From the Guidelines
The workup for poorly controlled hypertension should begin with confirming true resistant hypertension by ensuring proper blood pressure measurement technique and ruling out white coat hypertension with home or ambulatory monitoring. A comprehensive history should assess medication adherence, lifestyle factors (sodium intake, alcohol consumption, physical activity), and use of substances that can elevate blood pressure like NSAIDs, decongestants, or stimulants 1. Physical examination should include proper BP measurement in both arms, BMI calculation, cardiovascular assessment, and evaluation for signs of end-organ damage.
Key Components of Workup
- Laboratory testing should include basic metabolic panel, urinalysis, lipid profile, fasting glucose, and thyroid function tests.
- Additional testing may include plasma aldosterone-to-renin ratio if primary aldosteronism is suspected, especially in patients with hypokalemia.
- Imaging studies like renal ultrasound or renal artery duplex should be considered to evaluate for renal artery stenosis, particularly in younger patients or those with abrupt BP changes.
- Echocardiogram may be appropriate to assess for left ventricular hypertrophy.
- Sleep study should be considered if obstructive sleep apnea is suspected. According to the 2024 ESC guidelines for the management of elevated blood pressure and hypertension, when BP is still uncontrolled under maximally tolerated triple-combination therapy, the patient should be considered resistant and referred to an expert centre for appropriate work-up 1. This comprehensive approach helps identify secondary causes of hypertension such as renal disease, endocrine disorders (pheochromocytoma, Cushing's syndrome, hyperparathyroidism), or anatomical issues like coarctation of the aorta, which occur in approximately 10% of hypertensive patients and require specific treatment approaches.
Treatment Considerations
- The addition of spironolactone should be considered if BP remains uncontrolled.
- If spironolactone is not tolerated, eplerenone or other MRA, or beta-blockers (if not already indicated), should be considered.
- Eplerenone may need to be dosed higher (50–200 mg) for effective BP lowering.
- A vasodilating beta-blocker (e.g. labetalol, carvedilol, or nebivolol) is preferred when a beta-blocker is chosen.
From the FDA Drug Label
The provided drug labels do not directly address the workup for a patient with poorly controlled Hypertension (HTN).
The FDA drug label does not answer the question.
From the Research
Workup for Poorly Controlled Hypertension
The workup for a patient with poorly controlled hypertension (HTN) involves several steps, including:
- Identifying complications of the condition and comorbid cardiovascular risk factors 2
- Assessing the patient's blood pressure using ambulatory and home blood pressure monitoring to improve diagnostic accuracy 2
- Evaluating the patient's lifestyle and providing counseling on effective lifestyle interventions, such as:
- Initiating or adjusting antihypertensive medication, with first-line options including:
- Setting blood pressure goals, with evidence supporting reduction to less than 140/90 mm Hg to reduce the risk of all-cause and cardiovascular mortality 2
- Considering combination therapy for patients who require multiple medications to achieve blood pressure control 4
Special Considerations
- For patients with stage 1 hypertension and a low 10-year risk for cardiovascular disease, lifestyle therapy is recommended for at least 6 months before considering pharmacologic treatment 5
- For older adults or those with mild hypertension, clinical judgment and shared decision-making should guide treatment to minimize adverse effects of antihypertensive medications and tight blood pressure control 2