What is the recommended evaluation and treatment approach for an adult with uncontrolled hypertension?

Management of Uncontrolled Hypertension

For adults with uncontrolled hypertension, immediately confirm true resistance through home or ambulatory BP monitoring, assess medication adherence objectively, and intensify therapy using two-drug single-pill combinations (ACE inhibitor/ARB plus amlodipine or chlorthalidone) with monthly follow-up until BP <130/80 mm Hg is achieved. 1, 2

Step 1: Confirm True Uncontrolled Hypertension

Before escalating therapy, rule out pseudo-resistance:

• Verify proper BP measurement technique: Use appropriate cuff size, ensure patient is seated with back supported and feet flat after 3-5 minutes of rest 2
• Obtain out-of-office BP monitoring: Use home BP monitoring (twice daily, 2 readings 1 minute apart for 2 weeks) or 24-hour ambulatory monitoring to exclude white coat hypertension, which affects a significant proportion of patients with elevated office readings 3, 2
• Assess medication adherence objectively: Review pharmacy refill records, as non-adherence accounts for up to 50% of apparent treatment failure and 25% of patients never fill their initial prescription 3, 4, 2
• Review interfering substances: Identify NSAIDs, decongestants, stimulants, oral contraceptives, herbal supplements with sympathomimetics, and excessive alcohol intake 2

Step 2: Screen for Secondary Hypertension

Screen when BP remains uncontrolled despite appropriate therapy or when specific clinical features are present 3:

• Renal parenchymal disease: Check urinalysis, serum creatinine, and renal ultrasound if history of urinary tract infections, hematuria, or family history of polycystic kidney disease 3
• Primary aldosteronism: Measure aldosterone-to-renin ratio in patients with resistant hypertension, spontaneous or diuretic-induced hypokalemia, or incidental adrenal mass 3
• Renovascular disease: Consider renal Duplex Doppler if abrupt onset hypertension, flash pulmonary edema, or abdominal bruit present 3
• Obstructive sleep apnea: Screen young obese adults first, as this is the most common secondary cause in this population 4

Step 3: Optimize Pharmacologic Therapy

Initial drug intensification strategy 1, 2, 5:

• Start with two-drug single-pill combination to improve adherence: ACE inhibitor or ARB plus either amlodipine (preferred calcium channel blocker) or chlorthalidone/indapamide (preferred thiazide-like diuretics, more potent than hydrochlorothiazide) 4, 2, 5
• Never combine two RAS blockers (ACE inhibitor plus ARB together) 4, 2
• Use once-daily dosing: Adherence ranges from 71-94% with once-daily dosing versus lower rates with multiple daily doses 3, 4

Sequential medication additions if BP remains ≥130/80 mm Hg 1, 2:

• Third agent: Add the complementary drug class not yet used (if on ACE inhibitor/ARB + amlodipine, add chlorthalidone; if on ACE inhibitor/ARB + chlorthalidone, add amlodipine) 2, 5
• Fourth agent: Add spironolactone 25-50 mg daily, which is the most effective add-on therapy for resistant hypertension 2, 6
• Resistant hypertension is now defined as BP ≥130/80 mm Hg despite adherence to ≥3 optimally dosed antihypertensive agents (including a diuretic), or requiring ≥4 medications 1, 7

Step 4: Implement Intensive Lifestyle Modifications

Dietary interventions 2, 5:

• Sodium restriction to <2,000 mg/day within 1 month 2
• DASH diet pattern: 4-5 servings fruits, 4-5 servings vegetables, 2-3 servings low-fat dairy daily 2
• Potassium supplementation through dietary sources enhances BP lowering 5

Weight and exercise targets 2, 5:

• Weight loss of 5-10% if BMI >25 kg/m² 2
• 150 minutes moderate-intensity aerobic exercise weekly (e.g., 30 minutes brisk walking 5 days/week) 2
• Limit alcohol to ≤2 drinks/day for men, ≤1 drink/day for women 2

Tobacco cessation is crucial for overall cardiovascular risk reduction 3

Step 5: Establish Systematic Follow-Up and Monitoring

Follow-up schedule 3, 1:

• Monthly visits after initiating or adjusting antihypertensive regimen until BP control (<130/80 mm Hg) is achieved 3
• Yearly follow-up once BP is controlled and stable 4

Home BP monitoring protocol 2:

• Measure twice daily (morning and evening), taking 2 readings 1 minute apart using validated automated monitor with appropriate cuff size 2
• Measure daily for 2 weeks after medication changes, then weekly thereafter 2
• Bring stored readings to every appointment for clinical decision-making 2

Team-based care implementation 3, 1, 2:

• Engage pharmacists, nurses, or community health workers for medication titration, which can improve BP control rates from 44% to 80% 2
• Use telehealth and secure messaging for between-visit monitoring and medication adjustments 2
• Enable remote monitoring through Wi-Fi-connected BP devices that transmit data directly to the care team 2

Step 6: Address Medication Adherence Barriers

Create a blame-free environment where patients can honestly discuss treatment challenges 3:

• Simplify regimens: Use once-daily dosing and fixed-dose combination pills 3, 4
• Use objective adherence measures: Pill counts and pharmacy refill data in addition to self-report 3
• Employ motivational strategies: Goal setting, self-monitoring, feedback, and motivational interviewing 3
• Address social determinants: Consider race, ethnicity, socioeconomic status, health literacy, and financial barriers 3, 8

Critical Pitfalls to Avoid

• Therapeutic inertia is the most common management error—ensure medication adjustment occurs at every visit until goal BP is reached 2
• Relying solely on office BP without home or ambulatory monitoring leads to misclassification of white coat or masked hypertension 2
• Failing to screen for secondary causes in young adults (<40 years) with hypertension, except obese young adults where sleep apnea should be evaluated first 4
• Combining two RAS blockers (ACE inhibitor + ARB) is contraindicated 4, 2
• For women of childbearing age: Immediately discontinue ACE inhibitors, ARBs, and direct renin inhibitors if pregnancy occurs; switch to methyldopa, nifedipine, or labetalol 1

Blood Pressure Targets

Target BP <130/80 mm Hg for most adults with confirmed hypertension and known CVD or 10-year ASCVD risk ≥10% (Class I recommendation) 1, 5. For noninstitutionalized adults ≥65 years, target SBP <130 mm Hg 1. The 2017 ACC/AHA guidelines represent a significant shift from the previous threshold of ≥140/90 mm Hg, with this lower target supported by the SPRINT trial demonstrating that intensive BP control (SBP <120 mm Hg) reduced cardiovascular events and all-cause mortality 1.