How to manage uncontrolled hypertension in a male patient with a history of resolved Baker's cyst and previously discontinued antihypertensive medication?

Management of Uncontrolled Hypertension After Medication Discontinuation

Restart the previously discontinued antihypertensive medication immediately, as the patient's blood pressure has become uncontrolled following its discontinuation, and he tolerated it well without side effects. 1

Immediate Assessment and Intervention

Confirm True Hypertension

• Obtain out-of-office blood pressure measurements (home monitoring or ambulatory BP monitoring) to exclude white coat hypertension, which occurs in 20-30% of patients with apparent resistant hypertension 1
• Use proper measurement technique: ensure patient sits quietly for 5 minutes before measurement and use appropriately sized cuff to avoid falsely elevated readings 1

Medication Restart Strategy

• Resume the previously discontinued medication at the prior effective dose since the patient had controlled BP readings (in the specified range) when on therapy and experienced no adverse effects 1
• The temporal relationship between medication discontinuation and BP elevation strongly suggests the medication was providing effective control 1
• Investigate why the medication was discontinued to prevent future inappropriate cessation 1

Addressing Poor Adherence

Key Considerations

• Poor adherence is one of the most common causes of uncontrolled hypertension, with approximately 40% of patients discontinuing medications within the first year 1
• Therapeutic inertia and non-adherence are major barriers to BP control, requiring systematic approaches 1

Strategies to Improve Adherence

• Use once-daily dosing regimens and combination pills when possible to improve adherence 1
• Implement team-based care involving pharmacists, nurses, or other healthcare professionals for medication management and patient education 1
• Increase patient-clinician communication and provide patient education about the importance of continuous therapy for asymptomatic hypertension 1

If BP Remains Uncontrolled on Monotherapy

Optimization Approach

• Add a thiazide-type diuretic (chlorthalidone or indapamide preferred over hydrochlorothiazide) as second-line therapy, as diuretics provide additive benefit with most antihypertensive classes 1
• Maximize diuretic therapy first, as volume overload is a frequent contributor to resistant hypertension and is often undertreated 1

Third-Line Options for Resistant Hypertension

• Add a mineralocorticoid receptor antagonist (spironolactone 25-50 mg daily or eplerenone) if BP remains uncontrolled on three medications including a diuretic 1, 2
• Spironolactone provides significant additional BP reduction (average 25/12 mmHg) when added to multidrug regimens 1
• Monitor serum potassium and creatinine when using aldosterone antagonists, especially with concurrent ACE inhibitors or ARBs 1

Exclude Secondary Causes and Interfering Substances

Medication Review

• Discontinue or minimize NSAIDs, which are among the most common medications interfering with BP control 1
• Review for other interfering substances: decongestants, stimulants, alcohol excess, oral contraceptives, herbal supplements 1
• If analgesics are necessary, acetaminophen is preferable to NSAIDs in patients with resistant hypertension 1

Consider Secondary Hypertension

• Evaluate for obstructive sleep apnea, particularly if the patient has symptoms of snoring, daytime somnolence, or obesity 1
• Screen for primary aldosteronism if hypertension remains resistant despite optimal therapy 1
• Consider renal artery stenosis in appropriate clinical contexts 1

Referral Criteria

Refer to a hypertension specialist if BP remains uncontrolled despite three antihypertensive agents at optimal doses (including a diuretic), or if secondary hypertension is suspected 1

Baker's Cyst Considerations

The resolved Baker's cyst is not relevant to hypertension management in this case 3, 4. Baker's cysts can cause neurovascular compression syndromes affecting the popliteal vessels, but these present with claudication, venous thrombosis, or nerve symptoms—not systemic hypertension 4. The patient's cyst has resolved with physical therapy, and his leg symptoms have completely resolved 3.