Investigations to be advised in newly suspected hypertension patient
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"Hypertension"[MeSH Terms] AND evaluation
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2024 hypertension guideline initial diagnostic evaluation laboratory tests ECG urinalysis
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https://pmc.ncbi.nlm.nih.gov/articles/PMC12011322
For a patient with newly suspected hypertension, investigations should confirm persistent hypertension, assess cardiovascular risk and target-organ damage, and screen for secondary causes when indicated.
1. Confirm the diagnosis
- Repeat properly measured clinic BP on separate occasions.
- Home blood-pressure monitoring (HBPM) or 24-hour ambulatory BP monitoring (ABPM), preferred where available, to identify white-coat or masked hypertension.
- Measure BP in both arms initially.
- Check postural BP in older adults, people with diabetes, symptoms of dizziness, or suspected autonomic dysfunction.
2. Routine baseline tests
Urine
- Urinalysis/dipstick: protein, blood, glucose.
- Urine albumin-creatinine ratio (ACR), or protein-creatinine ratio if appropriate.
Blood
- Serum creatinine and eGFR
- Serum electrolytes, especially sodium and potassium
- Fasting plasma glucose or HbA1c
- Fasting lipid profile: total cholesterol, LDL-C, HDL-C, triglycerides
- Complete blood count
- Consider liver function tests, serum uric acid, calcium, and TSH based on history and local protocol.
Cardiac
- Resting 12-lead ECG: look for left-ventricular hypertrophy, ischaemia, arrhythmia such as atrial fibrillation.
The three key aims of initial assessment are accurate BP determination, cardiovascular-risk assessment, and selected screening for secondary hypertension, as described in Goldman-Cecil Medicine (Diagnosis section). Current ESC guidance recommends creatinine/eGFR, urine ACR, and a 12-lead ECG in all patients with hypertension, as summarized in this 2024 ESC guideline review.
3. Tests for hypertension-mediated organ damage, if indicated
- Echocardiography: abnormal ECG, murmur, symptoms/signs of heart disease, or suspected LVH/heart failure.
- Fundoscopy: severe hypertension, hypertensive emergency, diabetes, or visual symptoms.
- Renal ultrasound: CKD, abnormal urinalysis, asymmetrical kidneys, or possible renal disease.
- Ankle-brachial index, carotid ultrasound, coronary assessment, or brain imaging only if symptoms or clinical findings warrant them.
4. Directed evaluation for secondary hypertension
Do not order these routinely. Consider them with onset at a young age, abrupt or severe hypertension, resistant hypertension, hypokalaemia, renal impairment, episodic symptoms, or suggestive examination findings.
| Suspected cause | Initial investigation |
|---|---|
| Renal parenchymal disease | Urinalysis, ACR, creatinine/eGFR, renal ultrasound |
| Primary aldosteronism | Plasma aldosterone-renin ratio, particularly with spontaneous/diuretic-induced hypokalaemia or resistant hypertension |
| Renal artery stenosis | Renal Doppler ultrasound, CT angiography, or MR angiography in selected patients |
| Phaeochromocytoma/paraganglioma | Plasma free metanephrines or urinary fractionated metanephrines |
| Cushing syndrome | Overnight dexamethasone suppression test, late-night salivary cortisol, or urinary free cortisol |
| Thyroid disease | TSH, with free T4 if abnormal |
| Obstructive sleep apnoea | Sleep study if snoring, witnessed apnoeas, daytime sleepiness, or obesity |
| Coarctation of aorta | Four-limb BP, femoral pulse examination, echocardiography/CT/MR angiography if suspected |
Practical minimum order set: HBPM/ABPM, urinalysis plus urine ACR, creatinine/eGFR, sodium/potassium, HbA1c or fasting glucose, lipid profile, CBC, and ECG.
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