What are the current treatment guidelines for uncontrolled hypertension?

Current Treatment Guidelines for Uncontrolled Hypertension

For uncontrolled hypertension, treatment should follow a stepwise approach starting with combination therapy using drugs from three main classes: thiazide/thiazide-like diuretics, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), and long-acting calcium channel blockers (CCBs). 1

Initial Assessment and Diagnosis

• Define uncontrolled hypertension as:

  • BP consistently ≥140/90 mmHg despite treatment
  • BP ≥160/100 mmHg requiring immediate treatment
  • BP ≥130/80 mmHg in high-risk patients (CVD, diabetes, CKD)

• Confirm diagnosis with:

  • Multiple office BP measurements (average of readings)
  • Home BP monitoring (target <135/85 mmHg)
  • 24-hour ambulatory BP monitoring when available (target <130/80 mmHg) 1

Treatment Algorithm

Step 1: Optimize Current Therapy

• Assess and address medication adherence
• Consider single-pill combinations to improve compliance
• Evaluate lifestyle modifications (sodium restriction, weight loss, physical activity)

Step 2: Combination Therapy Approach

• For non-Black patients:

  1. Start with low-dose ACEI/ARB
  2. Add long-acting dihydropyridine CCB
  3. Add thiazide/thiazide-like diuretic 1

• For Black patients:

  1. Start with low-dose ARB + dihydropyridine CCB or
  2. Dihydropyridine CCB + thiazide/thiazide-like diuretic
  3. Increase to full doses 1

Step 3: Resistant Hypertension Management

If BP remains uncontrolled on full doses of three medications:

• Add spironolactone (first choice)
• If not tolerated or contraindicated, consider:
  • Amiloride
  • Doxazosin
  • Eplerenone
  • Clonidine
  • Beta-blocker 1

Blood Pressure Targets

• General population: <140/90 mmHg 1
• High-risk patients (CVD, diabetes, CKD): <130/80 mmHg 1
• Elderly patients: Individualize based on frailty, with target generally <140/90 mmHg 1, 2
  • Avoid diastolic BP <70 mmHg in elderly patients 2

Monitoring and Follow-up

• Monthly follow-up after initiation or change in medications until target BP is reached 1
• Once controlled, follow-up every 3-5 months 1
• Aim to achieve target BP within 3 months 1

Special Considerations

• Hypertensive crisis (BP >180/120 mmHg):

  • Assess for end-organ damage
  • If present (hypertensive emergency): admit to ICU for IV antihypertensive therapy
  • If absent (hypertensive urgency): may treat with oral medications as outpatient 3

• Elderly patients:

  • Consider starting with lower doses
  • Monitor for orthostatic hypotension and adverse effects
  • Avoid excessive BP lowering that might lead to falls 2

• Medication selection:

  • Chlorthalidone may be preferred over hydrochlorothiazide among thiazide diuretics based on outcome data 4
  • Avoid combining ACEI and ARB due to increased adverse effects without additional benefit 1

Implementation Considerations

• Treatment can be provided by non-physician professionals (pharmacists, nurses) with proper training, protocols, and physician oversight 1
• Simplify regimens with once-daily dosing and single-pill combinations to improve adherence 1
• Monitor for adverse effects, particularly electrolyte abnormalities with diuretics and hyperglycemia with thiazides 4

By following this structured approach to uncontrolled hypertension, clinicians can optimize outcomes and reduce cardiovascular morbidity and mortality in patients with this common but dangerous condition.