What does uncontrolled blood pressure (BP) mean?

Definition of Uncontrolled Blood Pressure

Uncontrolled blood pressure means blood pressure that remains at or above 130/80 mm Hg despite treatment, or any blood pressure at or above 140/90 mm Hg in treated patients, depending on which guideline threshold is applied. 1

Current Guideline Definitions

2017 ACC/AHA Definition

• Uncontrolled BP is defined as systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg in patients receiving antihypertensive medication 1
• This represents the most recent major U.S. guideline threshold and applies to most adults with hypertension 1
• The prevalence of uncontrolled hypertension increased substantially with this definition compared to older thresholds 1

2024 ESC Definition

• Uncontrolled BP is defined as office systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg in treated patients 1
• This threshold must be confirmed by out-of-office measurements (home or ambulatory BP monitoring) 1
• The European guidelines maintain the traditional 140/90 mm Hg threshold rather than adopting the lower U.S. targets 1

Key Distinction: Uncontrolled vs. Resistant Hypertension

Uncontrolled hypertension is NOT the same as resistant hypertension. 1

Uncontrolled Hypertension Includes:

• Patients with poor medication adherence 1
• Patients on inadequate treatment regimens (therapeutic inertia) 1
• Patients with white coat effect 1
• Patients with true treatment resistance 1

Resistant Hypertension Specifically Means:

• BP remains ≥140/90 mm Hg (or ≥130/80 mm Hg per ACC/AHA) despite concurrent use of 3 antihypertensive agents from different classes at optimal doses, including a diuretic 1
• Also includes patients requiring 4 or more medications to achieve control 1
• Must exclude pseudo-resistance from non-adherence and white coat effect 1

Clinical Context and Prevalence

Overall Uncontrolled Rates

• In the U.S., only 53% of treated hypertensive patients achieved control to 140/90 mm Hg in NHANES data 1
• Among higher-risk populations (diabetes, chronic kidney disease), control rates are even lower—only 37% of CKD patients controlled to 130/80 mm Hg 1
• More than half of uncontrolled hypertensive patients remain completely untreated (52.2% in 2005-2008) 2

Common Causes of Uncontrolled BP

• Therapeutic inertia: Most treated but uncontrolled patients take only 1-2 medications when more are needed, comprising 72% of treated uncontrolled patients 2
• Non-adherence: Up to 25% of patients don't fill initial prescriptions, and only 1 in 5 has adherence high enough to achieve trial-demonstrated benefits 1
• Inadequate dosing or drug combinations by providers 3
• Masked uncontrolled hypertension: 31.1% of patients with controlled clinic BP have elevated ambulatory BP, most commonly due to nocturnal hypertension 4

Verification Requirements

Out-of-office BP measurement is essential to confirm uncontrolled hypertension and exclude white coat effect. 1

• Use home BP monitoring or 24-hour ambulatory monitoring 1
• For ambulatory monitoring: uncontrolled if 24-hour average ≥130/80 mm Hg 4
• White coat effect is particularly common in patients on multiple medications 1
• Masked uncontrolled hypertension (normal clinic BP but elevated home/ambulatory BP) occurs in approximately one-third of seemingly controlled patients 4

Clinical Implications

Cardiovascular Risk

• Uncontrolled BP significantly increases risk of stroke, myocardial infarction, heart failure, and cardiovascular death 1
• Each 20/10 mm Hg increase in BP doubles the risk of fatal cardiovascular events 1
• Patients with resistant hypertension have 2- to 6-fold higher risk of major cardiovascular events compared to controlled hypertension 1

Management Priority

• Address non-adherence first through patient education, simplified regimens, and once-daily dosing 1, 3
• Overcome therapeutic inertia by intensifying treatment in undertreated patients 1, 2
• Optimize diuretic therapy as most uncontrolled patients need adequate diuretic dosing 1, 5
• Consider referral to hypertension specialist if BP remains uncontrolled despite optimization 1, 5