms present to assess LVH, systolic/diastolic dysfunction 1, 2
• Carotid ultrasound: To detect atherosclerotic plaques when clinically indicated 2
• Ankle-brachial index: For suspected peripheral artery disease 2
• Brain CT/MRI: When neurologic symptoms present 2

When to Screen for Secondary Hypertension

Reserve secondary hypertension work-up for these specific scenarios 1, 4, 2:

• Age <30 years with severe hypertension 4, 2
• Sudden onset or rapid progression 4
• Resistant hypertension (uncontrolled on 3 drugs including diuretic) 4, 2
• Hypokalemia (spontaneous or diuretic-induced) 1
• Abdominal bruit (renovascular disease) 1
• Symptoms of pheochromocytoma (episodic headaches, palpitations, sweating) 1, 4

Specific Tests for Secondary Causes

• Aldosterone-renin ratio: For primary aldosteronism (best done before starting interfering antihypertensives) 1, 2, 5
• Plasma free metanephrines: For pheochromocytoma 1, 2
• Late-night salivary cortisol or 24-hour urinary free cortisol: For Cushing syndrome 1, 2
• Renal artery imaging (CT/MR angiography or Duplex ultrasound): For renovascular disease 1, 2
• Renal ultrasound: For renal parenchymal disease 2

Common Pitfalls to Avoid

• Do not perform extensive secondary hypertension screening in all patients—this is expensive and low-yield; reserve for specific clinical scenarios 5, 6
• Do not skip out-of-office BP confirmation—white coat hypertension affects 15-30% of patients 1, 2
• Do not forget orthostatic BP measurement in elderly, diabetic patients, or those on multiple medications—orthostatic hypotension predicts worse outcomes 1
• Do not measure aldosterone-renin ratio while patient is on interfering drugs (ACE inhibitors, ARBs, diuretics, beta-blockers) without considering their effect on interpretation 5
• Do not overlook medication and substance use—NSAIDs, steroids, cocaine, and amphetamines are common reversible causes 1, 4