When patients who are receiving drug therapy fail to reach the target blood pressure goal or fail to maintain the blood pressure goal, they should have the initial drug dose increased until the goal is reached (Figure 2). Those who fail initial drug therapy at full doses should have a second drug added and increased until the blood pressure goal is reached. Those who fail initial and second drug therapy at full doses should have a third drug added and increased until the pressure goal is reached. Patients who fail to reach the goal on maximal doses of 3 drugs have, by definition, resistant hypertension and will require evaluation by a physician with expertise in managing resistant hypertension. A cause should be sought each time a patient fails to respond to a drug or fails to maintain blood pressure control on a drug that had previously controlled the pressure (Table 3).
TABLE 3
PARTIAL LISTING OF CAUSES OF FAILURE TO REACH OR MAINTAIN TARGET BLOOD PRESSURE
| Volume overload: failure to start a diuretic |
| Nonadherence to therapy: dementia, side effects, complex regimen |
| Drug-induced: prescription, over-the-counter, herbal, or illicit drugs |
| Diet/stimulant induced: caffeine, licorice, salt, alcohol, nicotine |
| Associated conditions: obesity, sleep apnea, anxiety, chronic pain |
| Identifiable causes: chronic renal disease, renovascular disease, hyperaldosteronism, Cushing’s syndrome, pheochromocytoma |
| Pseudoresistance: wrong cuff size, white-coat hypertension |
Lifestyle modifications
Several lifestyle modifications are recommended in all treatment categories. Aerobic exercise (45 to 60 minutes at least 3 days per week), low-salt, low-fat, and high fruit and vegetable diet, limited alcohol consumption (less than 3 drinks per day), and modest weight loss (3% to 9% of total body weight) have been demonstrated to yield modest blood pressure reductions, but there is insufficient evidence to suggest that these measures alone reduce morbidity or mortality in hypertensive patients.27-33 A systematic review of randomized controlled trials found an average 4.4/2.5 mm Hg reduction in blood pressure with no evidence of harm (among patients who were not at risk for hyperkalemia) when diet was supplemented with about 2000 mg of potassium daily.34 A comparable reduction in blood pressure was seen with a daily supplement of more than 3 grams of fish oil.35 Research concerning the value of calcium and magnesium supplementation is conflicting and insufficient for supplementation to be considered standard therapy at this time.
Alternative therapy
The number and the quality of studies evaluating acupuncture, biofeedback, herbal medicine, transcendental meditation, and yoga are, for the most part, limited. They have focused on reduction in blood pressure, not patient-oriented outcomes, such as a reduction in morbidity and mortality. Acupuncture does not appear to have a significant effect on blood pressure levels.36,37 Biofeedback and other behavioral techniques have not been demonstrated to reduce blood pressure.38,39 The effect of garlic on blood pressure is unclear with mixed study results.40,41 Transcendental meditation and yoga may reduce blood pressure, but studies of these modalities are small and the experimental designs have a limited capacity to detect an independent treatment effect or a placebo effect.42,43
Therefore, physicians who include any of these modalities in their hypertension treatment plan should carefully monitor each patient for adequacy of blood pressure control, development of risk factors, and evidence of end-organ damage. At this time, alternative therapies should be considered experimental adjuncts to lifestyle modification and medical therapy that have not been shown to improve patient-oriented outcomes.
Follow-up of patients with hypertension
Follow-up visits should be designed to identify new risk factors, evidence of end-organ damage, and adequacy of blood pressure control. Follow-up visits may include an interval history, limited physical examination, radiologic evaluation, and laboratory testing. The frequency and nature of follow-up hypertension evaluations will vary according to the presence or absence of preexisting risk factors, evidence of end-organ damage, the nature of the treatment the patient is receiving, and the stability of blood pressure control. Unfortunately, there is little evidence to support specific recommendations for the frequency and nature of follow-up hypertension evaluations.
In the absence of evidence, several general principles may be suggested. Patients should be seen within 2 months of initiation of treatment. Follow-up history should focus on the cardiovascular and neurologic review of systems. The examination should include a focused cardiovascular work-up (eg, retinopathy, carotid bruits). Consideration should be given to periodic laboratory testing for diabetes, renal insufficiency, and hyperlipidemia. Periodic (but less frequent) chest x-rays and electrocardiograms may be helpful to detect cardiomegaly, but there is no evidence to support such testing in the absence of symptoms.
Follow-up visits should be more frequent among patients who have marginal blood pressure control, preexisting risk factors, or end-organ damage. Evaluations may be less frequent among those with good control and no preexisting risk factors or endorgan damage. Office visits and testing should be more frequent whenever changes are made in treatment. The frequency and nature of follow-up testing will also depend on the nature of treatment. Patients taking diuretics should have their potassium levels checked periodically. Renal function and potassium should be monitored in patients who are taking ACE inhibitors, especially during the first few weeks of therapy.