Diagnostics

• Screen patients using in-office blood pressure measurement.

• Confirm elevated values with ABPM or HBPM.

• Perform a thorough physical examination and obtain initial laboratory studies.

  • Stratify patients by cardiovascular risk (using the ASCVD risk estimator tool).

  • Evaluate for target organ damage.

• Consider diagnostic workup for secondary causes of hypertension in patients with:

  • Abnormalities identified during evaluation for newly diagnosed hypertension

  • Signs suggestive of secondary hypertension

• Annual screening

  • Individuals > 40 years of age

  • Adults of any age with risk factors for primary hypertension

• Screening every 3–5 years: individuals 18–39 years of age with previously normal blood pressure (< 130/85 mm Hg) and no risk factors

• in-office blood pressure measurement

  • If elevated, measurements should be repeated on both arms.

  • Elevated average blood pressure on at least two readings obtained on at least two separate visits supports a diagnosis of hypertension.

∼ 20% of individuals with high blood pressure are unaware they have hypertension.

Out-of-office measurement is recommended in all individuals for confirmation of hypertension before initiating treatment.

• Ambulatory blood pressure measurement (ABPM): preferred method

  • A device measures blood pressure at fixed intervals (e.g., every 15–30 minutes) over 12–24 hours.

  • Takes measurements while the individual is carrying out normal activities during the day and at nighttime

• Home blood pressure monitoring (HBPM): Blood pressure is measured by the individual at periodic intervals.

Patients should be taught to measure their own blood pressure to allow for long-term monitoring and assessment of treatment.

The initial exam should focus on evaluation for signs indicating secondary hypertension and target organ damage, and the assessment of ASCVD risk.

• Physical examination and patient history

• Routine studies

  • Fasting blood glucose

  • Serum sodium, potassium, and calcium levels

  • Renal function tests: serum creatinine and eGFR

  • CBC

  • TSH

  • Lipid profile (HDL, LDL, and triglycerides levels)

  • Urinalysis and urinary albumin-to-creatinine ratio

  • Electrocardiogram (ECG)

• Additional studies

  • Hemoglobin A1c

  • Liver chemistries

  • Serum uric acid

  • Echocardiogram

The initial evaluation should include an assessment for orthostatic hypotension (by measuring blood pressure while sitting and standing), especially in older adults. All adults ≤ 30 years of age with elevated brachial blood pressure should also have their blood pressure measured in their thigh to rule out coarctation of the aorta.