A 52-year-old man from rural Maharashtra is screened under NPCDCS at a primary health centre. He has a blood pressure of 160/100 mmHg on two separate occasions. Which investigation is most appropriate to confirm the diagnosis of hypertension and assess for target organ damage as per NPCDCS guidelines?

## Investigation of Choice for Hypertension Confirmation and Risk Stratification ### NPCDCS Framework for Hypertension Diagnosis **Key Point:** NPCDCS recommends confirmation of hypertension diagnosis through repeat measurements, followed by assessment of target organ damage and cardiovascular risk stratification using biochemical investigations. ### Why Serum Creatinine and UACR? Once hypertension is confirmed by repeat office readings (≥140/90 mmHg on two occasions), the next step is: 1. **Renal function assessment** — serum creatinine estimates glomerular filtration rate (GFR) and identifies hypertensive nephropathy 2. **Albuminuria detection** — urine albumin-to-creatinine ratio (UACR) is the gold standard for detecting early diabetic and hypertensive kidney disease 3. **Cardiovascular risk stratification** — both findings determine absolute cardiovascular risk and guide intensity of treatment **High-Yield:** NPCDCS emphasizes that all newly diagnosed hypertensive patients require baseline renal function and proteinuria screening to identify those with target organ damage (TOD), which escalates them to high-risk category. ### Comparison of Investigation Options | Investigation | Role | Timing in NPCDCS Protocol | |---|---|---| | Home BP monitoring | Confirms white-coat HTN; useful but not diagnostic | After office diagnosis confirmed | | 24-hour ABPM | Gold standard for diagnosis in specialized settings | Not routine in primary care/NPCDCS | | **Serum Cr + UACR** | **Detects TOD; guides risk stratification** | **Immediately after diagnosis confirmed** | | Fundoscopy | Detects hypertensive retinopathy | Supportive; not first-line investigation | **Clinical Pearl:** In the NPCDCS context (resource-limited primary health centres), serum creatinine and spot UACR are feasible, cost-effective investigations that directly influence management intensity and prognosis communication. ### NPCDCS Algorithm for Hypertension ```mermaid flowchart TD A[BP ≥140/90 mmHg on first visit]:::outcome --> B[Repeat BP on 2 more visits]:::action B --> C{BP ≥140/90 on repeat?}:::decision C -->|No| D[Normal; counsel on lifestyle]:::outcome C -->|Yes| E[Hypertension confirmed]:::outcome E --> F[Assess target organ damage]:::action F --> G[Serum Cr + UACR]:::action G --> H[Calculate absolute CVD risk]:::action H --> I[Risk stratification & treatment]:::action ``` **Mnemonic: TOD-CRISP** — Target Organ Damage assessment in hypertension requires: **Cr**eatinine, **R**etinopathy, **I**schaemic heart disease, **S**troke history, **P**roteinuria.