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{{Template:Hypertension}}
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{{Chronic hypertension}}


{{CMG}}
{{CMG}}; '''Assistant Editor-In-Chief:''' [[User:YazanDaaboul|Yazan Daaboul]], [[User:Sergekorjian|Serge Korjian]]


'''Associate Editor in Chief''': Firas Ghanem, M.D. and Atif Mohammad, M.D.
==Overview==
Patients identified to be hypertensive must have an initial work-up to identify the presence and extent of target organ damage. Initial work-up is important because it recognizes initial baseline values that can aid the patient and the healthcare provider in assessing the evolution of hypertension and its complications with follow-up visits and lab tests. A more extensive work-up is only indicated when hypertension is not controlled with appropriate therapy or initial laboratory testing suggests a specific etiology of secondary hypertension.


{{EH}}
==Laboratory Tests==
Patients identified to be hypertensive must have an initial work-up to identify the presence and extent of target organ damage. Initial work-up is important because it recognizes initial baseline values that can aid the patient and the healthcare provider in assessing the evolution of hypertension and its complications with follow-up visits and lab tests.


==Laboratory Tests==
'''JNC 7 recommends the following routine laboratory tests before initiation of therapy for hypertension:'''<ref name="pmid16512265">{{cite journal| author=Cuddy ML| title=Treatment of hypertension: guidelines from JNC 7 (the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 1). | journal=J Pract Nurs | year= 2005 | volume= 55 | issue= 4 | pages= 17-21; quiz 22-3 | pmid=16512265 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16512265 }} </ref>
===Investigations commonly performed in newly diagnosed hypertension===
 
Tests are undertaken to identify possible causes of secondary hypertension, and seek evidence for end-organ damage to the heart itself or the eyes (retina) and kidneys. Diabetes and raised cholesterol levels being additional risk factors for the development of cardiovascular disease are also tested for as they will also require management.
* 12-Lead electrocardiogram (ECG)
* Urinalysis, including urinary albumin excretion or albumin/creatinine ratio
* Blood glucose
* Blood hematocrit
* Serum electrolytes, especially potassium
* Serum calcium
* Lipid profile: Total cholesterol, LDL, HDL, triglycerides
* Creatinine or equivalent to assess estimated GFR
 
A more extensive work-up is only indicated when hypertension is not controlled with appropriate therapy or initial laboratory testing suggests a specific etiology of hypertension.
 
===Diagnostic Tests for Secondary Hypertension===
Below is a table summarizing the diagnostic tests used in the case of secondary hypertension:<ref name="pmid12748199">{{cite journal| author=Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL et al.| title=The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. | journal=JAMA | year= 2003 | volume= 289 | issue= 19 | pages= 2560-72 | pmid=12748199 | doi=10.1001/jama.289.19.2560 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12748199}}</ref>


[[Blood test]]s commonly performed include:
{|border="1" style="border-collapse:collapse; text-align:left; font-size:120%;" cellpadding="5" align="center" width="900px"
* [[Creatinine]] ([[renal function]]) - to identify both underlying renal disease as a cause of hypertension and conversely hypertension causing onset of kidney damage. Also a baseline for later monitoring the possible side-effects of certain antihypertensive drugs.
| bgcolor="#67e1ff"|'''Etiology'''||bgcolor="#67e1ff"|'''Diagnostic Tests'''
* [[Electrolyte]]s ([[sodium]], [[potassium]])
|-
* [[Glucose]] - to identify [[diabetes mellitus]]
| bgcolor="#f3f3f3"|White coat hypertension
* [[Cholesterol]]
| 24-hour holter monitoring
|-
| bgcolor="#f3f3f3"|Chronic kidney disease
| Serum creatinine, urinalysis, urinary spot albumin, 24 hour urine collection for creatinine and albumin, renal ultrasound, renal biopsy
|-
| bgcolor="#f3f3f3"|Coarctation of aorta
| CT angiography
|-
| bgcolor="#f3f3f3"|Cushing's syndrome
| 24-hour urinary cortisol excretion, low-dose dexamethasone suppression test, late evening serum or salivary cortisol, and CRH after dexamethasone test
|-
| bgcolor="#f3f3f3"|Drug induced/related hypertension
| History, Drug/toxicology screening
|-
| bgcolor="#f3f3f3"|Pheochromocytoma
| 24 hour plasma free metanephrines and urinary fractionated metanephrines
|-
| bgcolor="#f3f3f3"|Primary aldosteronism and other mineralocorticoid excess states
| Ratio of plasma aldosterone to plasma renin activity, 24-hour urinary aldosterone levels
|-
| bgcolor="#f3f3f3"|Renovascular hypertension (Renal artery stenosis)
| Doppler flow study, Magnetic resonance angiography
|-
| bgcolor="#f3f3f3"|Sleep apnea
| Polysomnography
|-
| bgcolor="#f3f3f3"|Thyroid/Parathyroid disease
| TSH, Free T3/T4,PTH
|}


Additional tests often include:
==2013 ESH/ESC Guidelines For The Management of Arterial Hypertension (DO NOT EDIT)<ref name="pmid23771844">{{cite journal| author=Authors/Task Force Members. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A et al.| title=2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2013 | volume= 34 | issue= 28 | pages= 2159-219 | pmid=23771844 | doi=10.1093/eurheartj/eht151 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23771844  }} </ref>==
* Testing of urine samples for [[proteinuria]] - again to pick up underlying kidney disease or evidence of hypertensive renal damage.


== Laboratory Findings ==  
===Search for Asymptomatic Kidney Diseases (DO NOT EDIT)<ref name="pmid23771844">{{cite journal| author=Authors/Task Force Members. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A et al.| title=2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2013 | volume= 34 | issue= 28 | pages= 2159-219 | pmid=23771844 | doi=10.1093/eurheartj/eht151 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23771844  }} </ref>===
* [[Urinalysis]]
{|class="wikitable" align="center" width="900px"
* [[Glucose]]
|-
* [[Blood urea nitrogen]] ([[BUN]]) / [[creatinine]]
| colspan="1" style="text-align:center; background:LightGreen"|[[EHS ESC guidelines classification scheme#Classification of Recommendations|Class I]]
* Basic metabolic panel
|-
* [[Calcium]]
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1. '''Measurement of serum [[creatinine]] and estimation of [[GFR]] is recommended in all hypertensive patients. ''([[EHS ESC guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
* [[Lipid]]s
|-
* Urinary [[albumin]]
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2. '''Assessment of urinary protein is recommended in all hypertensive patients by dipstick. ''([[EHS ESC guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
* [[Glomerular filtration rate]]
|-
=== Electrolyte and Biomarker Studies ===
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3. '''Assessment of [[microalbuminuria]] is recommended in spot urine and related to urinary [[creatinine]] excretion. ''([[EHS ESC guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
* [[Electrolyte]]s
|}
=== [[Electrocardiogram]] ===
* ECG to make accurate diagnosis
=== Echocardiography or Ultrasound ===
* [[Echocardiogram]] for diagnosis
===MRI or CT===
* see [[Cardiac MRI]] in [[Hypertension]]


==References==
==References==
{{reflist|2}}
{{reflist|2}}
[[Category:Cardiology]]
{{WH}}
{{WH}}
{{WS}}
{{WS}}
[[Category:Aging-associated diseases]]
[[Category:Cardiology]]
[[Category:Emergency medicine]]
[[Category:Cardiovascular diseases]]
[[Category:Medical conditions related to obesity]]
[[Category:Nephrology]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date cardiology]]

Latest revision as of 14:03, 17 May 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Assistant Editor-In-Chief: Yazan Daaboul, Serge Korjian

Overview

Patients identified to be hypertensive must have an initial work-up to identify the presence and extent of target organ damage. Initial work-up is important because it recognizes initial baseline values that can aid the patient and the healthcare provider in assessing the evolution of hypertension and its complications with follow-up visits and lab tests. A more extensive work-up is only indicated when hypertension is not controlled with appropriate therapy or initial laboratory testing suggests a specific etiology of secondary hypertension.

Laboratory Tests

Patients identified to be hypertensive must have an initial work-up to identify the presence and extent of target organ damage. Initial work-up is important because it recognizes initial baseline values that can aid the patient and the healthcare provider in assessing the evolution of hypertension and its complications with follow-up visits and lab tests.

JNC 7 recommends the following routine laboratory tests before initiation of therapy for hypertension:[1]

  • 12-Lead electrocardiogram (ECG)
  • Urinalysis, including urinary albumin excretion or albumin/creatinine ratio
  • Blood glucose
  • Blood hematocrit
  • Serum electrolytes, especially potassium
  • Serum calcium
  • Lipid profile: Total cholesterol, LDL, HDL, triglycerides
  • Creatinine or equivalent to assess estimated GFR

A more extensive work-up is only indicated when hypertension is not controlled with appropriate therapy or initial laboratory testing suggests a specific etiology of hypertension.

Diagnostic Tests for Secondary Hypertension

Below is a table summarizing the diagnostic tests used in the case of secondary hypertension:[2]

Etiology Diagnostic Tests
White coat hypertension 24-hour holter monitoring
Chronic kidney disease Serum creatinine, urinalysis, urinary spot albumin, 24 hour urine collection for creatinine and albumin, renal ultrasound, renal biopsy
Coarctation of aorta CT angiography
Cushing's syndrome 24-hour urinary cortisol excretion, low-dose dexamethasone suppression test, late evening serum or salivary cortisol, and CRH after dexamethasone test
Drug induced/related hypertension History, Drug/toxicology screening
Pheochromocytoma 24 hour plasma free metanephrines and urinary fractionated metanephrines
Primary aldosteronism and other mineralocorticoid excess states Ratio of plasma aldosterone to plasma renin activity, 24-hour urinary aldosterone levels
Renovascular hypertension (Renal artery stenosis) Doppler flow study, Magnetic resonance angiography
Sleep apnea Polysomnography
Thyroid/Parathyroid disease TSH, Free T3/T4,PTH

2013 ESH/ESC Guidelines For The Management of Arterial Hypertension (DO NOT EDIT)[3]

Search for Asymptomatic Kidney Diseases (DO NOT EDIT)[3]

Class I
"1. Measurement of serum creatinine and estimation of GFR is recommended in all hypertensive patients. (Level of Evidence: B)"
"2. Assessment of urinary protein is recommended in all hypertensive patients by dipstick. (Level of Evidence: B)"
"3. Assessment of microalbuminuria is recommended in spot urine and related to urinary creatinine excretion. (Level of Evidence: B)"

References

  1. ↑ Cuddy ML (2005). "Treatment of hypertension: guidelines from JNC 7 (the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 1)". J Pract Nurs. 55 (4): 17–21, quiz 22-3. PMID 16512265.
  2. ↑ Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL; et al. (2003). "The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report". JAMA. 289 (19): 2560–72. doi:10.1001/jama.289.19.2560. PMID 12748199.
  3. ↑ 3.0 3.1 Authors/Task Force Members. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A; et al. (2013). "2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC)". Eur Heart J. 34 (28): 2159–219. doi:10.1093/eurheartj/eht151. PMID 23771844.

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