Clinical evaluation and diagnostic tests for hypertension: 2026 ISH update

Cardiology · Internal Medicine

Hypertension is a major contributor to cardiovascular and kidney disease, and its clinical evaluation extends beyond the confirmation of elevated blood pressure (BP). A comprehensive assessment is required to identify cardiovascular risk factors, detect hypertension-mediated organ damage (HMOD), recognise coexisting conditions and investigate possible secondary causes.[1]The 2026 International Society of Hypertension (ISH) update emphasises an integrated approach involving detailed medical history, physical examination, laboratory investigations and targeted imaging. This evaluation supports individualised risk stratification and helps guide appropriate treatment and follow-up.Medical history and cardiovascular risk assessmentAlthough hypertension is frequently asymptomatic, specific symptoms may indicate HMOD or an underlying secondary cause and should prompt further investigation. A detailed medical and family history should therefore be obtained, covering the onset and duration of hypertension, previous BP readings and any history of hypertensive disorders during pregnancy. Previous antihypertensive medications, adverse effects, treatment adherence and the use of drugs or substances that may elevate BP should also be documentedSymptoms potentially associated with HMOD should be assessed, including chest pain, dyspnoea, palpitations, claudication, peripheral oedema, headache, dizziness, blurred vision, nocturia and haematuria. Features suggestive of secondary hypertension should also be explored. Lifestyle assessment should include dietary patterns, sodium and alcohol consumption, smoking, physical activity and sleep habitsOverall cardiovascular risk should be evaluated by considering conventional risk factors, evidence of HMOD and established cardiovascular or kidney disease.Assessment categoryImportant factors and findingsCardiovascular risk factorsAge ≥55 years in men or ≥65 years in women; male sex before 65 years; premature family history of CVD; obesity (BMI ≥30 kg/m2, with lower thresholds relevant in Asian populations); diabetes; dyslipidaemia; smoking; chronic inflammatory disease; psychosocial and socioeconomic factors; obstructive sleep apnoea (OSA); resting heart rate >80 beats/min; early-onset menopause; hypertensive disorders of pregnancy; and poor adherence to cardiovascular risk-reduction treatment.HMODLeft ventricular hypertrophy (LVH); reduced estimated glomerular filtration rate (eGFR) or increased urinary albumin-to-creatinine ratio (UACR); cognitive decline; carotid plaque or coronary atherosclerosis; and increased arterial stiffness.Established cardiovascular or kidney diseaseCoronary artery disease, heart failure, atrial fibrillation, chronic kidney disease, stroke, transient ischaemic attack, vascular dementia and peripheral artery disease.HMOD may be identified through an eGFR below 60 mL/min/1.73 m2 and/or UACR ≥30 mg/g. Peripheral artery disease may be indicated by an ankle-brachial index below 0.90. These findings, together with conventional risk factors and established disease, should be incorporated into overall cardiovascular risk estimation.Physical examinationA comprehensive physical examination should be performed to identify cardiovascular abnormalities, HMOD and clinical features suggestive of secondary hypertension. The cardiovascular assessment should include pulse rate, rhythm and character, jugular venous pressure, apex beat, additional heart sounds, basal crackles and peripheral oedema. Carotid, abdominal and femoral bruits should be evaluated, while lower-limb pulses should be examined for evidence of peripheral vascular diseaseExamination of other systems should include assessment for enlarged kidneys and thyroid enlargement. Body mass index and waist circumference should be recorded, while a neck circumference greater than 40 cm may suggest an increased likelihood of OSA. These findings can help identify associated metabolic abnormalities and potential contributors to elevated BPLaboratory investigations and electrocardiographyRoutine laboratory investigations are recommended to assess renal function, metabolic risk factors and possible coexisting conditions. A 12-lead electrocardiogram (ECG) should also be obtained to identify cardiac abnormalities associated with hypertension.InvestigationParameters assessedClinical relevanceBlood testsSodium, potassium, serum creatinine and eGFR (calculated using the 2021 CKD-EPI equation)Evaluation of electrolyte balance and kidney functionMetabolic assessmentLipid profile and fasting glucoseIdentification of dyslipidaemia and diabetesAdditional blood testsUric acid and thyroid-stimulating hormone (TSH)Assessment of associated metabolic and thyroid abnormalitiesUrine dipstickProteinuria, haematuria and glycosuriaDetection of renal involvement and metabolic abnormalities12-lead ECGLVH, ischaemic heart disease and arrhythmiasIdentification of hypertension-associated cardiac damage and coexisting cardiac diseaseFurther investigations may be required when HMOD, secondary hypertension or additional comorbidities are suspected.Imaging and additional diagnostic investigationsTargeted imaging may be performed to establish the extent of organ involvement and investigate suspected underlying abnormalities. Echocardiography can be used to assess LVH, systolic and diastolic dysfunction, atrial enlargement and aortic root abnormalities, including aneurysm or coarctation. Carotid ultrasonography may be used to detect atherosclerotic plaques and stenosisRenal ultrasonography and renal artery duplex imaging may be considered when renal parenchymal disease or renal artery stenosis is suspected. Computed tomography (CT) or magnetic resonance angiography may be used to investigate renal vascular abnormalities, adrenal masses or enlargement and aortic aneurysms. Brain CT, magnetic resonance imaging (MRI) or angiography may be indicated when ischaemic or haemorrhagic cerebrovascular injury is suspectedAdditional investigations may be selected according to clinical findings:Urinary albumin-to-creatinine ratio: A first-morning spot urine sample may be used to identify albuminuria and assess renal involvementAnkle–brachial index: This may be measured to detect peripheral artery disease associated with atherosclerosisCognitive assessment: The Mini-Mental State Examination or clock-drawing test may be used to identify cognitive impairmentArterial stiffness assessment: Carotid–femoral or brachial–ankle pulse wave velocity may be measured to identify increased arterial stiffness and early vascular ageingSecondary hypertension investigations: Further targeted testing should be undertaken when clinical history, examination or initial investigations suggest an underlying secondary causeConclusionThe 2026 ISH update highlights the importance of a comprehensive clinical evaluation in individuals with hypertension. Detailed history-taking, cardiovascular risk assessment and physical examination should be integrated with routine laboratory testing and ECG to identify HMOD and associated conditions. Imaging and specialised investigations should be selected according to clinical indications, particularly when secondary hypertension or established organ damage is suspected. This structured approach enables more accurate risk stratification, supports individualised management and facilitates the early identification of complications.[2]Reference(s):1. Moiz A, Zolotarova T, Eisenberg MJ. Outpatient management of essential hypertension: a review based on the latest clinical guidelines. Ann Med. 2024;56(1):2338242. doi:10.1080/07853890.2024.2338242. https://pmc.ncbi.nlm.nih.gov/articles/PMC11011233/2. Stergiou GS, Kario K, Aristizabal D, et al. 2026 International Society of Hypertension Global Hypertension Practice Guidelines. J Hypertens. Published online October 20, 2026. doi:10.1097/HJH.0000000000004451. https://www.ovid.com/jnls/jhypertension/fulltext/10.1097/hjh.0000000000004451~2026-international-society-of-hypertension-global