Hypertension
Diagnosis confirmation, baseline workup, and first-line management steps.
Last reviewed January 5, 2026
Red flags
- Symptoms of hypertensive emergency (chest pain, neurologic deficit, acute dyspnea, vision changes).
- Rapid-onset or severe hypertension in pregnancy.
Diagnosis
- Confirm elevated blood pressure with standardized office technique and out-of-office readings (home or ambulatory).
- The 2025 primary-care definition is BP at least 130/80 mmHg; do not confuse the diagnostic threshold with the threshold for medication.
- Assess cardiovascular risk factors and review potential secondary causes.
Initial workup
- Baseline labs: electrolytes, creatinine/eGFR, fasting lipids, A1C, and urinalysis.
- ECG if long-standing hypertension or symptoms suggest target-organ effects.
- Document ASCVD risk and baseline complications (LVH, CKD, retinopathy).
First-line management
- Lifestyle: sodium reduction, DASH-style eating, weight management, exercise, limit alcohol.
- When medication is indicated, use the 2025 guideline's initial low-dose two-drug approach when appropriate; tailor to comorbidities and tolerability. Do not combine ACEi and ARB.
- Start medication at BP at least 140/90, or systolic 130-139 with high cardiovascular risk; aim for systolic below 130 if tolerated.
- Titrate every 4-6 weeks and re-check renal function and potassium after changes.
Referral triggers
- Resistant hypertension despite 3 agents including a diuretic.
- Suspected secondary hypertension, advanced CKD, or complex comorbidities.
References
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