Hypertension Initial Assessment

Last updated: 28 October 2025
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History

During the primary care visit, it is important to take a good history and physical examination. History should be taken with an emphasis on hypertension, diabetes mellitus, dyslipidemia, premature coronary heart disease, stroke, or renal disease.  

The level and duration of elevated BP, the usual range of BP, current or past antihypertensive medications, and history of adherence to treatment should all be known.  

Symptoms of secondary causes of hypertension (eg sweating, headache, and palpitations in pheochromocytoma; muscle weakness and tetany in hyperaldosteronism; hypersomnolence and snoring in obstructive sleep apnea; heat intolerance, weight loss, and palpitations in hyperthyroidism; fatigue, edema, and frequent urination in kidney disease or failure) should also be noted.  

Lifestyle and environmental evaluation should be done. It includes dietary intake of fat, salt and alcohol, physical activity, smoking status, weight gain since young adulthood. Medication history of prescribed and over-the-counter medications, use of herbal supplements and illicit drugs should also be taken into account in history taking.  

Any history or current symptoms of target organ damage (eg coronary heart disease, cerebrovascular disease, cognitive dysfunction) should be taken note of since the association between BP and CVD in Asians is stronger than in Westerners with stroke (eg hemorrhagic stroke). Nonischemic heart failure is a common end result of hypertension-related CVD.  

The history or current symptoms of concomitant diseases (eg diabetes mellitus, renal diseases, gout, urinary tract infection, thyroid disease, etc.) which may affect prognosis should also be noted in the history. Family history of high BP or hypertension, stroke, diabetes, CVD, coronary heart disease, renal disease, and dyslipidemia should also be known. History of hypertension in pregnancy or pre-eclampsia should be sought.  

Other important information that should be obtained during history-taking occupational history such as frequent travels or long trips, time changes, medication schedule, prevention of complications, and many more. 

Physical Examination

A complete physical examination should be done which includes:

  • Appropriate BP measurement with verification on the contralateral arm
  • Calculation of body mass index (BMI) and waist circumference since the risk for metabolic syndrome or for type 2 diabetes mellitus is high when the waist circumference is >102 cm in men or >88 cm in women
  • Heart rate (patient at rest) to search for arrhythmias, respiratory rate, and temperature
  • Examination of optic fundi
  • Auscultation for carotid, abdominal, and femoral bruits
  • Thorough examination of the heart and lungs; palpation of the thyroid gland
  • Examination of the abdomen for truncal obesity, enlarged kidneys, masses, distended urinary bladder, and abnormal aortic pulsation
  • Palpation of the lower extremities for edema and pulses (ankle-brachial index [ABI])
  • Neurological and mental status assessment

Screening

Clinical or Office BP Measurement  

BP is measured at least annually in individuals who are ≥18 years old but more frequently in those at moderate or high risk of vascular diseases.  

The patient should be seated comfortably for >5 minutes in a chair, with back supported, feet on the floor, and arm supported at heart level prior to measurement of blood pressure. The measurement of BP in the standing position is recommended for patients at risk of postural hypotension, patients with diabetes, and at the first visit of elderly patients.  

A cuff with a bladder of 12-13 cm wide and 35 cm long should be used and placed at the heart level of the patient. Wider cuffs (>32 cm circumference) are needed for large arms whereas smaller cuffs (<26 cm circumference) are for thin arms1. The bladder length should encircle at least 75-100% of the arm while the width should be at least 35-50% of the arm circumference. 

Using a validated oscillometric BP device, two to three measurements should be taken, spaced by 1-2 minutes. Take the measurements from sitting, lying, and standing (usually after 1 minute) positions to take note of drops in BP. A difference of >10 mmHg between the two arms suggests arterial stenosis and requires further investigation.
 
Use the appearance of the phase I Korotkoff sounds for systolic BP (SBP) and the disappearance of phase V for diastolic BP (DBP).  

1Please also refer to the Recommended Cuff Sizes table under Non-pharmacological Therapy.

Hypertension_Initial AssesmentHypertension_Initial Assesment



Confirmation of Hypertension  

In general, the diagnosis of hypertension is confirmed by taking the BP 1-4 weeks after the first measurement or the average of readings on ≥2 occasions or visits. A substantially elevated BP requires a shorter interval between visits, depending on the degree of BP elevation, and the presence of CVD or target organ damage. 

Out-of-Office BP Measurement  

Out-of-office BP measurement is recommended for the confirmation of hypertension diagnosis. It may also be used to measure BP in patients with increased CVD risk with screening office BP of 120-139/70-89 mmHg.

Ambulatory BP Monitoring (ABPM) uses a fully automated BP device which measures the patient’s BP at regular intervals over a 24-hour period. It is considered the de facto reference standard for out-of-office BP monitoring as it has stronger evidence linking it to CVD events compared with home BP monitoring (HBPM). Its advantages include the detection of masked (high BP only in home/ambulatory settings) or white coat (high BP only in the office) hypertension, determination of nocturnal BP patterns, identification of early-morning BP surge pattern, estimation of BP variability, allowing the recognition of hypotension, confirmation of borderline hypertension or abnormal HBPM results, and evaluation of the impact of antihypertensive treatments. It is the preferred method for ruling out white coat hypertension and masked hypertension in individuals not on antihypertensive medication. 

HBPM is the self-measurement of BP for over 5-7 days, possibly in duplicate measurements. It is useful in improving hypertension awareness, improving diagnostic accuracy, determining CV risk in patients with hypertension, evaluating treatment efficacy, monitoring drug titration, and improving treatment compliance and adherence. It is the basis for initiating and adjusting BP control treatment in telemedicine. It improves rates of BP control when combined with frequent interactions with multidisciplinary team members. It may also be used to screen for masked or white coat hypertension. It is also the preferred method for ruling out a white coat effect and masked uncontrolled hypertension in individuals on antihypertensive medication. Its main disadvantages are the possible errors in measurement and that there are no nocturnal BP readings. 

In Asians, out-of-office BP management includes focusing initially on the morning BP and then the nocturnal BP. Morning hypertension refers to a BP of ≥135/85 for both ABPM and HBPM in the morning period (between 6-10 AM) regardless of the BP taken during the rest of the day. It confers CV risk independent of the 24-hour ambulatory BP. It may be controlled with the use of long-acting antihypertensive agents given in appropriate, often in full doses, and in proper combinations. Bedtime dosing may be considered if morning BP is not controlled. The detection and management of masked and masked uncontrolled hypertension are important parts of hypertension treatment.  

BP LEVELS DEFINING HYPERTENSION
Category 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM* 2024 ESH**
SBP (mmHg) and/or DBP (mmHg) SBP (mmHg) and/or DBP (mmHg)
Clinic/Office BP ≥130 ≥80 ≥140 ≥90
Daytime ABPM ≥130 ≥80 ≥135 ≥85
Nighttime ABPM ≥110 ≥65 ≥120 ≥70
24-hour ABPM ≥125 ≥75 ≥130 ≥80
Home BP ≥130 ≥80 ≥135 ≥85
*Reference: 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults.
**Reference: 2024 ESC Guidelines for the management of elevated blood pressure and hypertension.

 
Presence of Secondary Cause or Evidence of Target Organ Damage

It must be noted that majority of hypertension cases have no known cause, ie primary or essential hypertension. Consider screening for secondary hypertension in patients who have an abrupt development of hypertension, early-onset hypertension in patients <30 years old, onset of BP of ≥160/100 mmHg in patients <40 years old, an onset of diastolic hypertension in patients ≥65 years old, hypertension that is either drug-resistant, accelerated or malignant, suboptimal treatment response, worsening hypertension, exacerbation of a previously controlled hypertension, a target organ damage that is out of proportion to the degree of hypertension, and excessive or unprovoked hypokalemia, insomnia or daytime sleepiness, concomitant adrenal nodule, history of early-onset stroke, family history of primary aldosteronism, and acute worsening of BP control in pregnant women with pre-existing hypertension. For adults with an indication for primary aldosteronism screening, continuation of most antihypertensive medications (except for mineralocorticoid receptor antagonists [MRAs]) before initial testing is recommended to reduce barriers or delays in screening. These patients should be referred to a specialist and treated appropriately if a secondary cause of hypertension is found. Consider optimizing or intensifying the patient’s antihypertensive treatment if screening test is negative for secondary hypertension. Further tests should likewise be done if target organ damage is found to evaluate the level of its severity.