From the Guidelines
The best approach to manage uncontrolled hypertension is to follow the 2024 ESC guidelines, which recommend reinforcement of lifestyle measures, addition of low-dose spironolactone, or further diuretic therapy, and consideration of catheter-based renal denervation in resistant cases.
Key Recommendations
- Reinforcement of lifestyle measures, especially sodium restriction, is crucial in managing uncontrolled hypertension 1.
- Addition of low-dose spironolactone to existing treatment is recommended for patients with resistant hypertension 1.
- Further diuretic therapy, such as eplerenone, amiloride, or a loop diuretic, may be considered if spironolactone is not effective or tolerated 1.
- Catheter-based renal denervation may be considered for resistant hypertension patients who have uncontrolled blood pressure despite a three-drug combination and who express a preference for the procedure after a shared risk-benefit discussion and multidisciplinary assessment 1.
Lifestyle Modifications
- Reducing sodium intake to less than 2300mg daily is essential for managing hypertension 1.
- Adopting the DASH diet rich in fruits and vegetables, limiting alcohol consumption, maintaining a healthy weight, and exercising regularly (150 minutes of moderate activity weekly) are also crucial lifestyle modifications 1.
Medication Therapy
- First-line treatment should include thiazide diuretics, calcium channel blockers, ACE inhibitors, or ARBs 1.
- For patients with blood pressure significantly above goal, consider initiating two medications from different classes simultaneously 1.
- If hypertension remains uncontrolled on two medications, add a third agent from a different class, typically including a thiazide diuretic if not already prescribed 1.
Monitoring and Adherence
- Home blood pressure monitoring is crucial for tracking progress, with a target of <130/80 mmHg for most adults 1.
- Medication adherence is vital, so simplifying regimens with once-daily dosing and combination pills can improve compliance 1.
From the FDA Drug Label
Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake Many patients will require more than 1 drug to achieve blood pressure goals. For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)
The best approach to manage uncontrolled hypertension is through comprehensive cardiovascular risk management, which includes:
- Lipid control
- Diabetes management
- Antithrombotic therapy
- Smoking cessation
- Exercise
- Limited sodium intake It is also important to note that many patients will require more than one drug to achieve blood pressure goals, and for specific advice on goals and management, published guidelines such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) should be consulted 2 3.
From the Research
Uncontrolled Hypertension Management
To manage uncontrolled hypertension, several approaches can be considered:
- The first-line treatment for hypertension in adults without diabetes or cardiovascular or renal disease is usually a thiazide diuretic, such as chlortalidone or hydrochlorothiazide 4.
- The use of combinations of antihypertensive drugs as first-line therapy has not been evaluated in terms of the complications of hypertension, except for certain diuretic-based combinations 4.
- ACE inhibitors, such as ramipril, and calcium antagonists, such as amlodipine, can be used as first-choice therapy for hypertension, especially in combination 5.
- Home blood pressure monitoring and pharmacist intervention can improve blood pressure control in patients with uncontrolled hypertension 6.
Blood Pressure Targets
The target blood pressure for patients with hypertension is generally considered to be less than 140/90 mmHg, although some guidelines suggest more intensive targets, such as less than 130/80 mmHg 7, 8.
- However, achieving these targets can be challenging, and therapeutic inertia can lead to poor blood pressure control and increased risk of cardiovascular events 8.
- The choice of antihypertensive medication and the use of combination therapy should be individualized based on the patient's specific needs and risk factors 4, 5.
Treatment Considerations
When selecting antihypertensive medication, consideration should be given to the patient's comorbidities, such as diabetes, cardiovascular disease, or renal disease 4, 8.