What are the next steps for a 62-year-old male with a history of hypertension, presenting with elevated blood pressure readings, who has been off his prescribed valsartan (angiotensin II receptor antagonist) 320 mg?

Management of Severe Hypertension in a Patient Who Discontinued Valsartan

The patient should be immediately restarted on valsartan 320 mg daily and have a second antihypertensive agent added, preferably a thiazide diuretic, to achieve rapid blood pressure control. 1

Assessment and Immediate Management

• Blood pressure readings of 194/144 and 162/94 indicate severe hypertension requiring prompt intervention
• This represents a hypertensive urgency due to medication non-adherence (valsartan discontinuation)
• The patient's baseline hypertension is likely severe, requiring the maximum dose of valsartan (320 mg)

Step 1: Restart Valsartan

• Immediately restart valsartan at the previous dose of 320 mg once daily 2
• The antihypertensive effect of valsartan will begin within 2 weeks, with maximal effect achieved after approximately 4 weeks 2
• Do not start at a lower dose as this patient previously tolerated 320 mg and requires urgent BP control

Step 2: Add a Second Agent

• Add a thiazide diuretic (preferably chlorthalidone) to the regimen 1
• The combination of valsartan with a thiazide diuretic significantly reduces the time to achieve BP control:
  • Median time to goal BP with valsartan 320 mg alone: 6.1 weeks
  • Median time to goal BP with valsartan 320 mg + HCTZ: 2.1 weeks 3

Follow-up Plan

Short-term Follow-up (1-2 weeks)

• Schedule follow-up within 1-2 weeks to assess response to restarted therapy
• Monitor serum creatinine, eGFR, and potassium levels 1
• Assess for medication adherence barriers and address them

Medication Adjustments

• If BP remains elevated after 2-4 weeks, consider:
  • Increasing HCTZ dose if using valsartan/HCTZ combination
  • Adding a calcium channel blocker (effective combination with ARBs) 1
• For patients with stage 2 hypertension, valsartan 320 mg/HCTZ can achieve BP goal in 75.8% of patients by week 8 3

Important Considerations

Medication Adherence

• Discuss reasons for medication discontinuation
• Consider once-daily dosing regimens to improve adherence
• Educate on risks of uncontrolled hypertension

Monitoring

• For patients on ARBs like valsartan, monitor serum creatinine/eGFR and potassium at least annually 1
• Watch for potential side effects, though valsartan is generally well-tolerated with adverse events similar to placebo 4

Caution

• Avoid combining valsartan with ACE inhibitors or direct renin inhibitors as these combinations increase adverse effects without additional benefit 1
• Be cautious with NSAIDs as they can counteract the blood pressure-lowering effects of ARBs 1

Long-term Management

• Target BP should be <140/90 mmHg for most patients, or <130/80 mmHg for high-risk patients with diabetes, chronic kidney disease, or cardiovascular disease 1
• Encourage lifestyle modifications including sodium restriction (1200-2300 mg/day), regular physical activity (150 minutes/week), and moderated alcohol consumption 1
• Consider 24-hour ambulatory BP monitoring to ensure adequate 24-hour control, as valsartan at doses of 80 mg and higher provides effective control over a full 24-hour period 5