A 50-year-old woman presents to the clinic after a high blood pressure reading of 165/85 mm Hg at a health fair. Past medical history is significant for hypothyroidism which is treated with levothyroxine. She does not smoke cigarettes or drink alcohol. She walks 30 minutes every day. Her father died at age 70 from myocardial infarction. Her blood pressure at this visit is 150/90 mm Hg. She has a body mass index (BMI) of 26. Physical examination is unremarkable. She is instructed to measure her blood pressure at home, and over the next 2 weeks confirms that her blood pressure is consistently elevated.
Which of the following is the most appropriate next step in management of this patient?
C) Electrocardiogram, CBC, thyroid stimulating hormone, chemistry panel, lipid panel, and urinalysis
The initial evaluation of hypertension is directed at identifying complications of hypertension or comorbid conditions that might influence management. Baseline assessment should include a serum chemistry panel (including electrolytes, fasting blood glucose, and creatinine) and hemoglobin/hematocrit, urinalysis to exclude hematuria and evaluate for proteinuria, and an electrocardiogram to screen for left ventricular hypertrophy or prior myocardial infarction. Some experts advise measuring serum TSH because thyroid disorders are common and increase the risk for hypertension. In addition, patients with hypertension are at increased risk for ischemic heart disease and should be screened for other major atherosclerotic risk factors. A lipid panel is recommended, and patients should be screened for diabetes mellitus with either fasting blood glucose, which may be obtained as part of a standard serum chemistry panel, or hemoglobin A1c.
Answer choice A: 24-hour urine cortisol and plasma fractionated metanephrines, is incorrect. A. 24-hour urine cortisol and plasma fractionated metanephrines are used for diagnosing secondary causes of hypertension such as Cushing syndrome or pheochromocytoma. They are not part of the initial workup for a patient with primary hypertension.
Answer choice B: Echocardiogram, HbA1C, thyroid stimulating hormone, and urine albumin/creatinine ratio, is incorrect. An echocardiogram is not routinely performed in the initial evaluation unless there are specific indications of cardiac disease. Though a urinary albumin/creatinine ratio can detect albuminuria which is recognized as an independent risk factor for cardiovascular disease, this test is not routinely indicated in the initial evaluation of hypertension.
Answer choice D: Plasma renin activity, fractionated metanephrines, and aldosterone levels, is incorrect. Plasma renin activity, fractionated metanephrines, and aldosterone levels are indicated for evaluating secondary causes of hypertension, such as hyperaldosteronism and pheochromocytoma, but are not necessary for the initial evaluation of uncomplicated primary hypertension.
Answer choice E: Renal ultrasound and magnetic resonance angiogram of the renal arteries, is incorrect. Renal ultrasound and magnetic resonance angiogram (MRA) of renal arteries are used for diagnosing renovascular hypertension (e.g., renal artery stenosis) and are not part of the routine initial evaluation for primary hypertension.
Key Learning Point
The initial evaluation of newly diagnosed hypertension evaluation aims to identify complications and comorbidities. It includes an ECG, CBC, TSH, serum chemistry panel, lipid panel, and urinalysis to guide treatment decisions by assessing cardiovascular and metabolic health.
