Diagnostic Approach to Chronic Uncontrolled Hypertension

Initial Evaluation

The American Heart Association recommends ordering basic laboratory tests, including sodium, potassium, creatinine with eGFR, fasting glucose, lipid profile, urinalysis with albumin-to-creatinine ratio, and a 12-lead ECG as the initial workup for chronic uncontrolled hypertension 1, 2
Baseline tests should include blood tests (sodium, potassium, serum creatinine with estimated glomerular filtration rate, fasting glucose, and lipid profile) and urine tests (dipstick urinalysis and urinary albumin-to-creatinine ratio) to detect kidney damage 1, 2, 3
A 12-lead ECG is essential to detect atrial fibrillation, left ventricular hypertrophy, and ischemic heart disease 1, 2, 4, 3

The European Society of Cardiology suggests that echocardiography is mandatory when ECG shows abnormalities, cardiac murmurs are present, or the patient has cardiac symptoms or signs of left ventricular dysfunction 5, 4, 3
Echocardiography should be considered when detection of left ventricular hypertrophy would influence treatment decisions, even with a normal ECG if resources permit 5, 4
Targeted testing should be ordered when clinical features suggest specific causes of secondary hypertension, such as primary aldosteronism, pheochromocytoma, Cushing syndrome, renal artery stenosis, or obstructive sleep apnea 1, 2, 3

Renal ultrasound may be considered for suspected kidney disease, chronic kidney disease assessment, or resistant hypertension 1, 4, 3
Carotid ultrasound may be considered to detect atherosclerotic plaques or stenosis in patients with documented vascular disease elsewhere 1, 5
Fundoscopy is essential in severe/uncontrolled hypertension to assess for retinal changes, hemorrhages, or papilledema 1, 3

The American College of Cardiology recommends that key laboratory findings, such as hypokalemia, hyperkalemia, elevated creatinine, or reduced eGFR, should guide management decisions 1, 3
Proteinuria or albuminuria indicates kidney damage and serves as an independent cardiovascular risk factor 3
Elevated glucose or HbA1c identifies comorbid diabetes, which significantly increases cardiovascular risk and lowers treatment thresholds 3
More than 50% of hypertensive patients have additional cardiovascular risk factors, which proportionally increase the risk of coronary, cerebrovascular, and renal diseases 1, 6