What is the recommended management for uncontrolled hypertension?

Management of Uncontrolled Hypertension

For patients with uncontrolled hypertension, a stepwise approach is recommended, starting with combination therapy of a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic, preferably as a single-pill combination, and progressing to a three-drug regimen if blood pressure remains uncontrolled. 1

Initial Assessment and Targets

• Blood pressure should be accurately measured using a validated automated device with appropriate cuff size, with readings taken in both arms at the first visit 1
• Target blood pressure should be 120-129 mmHg systolic for most adults, provided treatment is well tolerated 1
• For patients where this target cannot be achieved, aim for blood pressure that is "as low as reasonably achievable" (ALARA principle) 1
• Blood pressure control should be achieved within 3 months 1

Lifestyle Modifications

Lifestyle modifications should be implemented for all patients with hypertension:

• Weight reduction to achieve a healthy BMI (20-25 kg/m²) and waist circumference (<94 cm for men, <80 cm for women) 1, 2
• Adoption of healthy dietary patterns such as Mediterranean or DASH diets 1, 3
• Sodium restriction (consider goal <1,500 mg/day for individuals with diabetes and hypertension) 1
• Regular physical activity (30-60 minutes of aerobic exercise 4-7 days per week), complemented with resistance training 2-3 times weekly 1, 3, 4
• Moderation or elimination of alcohol consumption (preferably avoid completely, or limit to <100g/week) 1, 4
• Smoking cessation with appropriate support 1

Pharmacological Management Algorithm

Step 1: Initial Therapy

• For most patients with confirmed hypertension (≥140/90 mmHg), start with combination therapy 1
• Preferred combinations: RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or thiazide/thiazide-like diuretic 1
• Use single-pill combinations when possible to improve adherence 1

Step 2: Optimization

• If BP remains uncontrolled, increase to full doses of initial medications 1
• Consider administering one or more antihypertensive medications at bedtime 1

Step 3: Triple Therapy

• If BP remains uncontrolled on two drugs at full doses, add a third drug: typically a RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic 1
• Preferably use a single-pill combination to improve adherence 1

Step 4: Resistant Hypertension Management

• If BP remains uncontrolled on optimal doses of three drugs including a diuretic, add spironolactone 1
• If spironolactone is not tolerated or contraindicated, consider alternatives: amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Special Considerations

• For Black patients: Consider starting with a low-dose ARB + dihydropyridine CCB or CCB + thiazide/thiazide-like diuretic 1
• Avoid combining two RAS blockers (ACE inhibitor and ARB) as this is not recommended 1
• Beta-blockers should be used when there are specific indications (angina, post-MI, heart failure) 1
• For patients with metabolic syndrome, consider ARBs or ACE inhibitors as first-line agents due to their lower association with new-onset diabetes 1

Monitoring and Follow-up

• Check medication adherence at each visit 1
• Consider home blood pressure monitoring to assess control and improve adherence 1
• If BP remains uncontrolled despite confirmed adherence to optimal doses of at least three medications including a diuretic, evaluate for secondary causes of hypertension 1
• Refer to a hypertension specialist if BP remains uncontrolled despite appropriate therapy 1

Common Pitfalls to Avoid

• Failure to confirm true resistant hypertension (check adherence, proper BP measurement technique, white coat effect) 1
• Suboptimal dosing or inappropriate combinations of antihypertensive medications 1
• Overlooking potential secondary causes of hypertension in resistant cases 1
• Not considering fixed-dose combinations to improve adherence 1
• Discontinuing medications when BP goal is achieved (treatment should be maintained lifelong) 1