Hypertension Evaluation Labs

Aka: Hypertension Evaluation Labs, Hypertension Diagnostic Testing

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II. Labs: General for All Patients

  1. Urinalysis
  2. Complete Blood Count (Hemoglobin or Hematocrit minimum)
  3. Fasting lipid profile
    1. Non-Fasting LDL Cholesterol may be sufficient initially
    2. However, high Fasting Serum Triglyceride levels (with low HDL Cholesterol) may suggest Metabolic Syndrome
  4. Basic Metabolic Panel (Chem8, SMA7)
    1. Serum Glucose
      1. Fasting Glucose is preferred (esp. if non-Fasting Glucose is abnormal)
      2. Provides a baseline prior to initiating Antihypertensives (e.g. ACE Inhibitor or ARB, Spironolactone, Thiazide Diuretics)
    2. Serum Calcium
    3. Serum Potassium
      1. Consider primary Aldosteronism if Hypokalemia (even borderline low)
    4. Serum Creatinine
      1. With calculated Glomerular Filtration Rate (GFR)
      2. Serum Creatinine increased in Renal Artery Stenosis, Renal Failure, renal parenchymal disease
    5. Blood Urea Nitrogen (BUN)
  5. Electrocardiogram
    1. Left Ventricular Hypertrophy

III. Labs: Optional Studies (as indicated)

  1. Uric Acid
  2. Chest XRay (evaluate for coarctation, heart size)
  3. 24 hour Urine Creatinine
  4. 24 Hour Urine Protein

IV. Evaluation: Secondary Hypertension

  1. Indications
    1. Hypertension Onset under age 30 years (and esp. under age 12) or over age 60 years old
    2. Refractory Hypertension to maximal medical management (especially if previously controlled)
    3. Accelerated Hypertension or Malignant Hypertension
    4. Signs OR symptoms of Secondary Hypertension
  2. Labs
    1. Aortic Coarctation
      1. Arm to leg systolic Blood Pressure difference (abnormal if >20 mmHg)
      2. Chest XRay (notching of the lower rib borders)
      3. Echocardiogram (Children)
      4. MRI Chest (Adults)
    2. Cushing's Disease
      1. 24 hour Urine Cortisol
      2. Late Night Salivary Cortisol
      3. Low dose Dexamethasone Suppression Test
    3. Pheochromocytoma
      1. 24h Urine Metanephrine
      2. Plasma free metanephrines
    4. Renal parenchymal disease
      1. Serum Creatinine
      2. Urine Protein
      3. Urinalysis with microscopic exam
      4. Renal Ultrasound
    5. Renal Artery Stenosis
      1. Serum Creatinine increased at least 50% over baseline after starting ACE Inhibitor or ARB
      2. Renal bruit may be present on exam
      3. Renal artery Doppler Ultrasound (or CT Angiography or MR Angiography)
    6. Primary Aldosteronism (strongly consider if Hypokalemia)
      1. Morning Aldosterone to plasma renin ratio >20-30
      2. Serum Potassium decreased
  3. Age-based testing (in addition to general Hypertension labs as above)
    1. Age under 18 years old (renal parenchymal disease, Aortic Coarctation)
      1. Arm to leg systolic Blood Pressure difference (abnormal if >20 mmHg)
      2. Chest XRay
      3. Urinalysis and Urine Culture
      4. Renal Ultrasound
      5. Echocardiogram
      6. Consider Thyroid Stimulating Hormone (TSH)
    2. Age 19 to 39 years old (Thyroid dysfunction, Renal Artery Stenosis due to fibromuscular dysplasia)
      1. Thyroid Stimulating Hormone (TSH)
      2. Renal artery Doppler Ultrasound (or CT Angiography or MR Angiography)
      3. Echocardiogram
      4. Consider 24 hour Urine Cortisol
      5. Consider 24h Urine Metanephrine
    3. Age 40 to 64 years old (Hyperaldosteronism, Sleep Apnea, Cushing Syndrome, Pheochromocytoma)
      1. Thyroid Stimulating Hormone (TSH)
      2. Morning Aldosterone to plasma renin ratio (abnormal if >20-30)
      3. Consider Sleep Study for Obstructive Sleep Apnea
      4. 24 hour Urine Cortisol
      5. 24h Urine Metanephrine
    4. Age 65 years old and older (Atherosclerotic Renal Artery Stenosis, Renal Failure)
      1. Thyroid Stimulating Hormone (TSH)
      2. Urinalysis
      3. Renal Artery Stenosis imaging (renal artery Doppler Ultrasound or MRA or CTA)
      4. Consider 24 hour Urine Cortisol
      5. Consider 24h Urine Metanephrine

V. References

  1. Charles (2017) Am Fam Physician 96(7): 453-61 [PubMed]

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