Patients with a new diagnosis of hypertension should be evaluated with a history and physical exam and the following initial studies: serum potassium and creatinine, fasting serum glucose and lipid panel, hematocrit, urinalysis, and electrocardiogram (strength of recommendation [SOR]: C, based on a consensus of expert opinion). Consensus is lacking for measuring serum sodium, calcium, and uric acid. Testing for microalbuminuria is optional in the work-up for a patient without diabetes (SOR: C, expert consensus). Some expert panels list limited echocardiography as another option

Daniel, Brett V.

Jankowski, Terry Ann, 1951-

Kelsberg, Gary

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VOL 54, NO 9 / SEPTEMBER 2005 809w w w. j f p o n l i n e . c o mCLINICAL INQUIRIESWhat is the initial work-up in the diagnosis of hypertension?■ Evidence summaryThere are currently no large outcome studies evaluating the initial work-up ofhypertension; however, 4 internationalexpert panels have published recommen-dations.2–5 These panels advise 3 initialobjectives: 1) assess lifestyle and identifyother cardiovascular risk factors or concomitant disorders that may affectprognosis and guide treatment; 2) searchfor treatable causes of high blood pressure;and 3) assess for the presence of targetorgan damage that would change the management of the patient (such as chron-ic kidney disease or heart disease). In addition to a thorough history andphysical, the following studies are recom-mended for patients with newly diagnosedhypertension:Serum potassium and creatinine. All 4 panels recommend measuring serumpotassium and creatinine in order to: 1)monitor the effects of diuretics andangiotensin-converting enzyme (ACE)inhibitors used in hypertension therapy, 2)screen for unexplained hypokalemia thatmay indicate a low-renin form of hyper-tension, 3) calculate baseline creatinineclearance, and 4) screen for chronic kidneydisease. Fasting blood glucose. All 4 panels recommend measuring a fasting glucoselevel to screen for diabetes. An abnormalglucose level may also reveal glucose intol-erance, one of the diagnostic criteria ofmetabolic syndrome. Up to 60% of patientswith diabetes also have hypertension.6Fasting lipid panel. All 4 expert panelsBrett V. Daniel, MD, Gary Kelsberg, MDValley Family Medicine Residency, Renton, WashTerry Ann Jankowski, MLSUniversity of Washington, SeattlePatients with a new diagnosis of hypertensionshould be evaluated with a history and physicalexam and the following initial studies: serumpotassium and creatinine, fasting serum glucoseand lipid panel, hematocrit, urinalysis, and electrocardiogram (strength of recommendation[SOR]: C, based on a consensus of expert opinion). Consensus is lacking for measuringserum sodium, calcium, and uric acid. Testing for microalbuminuria is optional in the work-up for a patient without diabetes(SOR: C, expert consensus). Some expert panels list limited echocardiography as another option.E V I D E N C E - B A S E D A N S W E RNot all recommendations for working-up hypertensive patients are cost-effectiveThere is obvious enthusiasm among the expertpanels for a detailed workup of patients withhypertension. But are the recommendations cost-effective? Annual urine dipstick testingbeginning at age 30 for hypertensive patients ishighly cost-effective. Identification of proteinuriaand treatment with an ACE inhibitor orangiotensin receptor blocker prevents the progression of renal disease at a quality-adjustedlife-year cost of $15,484 to $26,320, depending onthe age group.1 Unfortunately, evaluation for secondary causes of hypertension, screening forLVH, and ruling out comorbidities have not beenexplicitly evaluated for cost-effectiveness.Brian Crownover, MD, FAAFP96th Medical Group, Family Medicine Residency, Eglin Air Force Base, Eglin, FlaC L I N I C A L C O M M E N T A R Y810 VOL 54, NO 9 / SEPTEMBER 2005  THE JOURNAL OF FAMILY PRACTICECLINICAL INQUIRIESrecommend screening for dyslipidemia witha fasting lipid panel to assess cardiovascularrisk. A cohort study evaluating 356,222men aged 35 to 57 years found a continu-ous, positive, graded correlation betweenplasma cholesterol levels and coronary risk.7Hematocrit. All 4 panels recommend ahematocrit to screen for anemia, whichmay be due to chronic kidney disease.Urinalysis. All 4 panels recommend aurinalysis to screen for renal disease.Electrocardiogram (ECG). All 4 panelsrecommend an ECG to screen for findingsassociated with hypertension, includingleft ventricular hypertrophy (LVH),myocardial infarction, and rhythm abnor-malities. A cohort study followed 2363patients for 14 years who had untreatedhypertension and were without pre-exist-ing cardiovascular disease. After control-ling for age, sex, diabetes, and mean bloodpressure, LVH by ECG conferred a signifi-cant increased risk for cerebrovascularevents (relative risk=1.79; 95% confidenceinterval [CI], 1.17–2.76).8 However, in acohort of 4684 subjects from theFramingham Heart Study, ECG had a sen-sitivity of only 6.9% for the detection ofLVH (specificity 98.8%; positive likeli-hood ratio=5.3; negative likelihoodratio=0.94).8Echocardiography. Two panels3,4 andan online text10 recommend echocardiog-raphy, preferably limited echo, as anoptional study. A systematic review ofstudies comparing the sensitivities andspecificities of ECG and echo found thateach was highly specific for the detectionof LVH (77%–97%), but the sensitivity ofechocardiography (88%–93%) exceededthat of ECG (21%–54%). However, LVHdetected by ECG is a better predictor ofcardiovascular complications.11 Becauseechocardiography may help assess diseaseduration and guide management, bothpanels recommend it for patients withsevere or refractory hypertension but without other target organ damage. Microalbuminuria. All panels listedmicroalbuminuria testing as an optionalstudy for patients without diabetes becauseof its association with an increased inci-dence of cerebrovascular disease.12 It isunclear whether microalbuminuria resultsfrom the increased intraglomerular pres-sure in hypertension or if it representsglomerular damage.13Sodium, calcium, uric acid. There is noconsensus on the routine inclusion of sever-al studies: serum sodium (recommended by2 panels and an online text4,5,10), serum cal-cium (recommended by 1 panel and thetext2,10), and uric acid (1 panel3 recom-mends it while the text10 lists it as optional). Recommendations from othersRecommendations from major organiza-tions are included in Evidence Summary,above.R E F E R E N C E S1. Boulware LE, Jaar BG, Tarver-Carr ME, Brancati FL,Powe NR. Screening for proteinuria in US adults. A cost-effective analysis. JAMA 2003; 290:3101–3114. 2. Chobanian AV, Bakris GL, Black HR, et al. Seventhreport of the Joint National Committee on Prevention,Detection, Evaluation, and Treatment of High BloodPressure. Hypertension 2003; 42:1206–1252.3. 2003 European Society of Hypertension-EuropeanSociety of Cardiology guidelines for the managementof arterial hypertension. J Hypertens 2003;21:1011–1053.4. Hemmelgarn BR, Zarnke KB, Campbell NRC, et al. The2004 Canadian Hypertension Education Program rec-ommendations for the management of hypertension:Part I—Blood pressure measurement, diagnosis andassessment of risk. Can J Cardiol 2004; 20:31–40.5. Institute for Clinical Systems Improvement (ICSI).Hypertension Diagnosis and Treatment. Bloomington,Minn: ICSI; 2004. 6. Arauz-Pacheco C, Parrott MA, Raskin P. The treatmentof hypertension in adult patients with diabetes.Diabetes Care 2002; 25:134–147.7. Stamler J, Wentworth D, Neaton JD. Is relationshipbetween serum cholesterol and risk of prematuredeath from coronary heart disease continuous andgraded? Findings in the 356,222 primary screenees ofthe Multiple Risk Factor Intervention Trial (MRFIT).JAMA 1986; 256:2823–2828.8. Verdecchia P, Porcellati C, Ambrosio G, et al. LeftVentricular Hypertrophy as an independent predictorof acute cerebrovascular events inessential hyperten-sion. Circulation 2001; 104:2039–2044.9. Levy D, Labib SB, Anderson KM, Christiansen JC,Kannel WB, Castelli WP. Determinants of sensitivityand specificity of electrocardiographic criteria for leftventricular hypertrophy. Circulation 1990; 81:815–820. 10. Kaplan, NM. Initial evaluation of the hypertensivepatient. UpToDate Monograph. Available atwww.uptodate.com. 11. Dijkstra RF, van Schayck CP, Bakx JC, Thien T, VerheugtFW, Mokkink HG. Left ventricular hypertrophy; differ-ences in the diagnostic and prognostic value of elec-LVH detected by ECG better predicts CV complicationsthan LVH detected byechocardiography FAST TRACKtrocardiography and echocardiography. Ned Tijdschr Geneeskd1997; 141:1969–1972.12. Gerstein HC, Mann JF, Yi Q, Yusuf S, et al. Albuminuria and risk ofcardiovascular events, death, and heart failure in diabetic and non-diabetic individuals. JAMA 2001; 286:421–426.13. Rosa TT and Palatini P. Clinical value of microalbuminuria in hyper-tension. J Hypertens 2000; 18:645–654.A C K N O W L E D G M E N T SThe opinions and assertions contained herein are the private views of theauthor and are not to be construed as official, or as reflecting the viewsof the US Air Force Medical Service or the US Air Force at large. 812 THE JOURNAL OF FAMILY PRACTICECLINICAL INQUIRIESWhat are Clinical Inquiries?Clinical Inquiries answer recent questions from the practices of family physicians.  Practicing family physicianschoose the most relevant questions submitted through aweb-based voting system operated by the Family PhysiciansInquiries Network (FPIN; online at www.fpin.org). FPIN is national, not-for-profit consortium of family medicine departments, community residency programs, aca-demic health sciences libraries, primary care practice-basedresearch networks, and other specialists. Once questions areselected, FPIN editors then organize teams of clinicians andlibrarians to answer them based on systematic review of theworld literature. Answers are developed through an explicit,systematic method:❚ FPIN librarians and editors identify questions recentlyanswered in best evidence sources (e.g. Cochrane Reviews,Clinical Evidence, the US Preventive Services Task Force,Evidence Based Guidelines, a published systematicreview).❚ FPIN librarians then conduct systematic and standardized literature searches of best evidence sources,Medline, and other databases in collaboration with an FPINclinician or clinicians. If a best evidence source has beenidentified, the search begins from the date of the searchconducted for that source. Otherwise, the searches are comprehensive. ❚ FPIN clinician authors then choose the highest quality original research sources, and critically appraise theresearch and integrate the findings in the Evidence BasedAnswer and Evidence Summary section of ClinicalInquiries. Authoritative sources are also quoted in the“Recommendations from Others” section of the ClinicalInquiry.❚ Each Clinical Inquiry is reviewed by 4 or more peers or editors before publication in JFP.❚ FPIN medical librarians are accountable for the thoroughnessof the literature search, for recording the databasessearched, search hedges used and the search terms.  The details of each search is available to any interestedreader (contact managingeditor@fpin.org).❚ Finally, a practicing family physician or other clinicianwrites an accompanying commentary to provide a clinicalperspective.Issues in Patient ManagementA Roundtable DiscussionThis supplement is supported by a grant from Procter & Gamble.■ Goutham Rao, MD, Roundtable ChairAssistant Editor, The Journal of Family PracticeAssociate Professor, PediatricsUniversity of Pittsburgh School of MedicineClinical Director, Weight Management & Wellness CenterChildren’s Hospital of PittsburghDirector, Medical InformaticsUPMC St. Margaret Family Medicine ResidencyPittsburgh, Pennsylvania■ Richard H. Davis, Jr, PA-CSenior Physician AssistantDivision of GastroenterologyUniversity of FloridaGainesville, Florida■ David A. Peura, MDProfessor of MedicineAssociate Chief, Division of GastroenterologyUniversity of Virginia Health Sciences CenterCharlottesville, Virginia■ Wendy L. Wright, MS, RN, ARNP, FNPAdjunct FacultyFay W. Whitney School of NursingUniversity of WyomingLaramie, WyomingFamily Nurse PractitionerBedford, New HampshireFAMILYPRACTICETHE JOURNAL OFFacultyLook for this supplement at www.jfponline.comHeartburn

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