What initial investigations should be performed in a patient presenting with a hypertensive crisis?

In a patient presenting with a hypertensive crisis, initial investigations should focus on rapidly assessing for target organ damage and identifying any secondary causes of hypertension. This includes:

• Blood tests: Measure electrolytes, creatinine, estimated glomerular filtration rate (eGFR), glycated haemoglobin (HbA1c), total cholesterol, and HDL cholesterol to assess renal function, metabolic status, and cardiovascular risk factors ¹.
• Urine analysis: Test for proteinuria by estimating the albumin:creatinine ratio and check for haematuria using a reagent strip to evaluate kidney involvement ¹.
• Electrocardiogram (ECG): Perform a 12-lead ECG to detect cardiac complications such as left ventricular hypertrophy or ischemia ¹.
• Fundoscopy: Examine the retinal vessels for hypertensive retinopathy, which indicates acute or chronic end-organ damage ¹.
• Blood pressure measurement: Confirm elevated blood pressure with repeated measurements, ideally in both arms, to rule out measurement error and assess for significant inter-arm differences ¹.

Additional urgent investigations may be warranted depending on clinical presentation, such as neuroimaging if neurological symptoms suggest a hypertensive emergency involving the brain (e.g., subarachnoid haemorrhage) ². Recent systematic reviews emphasize the importance of rapid assessment and monitoring to guide immediate management and prevent complications (Khan et al., 2024).

Overall, the initial workup in hypertensive crisis aims to identify the severity of organ involvement and guide urgent treatment decisions, integrating standard UK guideline recommendations with emerging evidence on management strategies (Khan et al., 2024) ¹.