Hypertension Workup & Cardiovascular Risk (ISH 2026)
Assess total cardiovascular (CV) risk in every person with hypertension. Risk decides whether drug treatment starts immediately or after 3 months of lifestyle change.
Step 1 — History (ESSENTIAL)
- Hypertension history: onset, duration, previous BP, hypertensive disorders of pregnancy, previous drugs, side effects, adherence
- Drugs/substances that raise BP: NSAIDs, combined OCP, SNRIs/MAOIs/tricyclics, calcineurin inhibitors, decongestants, stimulants, ADHD drugs, glucocorticoids, EPO, VEGF/tyrosine kinase inhibitors, triptans, liquorice, ephedra, St John's wort, excess caffeine/energy drinks
- CV risk factors (Step 4)
- Symptoms of organ damage: chest pain, breathlessness, palpitations, claudication, oedema, headache, blurred vision, nocturia, haematuria, dizziness
- Symptoms of secondary hypertension (see
ish-htn-resistant-and-secondary)
- Lifestyle: diet, salt, alcohol, smoking, physical activity, sleep
- Family history
Step 2 — Examination (ESSENTIAL)
- Circulation and heart: pulse rate/rhythm, JVP, apex beat, extra heart sounds, basal crackles, oedema, carotid/abdominal/femoral bruits, lower-limb pulses, radio-femoral delay
- Other: enlarged kidneys, neck circumference >40 cm (OSA), enlarged thyroid, BMI and waist circumference
Step 3 — Baseline tests
ESSENTIAL (everyone):
- Blood: sodium, potassium, creatinine with eGFR (2021 CKD-EPI), lipid profile, fasting glucose, uric acid, TSH
- Urine dipstick: protein, blood, glucose
- 12-lead ECG: LVH, ischaemia, arrhythmia
- LVH: Sokolow–Lyon SV1+RV5 ≥35 mm; Cornell voltage SV3+RaVL >28 mm (men) / >20 mm (women); Cornell product >2440 mm·ms
OPTIMAL (when organ damage, comorbidity or secondary hypertension suspected):
- Urine albumin-to-creatinine ratio (UACR) — first-morning spot
- Echocardiography — LVH, systolic/diastolic dysfunction, LA size, aortic root, coarctation (more sensitive than ECG)
- Carotid ultrasound — plaque, stenosis
- Renal/adrenal imaging — parenchymal disease, renal artery stenosis, adrenal mass
- Brain CT/MRI — if neurological symptoms or cognitive decline
- Pulse wave velocity — carotid-femoral >10 m/s (age 50–60) or brachial-ankle >18 m/s (age 60–70) = arterial stiffness
- Ankle-brachial index — <0.90 = peripheral artery disease
- MMSE or clock drawing — cognitive impairment
- Fundoscopy — if suspected hypertensive emergency, and in diabetes
Step 4 — List risk factors, organ damage and established disease
| CV risk factors | HMOD | Established CV/kidney disease |
|---|
| Age ≥55 (men), ≥65 (women) | Heart: LVH (ECG or echo) | Heart: CAD, heart failure, atrial fibrillation |
| Male sex (men > women at age <65) | Kidney: eGFR <60 and/or UACR ≥30 mg/g | Kidney: CKD (eGFR <60 and/or UACR ≥30) |
| Family history of premature CVD | Brain: cognitive decline (MMSE) | Brain: stroke/TIA, vascular dementia |
| BMI ≥30 (lower in Asians) | Arteries: carotid plaque or coronary atherosclerosis (calcium score, angiography); increased arterial stiffness (PWV) | Arteries: peripheral artery disease (ABI <0.90) |
| Diabetes | | |
| Dyslipidaemia (high LDL, TG, low HDL) | | |
| Smoking | | |
| Chronic inflammatory disease | | |
| Psychosocial/socioeconomic factors | | |
| Obstructive sleep apnoea | | |
| Resting heart rate >80/min | | |
| Early-onset menopause | | |
| Hypertensive disorders of pregnancy | | |
| Non-adherence to CV risk factor treatment | | |
Step 5 — Estimate total CV risk
Simplified grid (example for a 60-year-old man; varies with age and sex):
| Elevated BP 130–139/80–89 | Grade 1 140–159/90–99 | Grade 2 ≥160/100 |
|---|
| No risk factors, HMOD or CVD | Low | Low | Moderate–High |
| 1–2 risk factors | Low | Moderate | High |
| ≥3 risk factors or CKD G3a | Moderate | High | High |
| HMOD, CKD G3b–G5, diabetes or CVD | High | High | High |
Better: use a validated, region-appropriate risk score — SCORE2 (Europe), SCORE2-LAC (Latin America), PREVENT (USA), China-PAR, WHO risk charts (non-laboratory version available where cholesterol/glucose aren't measured). These may underestimate risk in South Asian and African populations.
No risk score needed if established CVD or HMOD — already high risk.
OPTIMAL — refine apparently low–moderate risk with: carotid plaque (ultrasound), Lp(a), coronary artery calcium score.
Step 6 — Use the risk to time treatment
| Risk / BP | When to start drugs |
|---|
| CVD, CKD, diabetes, HMOD, BP ≥160/100, or moderate–high risk | Immediately after diagnosis is confirmed |
| Low risk, BP 140–159/90–99 (ESSENTIAL) or 130–159/80–99 (OPTIMAL) | After 3 months of lifestyle change if BP still above threshold |
Then go to ish-htn-treatment-drug-strategy.
Guardrails
- Risk is often underestimated in people who look low–moderate risk — look for organ damage before labelling them low risk
- Finding HMOD reclassifies the patient as high risk — it changes management
- Don't run a risk score in established CVD/HMOD — they are high risk already
- Standard scores underestimate risk in South Asians — keep this in mind for Indian patients
- Advanced vascular tests (PWV, calcium score, carotid ultrasound) only when the result will change management
- Always ask about BP-raising drugs — NSAIDs and OCPs are common, reversible causes
Related MD2SKILL skills
ish-htn-diagnosis-bp-measurement — confirming the diagnosis firstish-htn-treatment-drug-strategy — next stepish-htn-resistant-and-secondary — when to suspect a secondary causeprevent-ascvd-risk-calculator-interpretation, dyslipidemia-cpr-framework-2026 — lipid/ASCVD risk (2026 ACC/AHA)
Source
Stergiou GS, Kario K, Aristizabal D, et al. 2026 International Society of Hypertension Global Hypertension Practice Guidelines. J Hypertens. 2026;44. DOI: 10.1097/HJH.0000000000004451. Sections 4–6; Tables 8, 14; Figure 4.