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Initial evaluation of adults with hypertension

Initial evaluation of adults with hypertension
Literature review current through: May 2024.
This topic last updated: Jul 29, 2022.

INTRODUCTION — Most patients with hypertension initially present with a modest elevation in blood pressure and no clinical cardiovascular disease or signs of hypertension-related target-organ damage. The diagnosis of hypertension is made in this setting only after a properly measured blood pressure in the hypertensive range has been confirmed on at least two occasions or, preferably, if a hypertensive blood pressure obtained in the office is confirmed by out-of-office measurements, such as ambulatory blood pressure monitoring or self-measured blood pressure (algorithm 1) [1-4]. Establishing the diagnosis of hypertension and the methods of measuring blood pressure are discussed elsewhere:

(See "Overview of hypertension in adults", section on 'Diagnosis'.)

(See "Blood pressure measurement in the diagnosis and management of hypertension in adults".)

The appropriate management of patients with hypertension, defined by persistent blood pressure values ≥130 mmHg systolic and/or ≥80 mmHg diastolic, depends upon several factors, including the presence or absence of specific comorbidities, the overall cardiovascular risk, and whether or not the hypertension is being caused by a second, potentially reversible disorder [5].

(See "Choice of drug therapy in primary (essential) hypertension".)

(See "Goal blood pressure in adults with hypertension".)

(See "Evaluation of secondary hypertension".)

Thus, after the presence of hypertension has been established, an evaluation should be performed to ascertain the following information:

The extent of target-organ damage

The patient's overall cardiovascular risk status (see "Overview of established risk factors for cardiovascular disease")

Whether or not identifiable (secondary) and often curable causes of hypertension exist (table 1) (see "Evaluation of secondary hypertension")

The patient with a systolic blood pressure ≥180 mmHg and/or diastolic blood pressure ≥120 mmHg requires immediate evaluation for signs of acute target-organ damage and, possibly, immediate treatment. The complete evaluation for potentially contributing causes is usually delayed in these circumstances until the blood pressure is brought to safer levels.

(See "Moderate to severe hypertensive retinopathy and hypertensive encephalopathy in adults".)

(See "Evaluation and treatment of hypertensive emergencies in adults".)

(See "Management of severe asymptomatic hypertension (hypertensive urgencies) in adults".)

THE BASIC WORKUP — The features of the history and physical examination described below are directed specifically toward hypertension. Additional features may need to be included for other indications.

History — The history should search for those facts that help determine the presence of precipitating or aggravating factors, the natural course of the blood pressure, the extent of target-organ damage, and the presence of other risk factors for cardiovascular disease (table 2). The patient should also be asked about the signs and symptoms that suggest an identifiable cause of hypertension (table 1). (See "Clinical presentation and diagnosis of pheochromocytoma".)

Delays in the diagnosis of hypertension and its treatment are common. While some of these individuals receive little health care, many receive regular health care, but their hypertension goes unrecognized [6]. In the National Health and Nutrition Examination Survey from 2011 to 2012, more than one-third of adults with uncontrolled hypertension were unaware and untreated. Among this group, more than 80 percent had health insurance and a usual source of care, and more than 60 percent of those had two or more health care visits in the previous year. Reviews of electronic health record information at several large health systems generally confirm that large numbers of patients with repeatedly elevated blood pressure are undiagnosed.

Another important consideration, particularly in the patient with severely elevated blood pressures (≥180/≥120 mmHg), is the history of prior treatment for hypertension and nonadherence to antihypertensive medications since this is a common finding in patients with severe hypertension.

Physical examination — Proper technique for measurement of blood pressure is detailed elsewhere. If feasible, all patients with elevated blood pressure obtained during a clinical encounter should undergo out-of-office measurement (preferably with 24-hour ambulatory blood pressure monitoring) to confirm the diagnosis of hypertension. This is discussed separately. (See "Blood pressure measurement in the diagnosis and management of hypertension in adults" and "Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring".)

The main goals on the physical examination are to evaluate for signs of end-organ damage (such as retinopathy) and for evidence of a cause of identifiable hypertension (table 3). (See "Ocular effects of hypertension".)

The various pulses should be palpated, and the abdomen should be auscultated for a renal artery bruit. The presence of an upper-abdominal bruit with a diastolic component that lateralizes toward one side is typically absent in patients with renovascular disease (approximately 40 percent sensitivity); however, if present, such a bruit is highly suggestive of renal artery stenosis (99 percent specificity) [7].

The 2018 American College of Cardiology/American Heart Association guidelines for adults with congenital heart disease recommend that every patient with hypertension should have the brachial and femoral pulses palpated simultaneously to assess timing and amplitude to evaluate for brachial-femoral delay characteristic of coarctation of the aorta [8]. In addition, supine bilateral arm (brachial artery) blood pressures and prone right or left supine leg (popliteal artery) blood pressures should be measured to search for differential pressure. (See "Examination of the arterial pulse", section on 'Unequal or delayed pulses'.)

Laboratory testing — The procedures that should be routinely performed to evaluate for underlying causes (and signs of end-organ damage), as well as cardiovascular risk, are (table 4) [9]:

Blood chemistries including electrolytes, glucose, and creatinine. An estimated glomerular filtration rate (eGFR) should be determined.

Lipid profile. Most patients with hypertension will have hyperlipidemia or sufficiently elevated cardiovascular risk to indicate statin therapy [10,11].

Urinalysis to detect hematuria and an albumin/creatinine ratio to estimate albumin excretion.

Electrocardiogram (ECG).

If there are abnormalities in the patient with severe hypertension, an attempt should be made to determine whether they are new or were previously documented since the patient with acute changes generally requires more aggressive blood pressure reduction.

Tests that are occasionally performed — Additional tests may be indicated in certain settings. These include:

Echocardiography — Routine echocardiographic evaluation of patients with hypertension is not recommended, unless there are specific indications, such as clinically evident heart failure, or if left ventricular dysfunction or coronary artery disease is suspected [12]. Echocardiography is a more sensitive method to detect left ventricular hypertrophy than the ECG. In patients suspected of having coronary artery disease, stress echocardiography (rather than standard echocardiography) may be preferred [13].  

Serum uric acid — Hyperuricemia has been found to be a precursor and possible pathogenetic factor for hypertension [14]. This issue is discussed elsewhere. (See "Asymptomatic hyperuricemia", section on 'Hyperuricemia and conditions unassociated with crystal deposition'.)

Plasma renin activity — Although the plasma renin activity (PRA) may provide prognostic information [15], the test is usually performed only in patients with possible low-renin forms of hypertension, such as primary mineralocorticoid excess. The PRA may provide guidance in the evaluation and treatment of resistant hypertension [16,17]. (See "Definition, risk factors, and evaluation of resistant hypertension" and "Diagnosis of primary aldosteronism" and "Pathophysiology and clinical features of primary aldosteronism".)

Testing for renovascular hypertension — Additional testing for renovascular disease is indicated only in patients in whom the history is suggestive (table 1). The identification of patients who should be evaluated for renovascular hypertension and the diagnosis of renovascular hypertension in such patients are presented in detail elsewhere. (See "Evaluation of secondary hypertension" and "Establishing the diagnosis of renovascular hypertension".)

ASSESSMENT OF CARDIOVASCULAR RISK — As well defined by data from the Framingham study, a number of other risk factors interact with hypertension to determine the overall risk status of each individual patient [18]. The presence or absence of other risk factors can influence the decision as to whether to institute antihypertensive medications in a patient with stage 1 hypertension (ie, systolic 130 to 139 mmHg or diastolic 80 to 89 mmHg) [3]. Several calculators are available to estimate overall cardiovascular risk (calculator 1 and calculator 2 and calculator 3). The atherosclerotic cardiovascular disease (ASCVD) risk calculator may be more strongly associated with cardiovascular outcomes than other calculators [19]. (See "Cardiovascular risks of hypertension".)

In patients with stage 1 hypertension, cardiovascular risk assessment is useful to determine the need for pharmacologic therapy. (See "Overview of hypertension in adults", section on 'Who should be treated with pharmacologic therapy?'.)

Cardiovascular risk assessment may also inform goal blood pressure (table 5).

Albuminuria — In patients with hypertension, moderately increased albuminuria (formerly, microalbuminuria) is associated with an increased incidence of cardiovascular disease. The value of measuring albumin excretion in patients with primary hypertension without diabetes is being increasingly advocated to assess cardiovascular risk; however, it does not have value as a screening tool for nephropathy in nondiabetic patients with hypertension [20,21]. (See "Moderately increased albuminuria (microalbuminuria) and cardiovascular disease" and "Moderately increased albuminuria (microalbuminuria) in type 1 diabetes mellitus" and "Moderately increased albuminuria (microalbuminuria) in type 2 diabetes mellitus".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Hypertension in adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Beyond the Basics topics (see "Patient education: High blood pressure in adults (Beyond the Basics)" and "Patient education: High blood pressure treatment in adults (Beyond the Basics)" and "Patient education: High blood pressure, diet, and weight (Beyond the Basics)").

SUMMARY AND RECOMMENDATIONS

Confirm the diagnosis – Among patients with uncomplicated stage 1 hypertension (ie, blood pressure 130 to 139/80 to 89 mmHg) in the absence of clinical cardiovascular disease or signs of hypertension-related target-organ damage), the diagnosis is made only after an elevated and properly measured blood pressure has been confirmed on multiple occasions or, preferably, if an elevated blood pressure obtained in the office is confirmed by out-of-office measurements (either by home or ambulatory monitoring) (algorithm 1). (See 'Introduction' above.)

Basic evaluation – The evaluation should determine the duration of hypertension, the presence and extent of target-organ damage, and the patient's 10-year atherosclerotic cardiovascular disease (ASCVD) risk. Among selected patients, secondary causes of hypertension should be ruled out. (See 'History' above and 'Physical examination' above.)

The physical examination should include evaluation for end-organ damage. The various pulses should be palpated, and the abdomen should be auscultated for a renal artery bruit. The presence of an upper-abdominal bruit with a diastolic component that lateralizes toward one side is highly suggestive of renal artery stenosis. (See 'Physical examination' above.)

Laboratory tests should include blood chemistries (electrolytes, glucose, creatinine), an estimated glomerular filtration rate (eGFR), a lipid profile, urinalysis, urine albumin/creatinine ratio, and electrocardiogram (ECG) (table 4). An attempt should be made to determine whether any abnormalities are new or were previously documented since the patient with acute changes generally requires more aggressive blood pressure reduction. (See 'Laboratory testing' above.)

Additional tests – Additional tests may be indicated in certain settings. (See 'Tests that are occasionally performed' above.)

  1. US Preventive Services Task Force, Krist AH, Davidson KW, et al. Screening for Hypertension in Adults: US Preventive Services Task Force Reaffirmation Recommendation Statement. JAMA 2021; 325:1650.
  2. Harris KC, Benoit G, Dionne J, et al. Hypertension Canada's 2016 Canadian Hypertension Education Program Guidelines for Blood Pressure Measurement, Diagnosis, and Assessment of Risk of Pediatric Hypertension. Can J Cardiol 2016; 32:589.
  3. Whelton PK, Carey RM, Aronow WS, et al. 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: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018; 71:e13.
  4. Shimbo D, Artinian NT, Basile JN, et al. Self-Measured Blood Pressure Monitoring at Home: A Joint Policy Statement From the American Heart Association and American Medical Association. Circulation 2020; 142:e42.
  5. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:2935.
  6. Wall HK, Hannan JA, Wright JS. Patients with undiagnosed hypertension: hiding in plain sight. JAMA 2014; 312:1973.
  7. Grim CE, Luft FC, Weinberger MH, Grim CM. Sensitivity and specificity of screening tests for renal vascular hypertension. Ann Intern Med 1979; 91:617.
  8. Stout KK, Daniels CJ, Aboulhosn JA, et al. 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019; 139:e637.
  9. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289:2560.
  10. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:2889.
  11. Egan BM, Li J, Qanungo S, Wolfman TE. Blood pressure and cholesterol control in hypertensive hypercholesterolemic patients: national health and nutrition examination surveys 1988-2010. Circulation 2013; 128:29.
  12. Dasgupta K, Quinn RR, Zarnke KB, et al. The 2014 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can J Cardiol 2014; 30:485.
  13. Senior R, Monaghan M, Becher H, et al. Stress echocardiography for the diagnosis and risk stratification of patients with suspected or known coronary artery disease: a critical appraisal. Supported by the British Society of Echocardiography. Heart 2005; 91:427.
  14. Forman JP, Choi H, Curhan GC. Uric acid and insulin sensitivity and risk of incident hypertension. Arch Intern Med 2009; 169:155.
  15. Laragh J. Laragh's lessons in pathophysiology and clinical pearls for treating hypertension. Am J Hypertens 2001; 14:603.
  16. Egan BM, Basile JN, Rehman SU, et al. Plasma Renin test-guided drug treatment algorithm for correcting patients with treated but uncontrolled hypertension: a randomized controlled trial. Am J Hypertens 2009; 22:792.
  17. Egan BM, Laken MA, Sutherland SE, et al. Aldosterone Antagonists or Renin-Guided Therapy for Treatment-Resistant Hypertension: A Comparative Effectiveness Pilot Study in Primary Care. Am J Hypertens 2016; 29:976.
  18. Kivimäki M, Batty GD, Singh-Manoux A, et al. Validating the Framingham Hypertension Risk Score: results from the Whitehall II study. Hypertension 2009; 54:496.
  19. Pursnani A, Massaro JM, D'Agostino RB Sr, et al. Guideline-Based Statin Eligibility, Coronary Artery Calcification, and Cardiovascular Events. JAMA 2015; 314:134.
  20. Mancia G, Laurent S, Agabiti-Rosei E, et al. Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document. J Hypertens 2009; 27:2121.
  21. Bakris GL, Molitch M. Microalbuminuria as a risk predictor in diabetes: the continuing saga. Diabetes Care 2014; 37:867.
Topic 3849 Version 21.0

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