What is the appropriate initial evaluation for individuals with hypertension?
In the absence of end organ damage, care should be taken to ensure the patient has sustained elevations in BP. This is particularly important in geriatric patients who are prone to white-coat hypertension and high BP variability due to high sodium intake. Young people, including pregnant women, should be closely evaluated given the lifelong implications of treatment and potential adverse fetal effects of antihypertensive therapy. Home BP readings are an excellent source of collateral information, but 24-hour ambulatory BP monitoring also can be performed.
Once sustained hypertension is documented, easily correctable causes of hypertension should be sought. The key to this is to evaluate for secondary causes of hypertension, the most common of which is primary hyperaldosteronism. Thus, one should ask about a history of hypokalemia that did not easily correct with supplements. Lifestyle factors, such as a high-salt diet, are a common cause of hypertension and can produce hypokalemia, although this is easily correctable with potassium supplements and low-sodium diet. Excessive alcohol intake, physical inactivity, and sleep/obstructive sleep apnea are important lifestyle issues to note as well, and they contribute to resistant hypertension. Common medications with hypertensive effects include nonsteroidal antiinflamatory drugs, oral contraceptives, stimulants, and perhaps decongestants and herbal supplements. Obesity, while a modifiable risk factor, is usually difficult for the patient to correct.
Traditional “secondary” causes, such as Cushing disease, primary hyperaldosteronism (most common cause), pheochromocytoma, thyroid disease, and renal artery stenosis, should be evaluated based on clinical suspicion. Finally, it should be standard practice to check the patient’s electrolyte levels, kidney function, and urine for albumin; assays for cholesterol and impaired glucose tolerance serve to further stratify the patient’s overall CV risk.