What to do if hypertension persists at 1 week?

Management of Persistent Hypertension at 1 Week

If blood pressure remains elevated at 1 week after initiating treatment, you should reassess medication adherence, verify blood pressure measurements with home or ambulatory monitoring, and intensify pharmacological therapy by uptitrating current medications to maximum tolerated doses or adding a second agent from a different class. 1, 2

Immediate Assessment Steps

Verify Blood Pressure Elevation

• Confirm persistent elevation with repeat office measurements using proper technique 1
• Consider home blood pressure monitoring or ambulatory blood pressure monitoring to exclude white coat hypertension and confirm sustained elevation 1, 2
• Document specific blood pressure values and compare to baseline measurements 2

Evaluate Treatment Adherence and Response

• Assess medication adherence directly—non-adherence is a leading cause of apparent treatment failure 3
• Review the current antihypertensive regimen: drug class, dose, and duration of therapy 2
• Remember that achieving steady state for long-acting antihypertensives typically takes one to two weeks, so some patients may still be responding 1

Treatment Intensification Algorithm

For Stage 1 Hypertension (140-159/90-99 mmHg) at 1 Week

• If on monotherapy, uptitrate the current medication to maximum tolerated dose 1, 2
• If already at maximum dose, add a second agent from a different first-line class (thiazide diuretic, ACE inhibitor/ARB, or calcium channel blocker) 1, 4
• Schedule follow-up in 1 month to reassess response 1

For Stage 2 Hypertension (≥160/100 mmHg) at 1 Week

• Intensify to combination therapy with two agents from different classes if not already prescribed 1
• Preferred combinations include: thiazide + ACE inhibitor/ARB, thiazide + calcium channel blocker, or ACE inhibitor/ARB + calcium channel blocker 4, 5
• Consider single-pill combination products to improve adherence 3
• Schedule closer follow-up within 2 weeks 2

For Very High Blood Pressure (≥180/110 mmHg) at 1 Week

• Reassess for signs of acute target organ damage (hypertensive emergency vs urgency) 1
• If no acute end-organ damage, initiate or intensify oral combination therapy immediately 2, 6
• Use three-drug combination if not already prescribed: thiazide + ACE inhibitor/ARB + calcium channel blocker 3
• Follow-up within 1 week is essential after severely elevated blood pressure presentation 1

Medication Selection Considerations

First-Line Agent Optimization

• Thiazide diuretics: Chlorthalidone or hydrochlorothiazide remain first-line with strong outcome data 4, 7
• ACE inhibitors/ARBs: Preferred in patients with diabetes, chronic kidney disease, or heart failure 1
• Calcium channel blockers: Particularly effective in elderly and Black patients who may have lower-renin hypertension 8, 5

Avoid Common Pitfalls

• Do not use beta-blockers as first-line therapy unless specific compelling indications exist (post-MI, heart failure with reduced ejection fraction, angina) 1
• Avoid overly rapid intensification within hours to days—antihypertensives require 1-2 weeks to reach steady state 1
• Do not combine ACE inhibitor + ARB + renin inhibitor—this is potentially harmful 1

Lifestyle Modification Reinforcement

Even with medication intensification, reinforce non-pharmacological interventions at the 1-week visit:

• Sodium restriction to <1500 mg/day or reduction of at least 1000 mg/day 1
• Weight loss of at least 1 kg if overweight/obese 1
• Increased dietary potassium intake (3500-5000 mg/day) 1
• Physical activity: 90-150 minutes/week of aerobic exercise 1
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 1
• DASH diet pattern rich in fruits, vegetables, whole grains, and low-fat dairy 1, 2

Follow-Up Schedule

Monitoring Frequency

• For patients with persistent stage 1 hypertension: monthly follow-up until blood pressure is controlled 1
• For patients with stage 2 hypertension: follow-up every 2-4 weeks during titration phase 2
• For severely elevated blood pressure (hypertensive urgency): follow-up within 1 week is critical 1, 2

Target Blood Pressures

• General target: <140/90 mmHg for most patients 1, 4
• Lower target <130/80 mmHg for patients with diabetes, chronic kidney disease, or established cardiovascular disease 1, 2, 4
• For adults ≥65 years: SBP <130 mmHg 4

Special Considerations

Assess for Secondary Causes

If blood pressure remains uncontrolled despite adherence to three-drug therapy at maximum tolerated doses, consider evaluation for secondary hypertension 3:

• Primary aldosteronism
• Renal artery stenosis
• Obstructive sleep apnea
• Medication or substance interference (NSAIDs, decongestants, stimulants) 1, 3

Risk of Inadequate Follow-Up

Approximately half of treated hypertensive patients do not achieve acceptable blood pressure control, often due to inadequate follow-up 2, 4. Most patients do not receive timely follow-up after initial diagnosis or hospitalization 1. Ensure structured follow-up appointments are scheduled before the patient leaves the office.