Diagnostic Evaluation of Stage 1 Hypertension

Basic Laboratory Testing

The American College of Cardiology recommends basic laboratory testing for patients with stage 1 hypertension, including fasting blood glucose, complete blood count, lipid profile, serum creatinine with eGFR, serum electrolytes, thyroid-stimulating hormone, urinalysis, and an electrocardiogram to assess for target organ damage and cardiovascular risk 1, 2, 3
Fasting blood glucose is recommended to screen for diabetes or prediabetes, which frequently coexists with hypertension 1
Complete blood count is recommended to evaluate for anemia or other hematologic abnormalities 1, 3
Lipid profile is recommended to assess cardiovascular risk 1
Serum creatinine with eGFR is recommended to assess kidney function and establish baseline renal status 1, 2
Serum electrolytes are recommended to identify electrolyte abnormalities that may suggest secondary causes of hypertension 1, 3
Thyroid-stimulating hormone is recommended to screen for hypothyroidism or hyperthyroidism, which are remediable causes of hypertension 1, 2
Urinalysis is recommended to screen for kidney disease 1, 3
Electrocardiogram is recommended to assess for left ventricular hypertrophy and other cardiac abnormalities 1, 3

Echocardiogram is recommended for patients with uncontrolled hypertension, suspected hypertensive heart disease, or abnormal ECG findings 2, 4, 5
Urinary albumin-to-creatinine ratio is recommended as a more sensitive test for detecting early kidney damage, particularly in patients with diabetes or high cardiovascular risk 1, 6
Serum uric acid may provide additional risk stratification information 1, 2
Ambulatory blood pressure monitoring or home blood pressure monitoring is recommended to identify white coat or masked hypertension 5, 7

Renal ultrasound is recommended for patients younger than 30 years, with poor response to standard treatment, abnormal kidney function tests, or suspected secondary hypertension 1, 2, 3
Advanced cardiovascular imaging, such as pulse wave velocity, carotid intima-media thickness, or coronary artery calcium scoring, may be considered for further risk stratification in selected cases 2

For patients with diabetes or chronic kidney disease, urinary albumin-to-creatinine ratio is strongly recommended, and a more comprehensive cardiovascular risk assessment is recommended 6, 8
For patients with resistant hypertension, a more extensive evaluation for secondary causes is recommended, and a sleep study may be considered to rule out obstructive sleep apnea 1, 2

Relying solely on office BP measurements without confirming with out-of-office measurements can lead to misdiagnosis 5, 7
Using urine dipstick alone instead of quantitative urinary albumin-to-creatinine ratio may miss early kidney damage 6
Overlooking the need for echocardiography in patients with uncontrolled hypertension 4
Failing to assess standing blood pressure to detect orthostatic hypotension, especially in older adults 1, 3