What is the management plan for a patient with well-controlled hypertension?

Management of Well-Controlled Hypertension

For patients with well-controlled hypertension, continue the current effective antihypertensive regimen without modification, while maintaining regular monitoring and reinforcing lifestyle modifications. 1

Continue Current Medication Regimen

• Maintain the existing antihypertensive therapy that has successfully achieved blood pressure control 1, 2
• Do not discontinue or reduce medications simply because blood pressure is well-controlled—this is a common pitfall that leads to loss of control 1
• There is no evidence supporting routine medication reduction or discontinuation in patients who have achieved target blood pressure 1

Target Blood Pressure Goals

For well-controlled hypertension, ensure blood pressure remains at goal:

• Adults <65 years: maintain BP <130/80 mmHg 1, 3
• Adults ≥65 years: maintain systolic BP <130 mmHg 1
• Patients with diabetes or chronic kidney disease: maintain BP <130/80 mmHg 1
• The 2024 ESC guidelines support even tighter control (120-129/70-79 mmHg) when well-tolerated 2

Monitoring Schedule

• Follow-up visits every 3-6 months once blood pressure is stable and well-controlled 1
• More frequent monitoring (every 2-4 weeks) is only needed if medications are adjusted 2
• Encourage home blood pressure monitoring to confirm sustained control 2
• Annual assessment for target organ damage and cardiovascular risk factors 1

Lifestyle Modifications (Ongoing)

Even with well-controlled hypertension, continue emphasizing:

• Dietary sodium restriction (<2 grams/day) and increased potassium intake 3
• DASH (Dietary Approaches to Stop Hypertension) dietary pattern 2, 3
• Regular physical activity (at least 150 minutes/week of moderate-intensity exercise) 2
• Weight management if overweight or obese 3
• Alcohol moderation or elimination 3
• These lifestyle measures are additive to medication effects and help maintain control 3

Medication Adherence Assessment

• Assess adherence at each visit, as non-adherence is the most common cause of loss of blood pressure control 1
• Single-pill combination formulations improve long-term adherence compared to multiple separate pills 1
• Consider switching to once-daily formulations if the patient is on twice-daily dosing 2

Common Pitfalls to Avoid

• Never discontinue or reduce medications in well-controlled patients without compelling reasons (e.g., adverse effects, patient preference after informed discussion) 1
• Do not assume control is permanent—regular monitoring remains essential 1
• Avoid therapeutic inertia if blood pressure begins to rise above target 2
• Do not overlook medication adherence issues, even in previously well-controlled patients 1
• Remember that "well-controlled" means consistently at goal, not just occasional normal readings 1

When to Intensify Monitoring

Increase monitoring frequency if:

• Blood pressure readings begin trending upward, even if still below diagnostic threshold for hypertension 1
• New comorbidities develop (diabetes, chronic kidney disease, cardiovascular disease) 1
• Patient experiences adverse effects from medications 1
• Significant weight gain occurs 3
• Patient starts medications that may interfere with blood pressure control (NSAIDs, decongestants, corticosteroids) 4

Special Considerations

• In elderly patients (≥70 years), assess for orthostatic hypotension at each visit 2
• Evaluate for frailty in older adults, which may warrant individualized targets 2
• Screen for secondary causes if previously well-controlled hypertension becomes difficult to control 4
• Assess cardiovascular risk annually and optimize management of other risk factors (lipids, diabetes, smoking) 1, 3