Management of Uncontrolled Hypertension

Diagnosis and Initial Evaluation

The American College of Cardiology recommends confirming true hypertension using proper measurement technique and excluding pseudoresistance, then systematically screening for secondary causes based on clinical clues, while simultaneously initiating or optimizing pharmacologic therapy with lifestyle modifications 1, 2
The American Heart Association suggests having the patient sit quietly with back supported for 5 minutes before measurement, using correct cuff size with air bladder encircling at least 80% of the arm, supporting arm at heart level, taking minimum 2 readings at 1-minute intervals, and averaging them 2
The European Society of Cardiology recommends measuring BP in both arms and using the arm with higher readings for future measurements 2
The American College of Cardiology suggests checking orthostatic BP, with a decline >20 mmHg systolic or >10 mmHg diastolic after 1 minute standing being abnormal 1

The American Heart Association recommends identifying clinical clues for secondary hypertension, including age of onset <30 years, resistant hypertension, abrupt onset or sudden worsening of previously controlled BP, severe or accelerated/malignant hypertension, and target organ damage disproportionate to duration/severity of hypertension 2, 4, 5
The European Society of Hypertension suggests considering obstructive sleep apnea, primary aldosteronism, renovascular disease, pheochromocytoma, Cushing syndrome, and renal parenchymal disease as potential secondary causes of hypertension 2, 4, 5

The American College of Cardiology recommends basic testing for all patients with newly diagnosed or uncontrolled hypertension, including fasting blood glucose, hemoglobin A1C, complete blood count, lipid profile, serum creatinine with estimated GFR, serum sodium, potassium, calcium, thyroid-stimulating hormone, urinalysis, and electrocardiogram 1
The American Heart Association suggests optional tests for target organ damage assessment, including echocardiogram, urinary albumin-to-creatinine ratio, and uric acid 1, 6

The American College of Cardiology recommends first-line agents, including thiazide diuretics, calcium channel blockers, ACE inhibitors, or ARBs, with most patients requiring ≥2 medications to achieve BP control 5, 1
The European Society of Cardiology suggests maximizing diuretic therapy first for resistant hypertension, using thiazide-like diuretics rather than classic thiazides, and adding mineralocorticoid receptor antagonist as fourth-line agent if serum potassium <4.5 mmol/L and eGFR >45 mL/min/1.73m² 2, 3, 6

The American Heart Association recommends sodium restriction to <1500 mg/day, increasing dietary potassium to 3500-5000 mg/day, weight loss if overweight/obese, physical activity, alcohol moderation, and DASH diet 5
The American College of Cardiology suggests smoking cessation and considering CPAP therapy for obstructive sleep apnea 1, 5

The American College of Cardiology recommends rechecking BP within 2-4 weeks after medication adjustment, monitoring serum sodium, potassium, and creatinine during diuretic or RAS blocker titration, and rechecking creatinine and electrolytes 1-2 weeks after starting ACE inhibitor/ARB 8, 1
The American Heart Association suggests referring to hypertension specialist if BP remains uncontrolled after 6 months of treatment or if secondary cause identified 2, 8