From the Guidelines
Uncontrolled hypertension poses significant health risks, and the primary goal is to reduce blood pressure to minimize the risk of cardiovascular morbidity and mortality, with a target blood pressure of <130 mmHg, as recommended by the 2017 ACC/AHA guideline 1. The risks associated with uncontrolled hypertension include heart attack, stroke, kidney damage, vision loss, and cognitive decline, which can be mitigated by proper treatment and management.
Treatment Options
Treatment typically begins with lifestyle modifications, such as:
- Reducing sodium intake
- Maintaining a healthy weight
- Regular exercise
- Limiting alcohol
- Quitting smoking When these measures are insufficient, medication therapy is necessary, with first-line medications including:
- Thiazide diuretics (like hydrochlorothiazide 12.5-25mg daily)
- ACE inhibitors (such as lisinopril 10-40mg daily)
- Angiotensin II receptor blockers (like losartan 25-100mg daily)
- Calcium channel blockers (such as amlodipine 5-10mg daily) Many patients require combination therapy using two or more medications from different classes to achieve target blood pressure below 130/80 mmHg.
Management and Monitoring
Medication adherence is crucial, as inconsistent use can lead to blood pressure fluctuations and complications. Regular monitoring is essential, ideally with home blood pressure measurements in addition to clinical visits. Patients should be aware that hypertension is typically a lifelong condition requiring ongoing management, and medication adjustments may be necessary over time as the body changes or develops tolerance to certain treatments, as noted in the 2017 ACC/AHA guideline 1.
Recent Guidelines and Recommendations
Recent studies have highlighted the importance of proper treatment and management of hypertension, with a focus on reducing blood pressure to minimize the risk of cardiovascular morbidity and mortality 1.
From the FDA Drug Label
Lowering blood pressure lowers the risk of fatal and non-fatal cardiovascular events, primarily strokes and myocardial infarctions Elevated systolic or diastolic pressure causes increased cardiovascular risk, and the absolute risk increase per mmHg is greater at higher blood pressures, so that even modest reductions of severe hypertension can provide substantial benefit Relative risk reduction from blood pressure reduction is similar across populations with varying absolute risk, so the absolute benefit is greater in patients who are at higher risk independent of their hypertension (for example, patients with diabetes or hyperlipidemia), and such patients would be expected to benefit from more aggressive treatment to a lower blood pressure goal
The risks of uncontrolled hypertension include:
- Fatal and non-fatal cardiovascular events
- Strokes
- Myocardial infarctions The treatment options for uncontrolled hypertension may involve:
- Monotherapy with antihypertensive agents such as lisinopril or amlodipine
- Combination therapy with multiple antihypertensive agents
- Lifestyle modifications such as lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake 2 3
From the Research
Risks of Uncontrolled Hypertension
- Uncontrolled hypertension significantly increases the risk of cardiovascular disease and death 4
- It can lead to heart failure, as chronic hypertension drives cardiac remodeling within the left ventricle resulting in hypertensive heart disease 5
- Uncontrolled hypertension also increases the risk of all-cause and cardiovascular disease mortality in US adults 6
- The likelihood of uncontrolled hypertension is higher in patients with certain characteristics, such as black race, self-pay, prior emergency room visit, and no attributed primary care provider 4
Treatment Options for Uncontrolled Hypertension
- Lifestyle interventions, including the Dietary Approaches to Stop Hypertension (DASH) diet, dietary sodium restriction, potassium enrichment, regular exercise, weight loss, and moderation of alcohol consumption, can help manage hypertension 7
- First-line antihypertensive medications include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, and thiazide diuretics 7
- However, some studies suggest that angiotensin receptor blockers (ARBs) may be a better option than angiotensin-converting enzyme (ACE) inhibitors due to their equal outcome efficacy and fewer adverse events 8
- Achieving blood pressure goals in conjunction with using evidence-based treatments can improve clinical outcomes for patients with comorbid hypertension and heart failure 5
Factors Associated with Uncontrolled Hypertension
- Patient characteristics, such as black race, self-pay, prior emergency room visit, and no attributed primary care provider, can increase the likelihood of uncontrolled hypertension 4
- Readings taken in the evening and at specialty practices are more likely to meet thresholds for uncontrolled hypertension and hypertensive crisis 4
- The timing of blood pressure measurement and the type of healthcare provider can also impact the diagnosis and management of hypertension 4