A 46-year-old woman comes to the clinic for follow-up treatment of hypertension. The patient was diagnosed with hypertension 2 years ago and nonpharmacological management was initially advised. A year ago, she was started on valsartan and amlodipine after her blood pressure was measured at 144/86 mm Hg. A month after treatment initiation, she reported no adverse effect from the medication and blood pressure was 130/80 mm Hg. Since then, the patient has missed several follow-up appointments, which she attributes to being busy at work. She currently has no concerns and overall feels "great." She has had no chest pain, headaches, lightheadedness, or syncope. The patient has no other medical issues and does not use tobacco or alcohol. She works as a salesperson and eats fast food a few times a month. Her mother died of a stroke at age 67. Today, blood pressure is 152/88 mm Hg in the right arm and 148/86 mm Hg in the left arm; pulse is 76/min and regular. Repeat blood pressure measurements after 15 minutes of rest are similar. BMI is 28 kg/m². Estimated jugular venous pressure is normal. There are no carotid bruits. Heart sounds are normal with no murmurs. Lung examination is unremarkable. Peripheral pulses are full and symmetric. There is no peripheral edema. Laboratory results are as follows: ECG shows normal sinus rhythm with nonspecific T-wave changes. Which of the following is the best next step in management of this patient?

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Explanation: Uncontrolled hypertension can represent true resistant hypertension or pseudoresistant hypertension; pseudoresistant hypertension is more common and can occur due to any of the following: Medication nonadherence Suboptimal medication regimen Poor adherence to lifestyle changes White-coat hypertension Inaccurate measurement of blood pressure (BP) in the clinic Medication nonadherence may account for >40% of cases of uncontrolled hypertension. This patient showed an initial improvement in her BP after initiation of valsartan and amlodipine, followed by a return to stage II hypertension after a period of poor follow-up; this suggests medication nonadherence. Because there is often misunderstanding about a prescribed antihypertensive regimen, such patients should be questioned about medication adherence and provided education about hypertension treatment goals prior to additional diagnostic testing or treatment changes. stage II hypertension (Choice A) A diuretic (eg, chlorthalidone) would be the most appropriate next medication to add to this patient's antihypertensive regimen; however, medication nonadherence should be addressed prior to adding additional medications. (Choice B) This patient's occasional fast-food intake represents suboptimal adherence to a low-sodium diet. However, it is unlikely that this mild indiscretion is the main contributor to her uncontrolled hypertension; medication nonadherence is more likely. (Choice C) True resistant hypertension exists in patients whose BP remains uncontrolled despite adherence to a regimen of ≥3 antihypertensive medications (1 being a diuretic) and reasonable optimization of lifestyle changes (eg, weight loss, low-sodium diet). It is often the result of a secondary cause (eg, primary hyperaldosteronism). This patient does not have true resistant hypertension, and workup for a secondary cause is not indicated. secondary cause (Choice D) 24-hour ambulatory BP monitoring is useful in patients with suspected white-coat hypertension (ie, high BP readings in the clinic but normal BP on average throughout the day). However, the persistence of hypertension in this patient with measurements taken 15 minutes apart makes white-coat hypertension less likely. Educational objective: Uncontrolled hypertension more commonly represents pseudoresistant hypertension rather than true resistant hypertension. Medication nonadherence is a common cause of pseudoresistant hypertension and should be suspected and adequately addressed prior to treatment changes or workup for secondary causes of hypertension. References: Medication adherence and resistant hypertension (http://www.ncbi.nlm.nih.gov/pubmed/25209307) 2017 ACC/AHA Blood Pressure Treatment Guideline Recommendations and Cardiovascular Risk (http://www.ncbi.nlm.nih.gov/pubmed/30189994) Refractory and Resistant Hypertension: Antihypertensive Treatment Failure versus Treatment Resistance (http://www.ncbi.nlm.nih.gov/pubmed/27721847)

A 46-Year-Old Woman Comes to the Clinic for Follow-Up Treatment