From the Guidelines
The evaluation of hypertension should begin with accurate blood pressure measurements, using a validated device, with the patient seated quietly for 5 minutes, feet flat on the floor, back supported, and arm at heart level, as recommended by the 2019 AHA/ACC clinical performance and quality measures for adults with high blood pressure 1.
Key Components of Evaluation
The evaluation process has three main objectives:
- to assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that may affect prognosis and guide treatment
- to reveal identifiable causes of high BP
- to assess the presence or absence of target organ damage and CVD, as outlined in the seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure 1.
Patient Evaluation
Patient evaluation is made through:
- medical history
- physical examination, including an appropriate measurement of BP, with verification in the contralateral arm; examination of the optic fundi; calculation of body mass index (BMI); auscultation for carotid, abdominal, and femoral bruits; palpation of the thyroid gland; thorough examination of the heart and lungs; examination of the abdomen for enlarged kidneys, masses, distended urinary bladder, and abnormal aortic pulsation; palpation of the lower extremities for edema and pulses; and neurological assessment, as recommended by the seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure 1
- routine laboratory tests, such as complete blood count, comprehensive metabolic panel, lipid profile, urinalysis, and electrocardiogram
- other diagnostic procedures, such as echocardiogram to assess for left ventricular hypertrophy, urine albumin-to-creatinine ratio to detect kidney damage, and home or ambulatory blood pressure monitoring to confirm the diagnosis and rule out white-coat hypertension.
Diagnosis and Treatment
Hypertension is diagnosed when blood pressure is consistently ≥130 and/or ≥80 mm Hg, as stated in the 2020 ACC/AHA hypertension guidelines 1. The guideline also emphasizes the importance of accurate blood pressure measurement and the use of absolute cardiovascular risk to determine high-risk status.
Additional Tests
For patients with suspected secondary hypertension based on clinical features (resistant hypertension, sudden onset, age <30 years), specific tests may include plasma renin activity, aldosterone levels, renal artery imaging, or sleep studies, as recommended by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. The evaluation of hypertension should be guided by the most recent and highest quality evidence, with a focus on accurate blood pressure measurement, comprehensive medical history, physical examination, and laboratory testing, as well as the identification of potential secondary causes and the assessment of cardiovascular risk, as outlined in the 2019 AHA/ACC clinical performance and quality measures for adults with high blood pressure 1.
From the FDA Drug Label
Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake Many patients will require more than one drug to achieve blood pressure goals. For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)
The protocol for evaluation of hypertension is not directly stated in the provided drug labels. However, it is mentioned that control of high blood pressure should be part of comprehensive cardiovascular risk management. This includes:
- Lipid control
- Diabetes management
- Antithrombotic therapy
- Smoking cessation
- Exercise
- Limited sodium intake It is also recommended to follow published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) 2 3.
From the Research
Protocol for Evaluation of Hypertension
The evaluation of hypertension involves a series of steps to determine the presence and severity of the condition, as well as to identify any underlying causes or risk factors. The following are the key components of the protocol:
- Initial Evaluation: A complete history, physical examination, and relatively simple laboratory procedures such as CBC, urinalysis, SMA-6 and 12, and ECG yield sufficient information to detect damage to target organs caused by elevated blood pressure and to exclude the presence of secondary causes fairly adequately 4.
- Blood Pressure Measurement: Accurate blood pressure measurement is essential, and this can be done using clinic, ambulatory, or home blood pressure monitoring 5.
- History and Physical Examination: A focused history and physical examination should be directed to the principal target organs, including the optic fundi, central nervous system, heart, and kidneys 6.
- Laboratory Evaluation: Laboratory tests should include urinalysis, ECG, and determinations of blood hemoglobin/hematocrit, creatinine, potassium, glucose, and cholesterol, including HDL fraction 6.
- Risk Factor Assessment: The evaluation should also include an assessment of other risk factors, such as family history, lifestyle, and presence of other cardiovascular risk factors 7, 8.
- Target Organ Damage: The evaluation should include an assessment of target organ damage, such as damage to the heart, kidneys, and eyes 7, 8.
- Secondary Causes: The evaluation should also include an assessment for secondary causes of hypertension, such as coarctation of the aorta, pheochromocytoma, primary aldosteronism, and renovascular hypertension 6.
Special Considerations
Certain patient groups may require more extensive evaluation, such as:
- Severe Hypertension: Patients with severe hypertension at any age, especially if there is a reliable negative family history, may require more extensive evaluation 8.
- Resistant Hypertension: Patients with resistant hypertension may require more extensive evaluation to rule out underlying secondary causes 8.
- Special Populations: Patients with certain underlying conditions, such as peripheral vascular disease or abnormal renal function, may require more extensive evaluation 8.