What management steps should be taken for an adult patient with hypertension on antihypertensive medication, such as Angiotensin-Converting Enzyme (ACE) inhibitors, calcium channel blockers, or thiazide diuretics, presenting for a blood pressure follow-up with no overt issues and a blood pressure reading within their target range of less than 130/80 mmHg?

Blood Pressure Follow-Up Management for Controlled Hypertension

For a patient with hypertension presenting for routine follow-up with blood pressure at target (<130/80 mmHg), continue current medications unchanged, verify medication adherence, reinforce lifestyle modifications, and schedule follow-up in 3-5 months. 1

Immediate Assessment Steps

Confirm Blood Pressure Control

• Measure blood pressure properly using a validated automated upper arm cuff device with appropriate cuff size 1
• Take the average of multiple readings (ideally 2-3 readings at this visit) 1
• Verify the BP is truly at target: <130/80 mmHg for most patients, individualized for elderly based on frailty 1

Assess Medication Adherence

• Directly ask about medication adherence - this is a critical step that guidelines explicitly recommend checking 1
• Inquire about missed doses, difficulty affording medications, or side effects that may affect compliance 1
• Consider simplifying the regimen with once-daily dosing or single-pill combinations if adherence is suboptimal 1

Ongoing Management Actions

Lifestyle Reinforcement

• Reinforce lifestyle interventions even when BP is controlled, as these remain foundational 1
• This includes dietary modifications, weight management, physical activity, and sodium restriction 1

Medication Continuation

• Continue current antihypertensive regimen without changes if BP is at target and patient tolerates medications well 1
• Do not reduce or discontinue medications simply because BP is controlled - the control is achieved because of the medications 1

Screen for Complications

• Check for target organ damage or complications if not recently assessed 1
• This may include basic metabolic panel (electrolytes, creatinine), urinalysis for proteinuria, and assessment for cardiovascular complications 1
• However, testing should not delay or impede ongoing treatment 1

Follow-Up Scheduling

Timing of Next Visit

• Schedule follow-up in 3-5 months for patients whose BP is controlled and stable 1
• This is in contrast to monthly follow-up, which is reserved for patients initiating new medications or those not yet at target 1

Out-of-Office Monitoring

• Consider home blood pressure monitoring (HBPM) to confirm sustained control and detect white coat effect or masked uncontrolled hypertension 1
• Home BP targets are <135/85 mmHg (slightly higher than office targets) 1

Common Pitfalls to Avoid

Do Not Prematurely Reduce Medications

• Avoid the temptation to reduce or stop medications when BP is well-controlled - this is a common error that leads to loss of control 1
• The patient's controlled BP is the result of treatment, not an indication to stop treatment 1

Do Not Overlook Adherence Issues

• Failure to assess adherence is a major reason for apparent treatment success that later fails 1
• Patients may have been non-adherent before the visit and temporarily compliant, or vice versa 1

Do Not Ignore Diastolic BP

• While systolic BP is the primary target, ensure diastolic BP is not excessively low (<60 mmHg), particularly in high-risk patients, as this may paradoxically increase cardiovascular risk 1

Documentation

• Record current BP, current medications and doses, adherence assessment, and plan for next follow-up 1
• Document that target BP has been achieved and maintained 1