Does controlled hypertension become uncontrolled when target organ damage (TOD) occurs?

From the Guidelines

Yes, controlled hypertension is considered uncontrolled when end organ damage is occurring, regardless of blood pressure readings. Hypertension is ultimately defined by its harmful effects on the body, not just by numbers. When organs such as the heart, kidneys, brain, or eyes show damage from high blood pressure—like left ventricular hypertrophy, declining kidney function, stroke, or retinopathy—this indicates that the current treatment approach is inadequate, even if blood pressure measurements appear to be within target range. According to the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1, hypertensive emergencies are defined as severe elevations in BP associated with evidence of new or worsening target organ damage.

Key Considerations

• The presence of end organ damage suggests that either blood pressure control has been inadequate over time, blood pressure measurements aren't capturing true average pressures (such as missing nocturnal hypertension), or that other factors beyond hypertension may be contributing to the damage and need to be addressed.
• In such cases, treatment intensification is necessary, which may include adding medications like ACE inhibitors (e.g., lisinopril 10-40 mg daily), ARBs (e.g., losartan 25-100 mg daily), calcium channel blockers (e.g., amlodipine 5-10 mg daily), or diuretics (e.g., hydrochlorothiazide 12.5-25 mg daily) as suggested by 1.
• More frequent monitoring is also warranted, typically every 2-4 weeks until stability is achieved, to ensure that the intensified treatment approach is effective in preventing further organ damage.

Management Approach

• The management of hypertensive emergencies, as outlined in 1, demands immediate reduction of BP to prevent or limit further target organ damage, though not necessarily to normal levels.
• Examples of target organ damage include hypertensive encephalopathy, intracerebral hemorrhage (ICH), acute ischemic stroke, acute myocardial infarction (MI), acute left ventricular failure with pulmonary edema, unstable angina pectoris, dissecting aortic aneurysm, acute renal failure, and eclampsia, all of which necessitate prompt and aggressive management.
• The guideline 1 also emphasizes the distinction between hypertensive emergencies and urgencies, with the former requiring immediate hospitalization and the latter potentially manageable in an outpatient setting with adjustments to antihypertensive therapy and treatment of anxiety as applicable.

From the Research

Relationship Between Controlled Hypertension and End Organ Damage

• Controlled hypertension can become uncontrolled when end organ damage is occurring, as the damage can lead to increased blood pressure and reduced effectiveness of antihypertensive therapy 2, 3.
• End organ damage in hypertension can be detected early and reflects the patient's overall cardiovascular risk, making it essential to prevent and treat with antihypertensive treatment 3.
• The treatment of end organ damage due to hypertension centers on blood pressure reduction, with blockade of the renin angiotensin-aldosterone system being an essential part of the treatment 3.

Factors Influencing End Organ Damage

• The effectiveness of antihypertensive therapy in preventing end organ damage depends on various factors, including the type of medication used, the patient's compliance, and the presence of other underlying health conditions 4, 5.
• Combination therapy with different classes of antihypertensive medications, such as calcium channel blockers and angiotensin receptor blockers, may be beneficial in reducing end organ damage 2, 4.
• The assessment of target organ damage is crucial in evaluating and following up with hypertensive patients, as it allows for better prediction of cardiovascular risk and guides treatment decisions 6.

Importance of Blood Pressure Control

• Appropriate blood pressure control is essential for improving renal impairment and cardiac damage in patients with accelerated hypertension 2.
• Blood pressure reduction is critical in preventing and treating end organ damage, and the choice of antihypertensive medication should be based on the patient's individual needs and response to treatment 3, 5.