People can have uncontrolled hypertension because they aren’t taking blood pressure-lowering medications or making changes in their diets or activity levels that support healthy blood pressure management. But if you’re taking your medications, trying to eat a heart-healthy diet, exercising more, and you still have uncontrolled high blood pressure, you and your health care provider may need to map out a more aggressive treatment plan.
Or you and your doctor may need to look for other reasons why your blood pressure remains stubbornly high and address those causes. Sometimes other medications or conditions like obstructive sleep apnea can raise your blood pressure.
Regardless of what is preventing you from getting your blood pressure under control, just remember that with the right treatment or combination of treatments, uncontrolled hypertension can often be managed effectively. The key is committing to a treatment plan you and your doctor work out.
Importance of Blood Pressure Control
Your blood pressure is a measure of the force blood applies against the walls of your arteries. High blood pressure can injure and damage your artery walls. The injury can make it easier for plaque — cholesterol, fats, and other substances — to clog your arteries and restrict blood flow to organs. Damage to blood vessels can trigger inflammation and, over time, arterial stiffness and worsening of blood pressure. Weakened arteries can also rupture, interrupting blood flow to organs and muscles.
Stage 1 high blood pressure is defined as a blood pressure that is 130/80 mm Hg or higher. Stage 2 high blood pressure is 140/90 or higher.
When your blood pressure is too high for too long, you are at risk for a number of serious health problems, says Rajesh Gupta, MD, an interventional cardiologist and an associate professor of cardiovascular medicine at the University of Toledo College of Medicine and Life Sciences.
“Achieving healthy blood pressure is critically important for lifelong cardiovascular health,” he says. “High blood pressure is one of the main causes of heart attack, heart failure, stroke, and even dementia.” Hypertension also raises the risk of kidney disease, vision loss, and sexual dysfunction.
Even though you may be genuinely trying to get your blood pressure into a healthy range, you and your doctor can work together to improve your treatment and lower your health risks.
Getting Started
If you’re being treated for hypertension, but your blood pressure still isn’t under control, you may need to get a more accurate and thorough picture of your blood pressure status, says Sandeep Kishore, MD, PhD, an associate professor at the University of California San Francisco School of Medicine. He explains that the first step is confirming whether you are at your target blood pressure on a consistent basis.
Sometimes people have a high blood pressure reading only at the doctor’s office, but at home and in other places maintain a normal or healthy blood pressure. This is called “white coat hypertension,” and it tends to happen when people become nervous around doctors or in a clinical setting.
“The most meaningful data often comes, not from the clinic, but from home,” Kishore says. “So I work deliberately to get the most accurate picture possible with devices at home. When values remain above target, I draw on a range of strategies tailored to each patient's context and circumstances.”
Kishore adds that uncontrolled hypertension treatment usually requires more medications or increasing the dosages of your current meds as well as getting serious about lifestyle changes. “One point I always make clear: Elevated blood pressure is not the patient's fault,” he says. “We build a plan together.”
Gupta says many things can contribute to poorly controlled blood pressure, such as a high-sodium diet, obesity, sedentary lifestyle, too much alcohol use, and high levels of the hormone aldosterone — which makes the body hold on to sodium and water — among many other factors. “Your physician should review these causes and adjust treatment as needed,” he says. “In addition, if you are having difficulty with blood pressure control, you should meet with a hypertension expert.”
Medication Management
If you’re taking one or two antihypertensive medications but you’re still not reaching your blood pressure goals, you and your doctor should review the drugs you’re taking and their current dosages. It’s possible you may need to add a medication to your hypertension treatment, increase the doses of your current blood pressure medication, or use a newer treatment.
Research suggests that about 1 in 4 people being treated for uncontrolled hypertension need at least three antihypertensive medications to reach their targets. Studies also suggest that taking multiple low-dose medications may be more effective than taking a single pill to lower blood pressure.
The choice of which medication or combination of medications to use depends on your overall physical health, your current blood pressure, and other things. The main types of antihypertensives include:
- Diuretics
- Beta-blockers
- Angiotensin converting enzyme (ACE) inhibitors
- Angiotensin II receptor blockers
- Calcium channel blockers
- Alpha blockers
- Alpha-2 receptor agonists
- Vasodilators
- Aldosterone synthase inhibitor (ASI)
- mineralocorticoid receptor antagonist (MRA)
Each drug works differently to help lower blood pressure. Diuretics (specifically thiazide diuretics), ACE inhibitors, and calcium channel blockers are often first-line treatments, meaning doctors may prescribe one of them to begin blood-pressure-lowering treatment. If you currently take one or more of those drugs, your doctor may add an additional drug at a low dose to see if it helps. Newer medications include drugs that block the effect or production of aldosterone, a hormone that works to increase water and sodium retention in the kidneys.
If you take three or more antihypertensives and your blood pressure still isn’t under control, you may be diagnosed as having resistant hypertension. An estimated 12% of U.S. adults have resistant hypertension.
Gupta says it’s important to take your medications exactly as prescribed, including the time of day for each pill. He also recommends being patient, as the combination of drugs and the strengths of each dose may change several times over the course of your treatment. “The goal for medication treatment of high blood pressure is effective control of blood pressure with limited or no side effects,” he says. “Your physician should work with you to achieve a treatment regimen that can achieve both goals of getting to a healthy blood pressure and limiting any side effects.”
If you do experience side effects or your home blood pressure checks show pressures that are too low or still too high, call your doctor’s office. You may be prescribed a different medication or a lower dose of a drug you’re currently taking. Don’t stop taking a medication without first talking with your health care provider.
A Lifestyle Review
Medications alone aren’t always enough to bring down uncontrolled hypertension. Your age, diet, activity levels, sleep habits, stress levels, and factors such as how much alcohol you drink, smoking, family history, and other factors all can affect your blood pressure.
You and your doctor should look at each of these factors and figure out whether any changes could be made to support blood pressure reduction. While you can’t change your age or family medical history, you can cut back on your sodium intake, for example. Read labels carefully and opt for lower sodium products whenever possible. Using seasonings other than salt when cooking can help, too.
Likewise, start walking or exercising a little more each day. Set reasonable goals for each week, with the idea of increasing your activity level steadily over time.
“A healthy lifestyle is always the cornerstone of lifelong cardiovascular health,” Gupta says. “We should all eat healthy foods including fresh foods, cooked at home, and made mostly with fresh vegetables and fruits. People should try to exercise most days of the week and aim for 150 minutes of moderate intensity activity like walking or 75 minutes of high intensity activity like running or tennis each week. This is the American Heart Association’s recommendation for healthy levels of physical activity.”
If poor sleep is a problem, talk to a sleep specialist who can test you for sleep apnea or other conditions. About half of all people with sleep apnea also have hypertension. And if you need help quitting smoking or cutting back on your alcohol intake, talk with your primary care doctor. There are many products and programs that can help.
Questions to Ask Your Doctor
Because blood pressure control involves so many different elements, it can be challenging to keep track of everything you should be doing and everything you should know. And during appointments with your health care provider, you may not remember everything to ask.
Kishore recommends asking the following questions, as well as any others that occur to you during or prior to your appointment:
- What is my blood pressure goal, and why is it that number for me?
- How exactly do you want me to measure at home (how often, when) and are there particular devices you recommend?
- Am I on the right combination of treatments, and could a single-pill combination simplify things? And be cheaper with lower copays?
- What's my overall cardiovascular risk — not just my blood pressure?
- Should we rule out any secondary causes of high blood pressure?
- What's the plan if we're not at our goal in three months?
“Blood pressure control is one of the most impactful promises in medicine and overall cardiovascular health — it prevents strokes, heart attacks, and death,” Kishore says. “The key for patients is consistency: medications and healthy habits work together. Taking meds as prescribed, maintaining a healthy weight, staying active, and eating well all help prevent serious complications, even when you feel fine.”
Show Sources
Photo Credit: DigitalVision/Getty Images
SOURCES:
American Heart Association: “Nearly 1 in 5 with supposed drug-resistant high blood pressure aren't taking meds.” “Health threats from high blood pressure,” “Types of blood pressure medications,”
CDC: “About High Blood Pressure.”
Cleveland Clinic: “Resistant Hypertension,” “Blood Pressure,” “Blood Pressure Medication,” “What Is White Coat Syndrome?”
Rajesh Gupta, MD, cardiologist; associate professor, cardiovascular medicine, University of Toledo College of Medicine and Life Sciences.
Sandeep Kishore, MD, PhD; associate professor, University of California San Francisco School of Medicine.
Cardiovascular Journal of Africa: “Several low-dose drugs better for BP than one pill: Australian meta-analysis.”
Drugs in Context: “Combination therapy in the treatment of hypertension.”
Mayo Clinic: “Choosing blood pressure medications,” “High blood pressure dangers: Hypertension's effects on your body.”
National Heart, Lung, and Blood Institute: “High blood pressure: Causes and risk factors.”
Hypertension: “Sleep Apnea and Hypertension: Interactions and Implications for Management.”
