What is the recommended management plan for a hypertensive patient with a normal blood pressure reading?

Management of Hypertension with Normal Blood Pressure at Today's Visit

Continue all current antihypertensive medications without any changes, as a single normal office reading does not indicate adequate blood pressure control. 1

Confirm True Blood Pressure Status

The most critical step is determining whether this patient has truly controlled hypertension or if today's reading represents white-coat effect, measurement error, or temporary variation:

• Obtain out-of-office blood pressure measurements immediately through either home blood pressure monitoring (HBPM) or 24-hour ambulatory blood pressure monitoring (ABPM) to confirm the BP category. 1
• A single normal office reading is insufficient to change the diagnosis or treatment plan, as blood pressure naturally fluctuates and office measurements can be unreliable. 1
• Out-of-office measurements are strongly recommended by current guidelines for confirming both elevated BP and hypertension before making treatment decisions. 1

If Out-of-Office Monitoring Confirms Controlled Hypertension

When HBPM or ABPM demonstrates sustained BP control (average <130/80 mmHg):

• Maintain current antihypertensive medications lifelong, even if blood pressure remains controlled. 1
• It is explicitly recommended to continue BP-lowering drug treatment lifelong, even beyond age 85 years, if well tolerated. 1
• Schedule follow-up visits at least yearly once treatment control is established. 1
• Continue reinforcing lifestyle modifications at every visit, as these enhance medication effectiveness and may eventually allow dose reduction. 1

Common pitfall to avoid: Never discontinue or reduce antihypertensive medications simply because BP is controlled—this control exists because of the medications. 1

If Out-of-Office Monitoring Shows Uncontrolled Hypertension

When home or ambulatory monitoring reveals BP ≥130/80 mmHg despite today's normal office reading:

• Assess medication adherence first—this is the most common cause of apparent treatment failure. 1, 2
• Consider switching to once-daily fixed-dose single-pill combinations, which are strongly recommended to improve adherence. 1, 3
• If the patient is on fewer than three medications, escalate therapy according to this sequence: 1
  • Step 1: RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker OR thiazide/thiazide-like diuretic (preferably as single-pill combination) 1
  • Step 2: If uncontrolled, advance to three-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic (preferably as single-pill combination) 1
  • Step 3: If still uncontrolled on maximally tolerated triple therapy, refer to hypertension specialist and consider adding spironolactone 1

Lifestyle Modifications to Reinforce

Regardless of current BP control status, intensively counsel on these evidence-based interventions at every visit:

• Weight reduction: Target BMI 18.5-24.9 kg/m²; even 5-10% weight loss reduces BP by 5-10 mmHg. 4, 3
• Sodium restriction: Limit intake to <2,000 mg/day (ideally <2,300 mg/day maximum). 1, 4, 3
• DASH dietary pattern: 8-10 servings of fruits/vegetables daily, low-fat dairy, reduced saturated fats. 1, 3
• Physical activity: 30-60 minutes of moderate-intensity aerobic exercise on most days. 4, 5
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women. 1, 3

These lifestyle measures provide additive BP reduction of 5-10 mmHg and enhance pharmacological therapy effectiveness. 1, 6

Blood Pressure Target

• Target BP is 120-129/70-79 mmHg for most adults to reduce cardiovascular morbidity and mortality. 1, 4
• For patients aged ≥65 years, the same target applies if well tolerated; if not achievable, use the "as low as reasonably achievable" (ALARA) principle. 1
• The 2024 ESC guidelines represent the most current evidence, moving away from the older <140/90 mmHg threshold to more intensive targets based on outcomes data. 1

Follow-Up Schedule

• Reassess BP within 1-3 months (preferably 1 month) to ensure target achievement. 1, 4
• Once BP is confirmed controlled on stable therapy, follow-up at least yearly. 1
• At each visit, evaluate medication adherence, tolerability, and reinforce lifestyle modifications. 4

Critical caveat: White-coat hypertension (elevated office BP with normal out-of-office BP) affects a significant proportion of patients and should not be treated with medications unless there are other compelling indications. 1 This is why out-of-office confirmation is essential before making any treatment changes.