BEYOND THE NUMBERS: IMPROVING HYPERTENSION DETECTION AND INTERVENTION
Faculty:
L. Austin Fredrickson, MD, FACP
L. Austin Fredrickson is an Associate Professor of Internal Medicine at Northeast Ohio Medical University, where he serves as core faculty and teaches diagnostics, therapeutics, clinical skills, and health humanities. He is board-certified in general internal medicine and practices rural primary care.
Liz Fredrickson, PharmD, BCPS
Liz Fredrickson, PharmD, BCPS, is an Associate Professor of Pharmacy Practice and Pharmaceutical Sciences at the Northeast Ohio Medical University (NEOMED) College of Pharmacy, where she is course director of the Parenteral Products and Basic Pharmaceutics Lab courses.
Jeannette Y. Wick, RPh, MBA, FASCP
Jeannette Y. Wick is the Director of the Office of Pharmacy Professional Development at the University of Connecticut.
Pamela Sardo, PharmD, BS
Pamela Sardo, PharmD, BS, is a freelance medical writer and licensed pharmacist. She is the founder and principal at Sardo Solutions in Texas. Pam received her BS from the University of Connecticut and her PharmD from the University of Rhode Island. Pam’s career spans many years in retail, clinics, hospitals, long-term care, Veterans Affairs, and managed health care responsibilities across a broad range of therapeutic classes and disease states.
Abstract
Despite the central role of statins in atherosclerotic cardiovascular disease (ASCVD) risk reduction, many patients need additional or alternative therapies due to intolerance, suboptimal response, or residual risk. This continuing education activity will review the practical, evidence-based use of non-statin therapies and describe where each fits in contemporary clinical care pathways. Learners will review indications, dosing, safety and monitoring strategies, and cost and access issues. Throughout this activity, the focus will be on team-based strategies to optimize patient outcomes.
Accreditation Statements
In support of improving patient care, RxCe.com LLC is jointly accredited by the Accreditation CouncilTM for Continuing Medical Education (ACCME®), the Accreditation Council for Pharmacy Education (ACPE®), and the American Nurses Credentialing Center (ANCC®), to provide continuing education for the healthcare team.
This activity was planned by and for the healthcare team, and learners will receive 2 Interprofessional Continuing Education (IPCE) credits for learning and change.
Joint Universal Activity Number: The Joint Accreditation Universal Activity Numbers assigned to this activity are as follows:
Pharmacists: JA4008424-0000-26-011-H01-P
Pharmacy Technicians: JA4008424-0000-26-011-H01-T
Credits: 2 contact hour(s) (0.2 CEU(s)) of continuing education credit.
Credit Types:
IPCE Credits - 2 Credits
AAPA Category 1 Credit™️ - 2 Credits
AMA PRA Category 1 Credit™️ - 2 Credits
Pharmacy - 2 Credits
Type of Activity: Knowledge and Application
Media: Computer-Based Training (i.e., online courses)
Estimated time to complete activity: 2 contact hour(s) (0.2 CEU(s)), including Course Test and course evaluation.
Release Date: January 26, 2026 Expiration Date: January 26, 2029
Target Audience: This educational activity is for Physicians, Physician Assistants, Pharmacists, and Pharmacy Technicians
How to Earn Credit: From January 12, 2026, through January 12, 2029, participants must:
Read the “learning objectives” and “author and planning team disclosures;”
Take the “Educational Activity Pre-Test;”
Study the section entitled “Educational Activity;” and
Complete the Educational Activity Post-Test. The Educational Activity Post-Test will be graded automatically. Following successful completion of the Educational Activity Post-Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)
CME Credit: Credit for this course will be uploaded to CPE Monitor® for pharmacists. Physicians may receive AMA PRA Category 1 Credit™️ and use these credits toward Maintenance of Certification (MOC) requirements. Physician Assistants may earn AAPA Category 1 CME credit, reportable through PA Portfolio. All learners shall verify their individual licensing board’s specific requirements and eligibility criteria.
Statement of Need
Hypertension affects nearly half of adults in the U.S., yet it remains underdiagnosed and undertreated. Only 24% of patients achieve adequate blood pressure control, and more than one-third are unaware of their condition. This contributes to hypertension-related deaths and large health care costs. Persistent gaps include inaccurate clinic measurements and missing ‘white coat hypertension.’ Complex regimens, side effects, and poor adherence are real-world scenarios that lead to inadequate patient care. Suboptimal acceptance of lifestyle changes, such as the DASH diet, exercise, and sodium reduction, and inconsistent out-of-office monitoring also contribute to suboptimal patient treatment. Interprofessional teams require collaborative skills in accurate blood pressure assessment, application of updated guidelines, individualized pharmacologic strategies, adherence support, and team-based approaches to overcome barriers. This activity aims to provide opportunities to improve hypertension detection and reduce CV risk in patients.
Learning Objectives: Upon completion of this educational activity, participants should be able to:
Explain the epidemiology and implications of undetected and undertreated hypertension
Recall evidence-based recommendations for hypertension screening, diagnosis, and intervention
Compare and contrast lifestyle and pharmacologic treatment strategies for blood pressure management
Explain the roles of interprofessional teams in the detection and treatment of hypertension
Disclosures
The following individuals were involved in planning, developing, and/or authoring this activity: L. Austin Fredrickson, MD, FACP; Liz Fredrickson, PharmD, BCPS; Jeannette Y. Wick, RPh, MBA, FASCP; and Pamela Sardo, PharmD, BS. None of the individuals involved in developing this activity has a conflict of interest or financial relationships related to the subject matter. There are no financial relationships or commercial or financial support relevant to this activity to report or disclose by RxCe.com or any of the individuals involved in the development of this activity.
© RxCe.com LLC 2026: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.
Educational Activity Pre-Test
Which of the following describes 'masked hypertension'?
Elevated BP in clinic but normal at home
Normal BP in clinic but elevated at home
Elevated BP in both settings (clinic and at home)
Elevated BP only at night
Which condition is present in >80% of adults with resistant hypertension?
Chronic kidney disease
Obstructive sleep apnea
Diabetes mellitus
Heart failure
How often should adults ≥40 years or those at higher risk be screened for hypertension?
Semiannually
Every 5 years
Annually
Monthly
Educational Activity
Beyond the Numbers: Improving Hypertension Detection and Intervention
Introduction
Hypertension is one of the most common chronic conditions worldwide, yet it is also one of the most frequently underdiagnosed and undertreated. Hypertension is a risk factor for atherosclerotic cardiovascular disease (ASCVD), but this risk is modifiable. Recent guideline updates emphasize earlier recognition, accurate measurement, and timely initiation of lifestyle and pharmacologic interventions for the management of hypertension. In addition, disparities in care and social determinants of health highlight the need for innovative, team-based strategies that extend beyond the clinic visit.
This continuing education activity provides a practical overview of hypertension detection and intervention. Learners will explore current recommendations for accurate blood pressure measurement, risk stratification, and treatment thresholds. Evidence-based lifestyle and pharmacologic strategies will be reviewed, along with emerging technologies such as home and ambulatory blood pressure monitoring. The roles of the interprofessional healthcare team members will be emphasized, with attention to communication, patient education, and adherence support.
The Prevalence and Cumulative Impact of Hypertension
Nearly 116 million Americans—about one-half of the adult population—are affected, with global prevalence rates similarly high.1-5 Despite its well-known risks, only 24% of patients achieve adequate blood pressure control, and more than one-third remain unaware of their condition.1-5 In 2020 alone, hypertension was listed as the primary cause of death on over 670,000 U.S. death certificates, highlighting the persistent gap between what is known about this disease and how it is managed in practice.1-5
Uncontrolled hypertension is a leading modifiable risk factor for cardiovascular disease (CVD), the foremost cause of death in the United States.6 It contributes to complications such as chronic kidney disease, heart failure, stroke, dementia, and vision loss. Because most cases are primary hypertension, which is both idiopathic and asymptomatic, the disease often goes undetected until irreversible damage occurs.6
The societal cost is equally striking, exceeding $131 billion annually in the United States alone.1-5 Raising awareness, improving detection, and intervening early are essential to reducing both cardiovascular morbidity and healthcare expenditures. Once hypertension is identified, patient education, appropriate pharmacologic management, and adherence support become critical.
The interprofessional healthcare team, comprised of physicians, advanced practice providers, pharmacists, nurses, dietitians, and other healthcare professionals, is uniquely positioned to address this gap. Through routine screening, collaborative management, and patient-centered education, the healthcare team can play a pivotal role in reducing the tremendous burden of hypertension. This continuing education program will review the prevalence and consequences of hypertension, emphasize the importance of early detection and intervention, and highlight strategies to improve outcomes through team-based care.
Defining and Classifying Hypertension
Hypertension occurs when the force of blood against arterial walls and through blood vessels dangerously increases.7 Blood pressure is measured with a sphygmomanometer (blood pressure cuff) and reported in millimeters of mercury (mm Hg) as two values: systolic blood pressure (SBP) and diastolic blood pressure (DBP). SBP (the upper number) reflects the force exerted as the heart contracts and ejects blood into circulation, while DBP (the lower number) reflects arterial pressure during cardiac relaxation between beats.7
Over the past few decades, definitions of “normal” BP have evolved. The Current consensus, which is reflected in the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines, identifies a normal BP as <130/80 mmHg.7 Readings of ≥140/90 mm Hg on repeated assessment generally require pharmacologic treatment, while 130/80 mmHg serves as the diagnostic cutoff for hypertension in most U.S. adults, whether or not they are taking antihypertensive therapy.7
Importantly, a diagnosis of hypertension requires blood pressure measurements both in the office and at home (ambulatory blood pressure measurements).8 Table 1 outlines the four categories of hypertension classification defined by the ACC/AHA guidelines.7
Table 1
Blood Pressure Classification in Adults7
| Category | Systolic (mmHg) | Diastolic (mmHg) |
|---|---|---|
| Normal | <120 | <80 |
| Elevated | 120–129 | <80 |
| Hypertension – Stage 1 | 130–139 | 80–89 |
| Hypertension – Stage 2 | ≥140 | ≥90 |
Note: If systolic and diastolic pressures fall into different categories, the higher value determines the classification.
Two other types of hypertension with which to be familiar include white coat hypertension and masked hypertension.7 White coat hypertension refers to elevated blood pressure readings in the clinical setting that are not confirmed by out-of-office measurements.7 Conversely, masked hypertension is characterized by normal readings in the office but elevated pressures when measured at home or with ambulatory monitoring. Both conditions highlight the importance of confirming office blood pressure findings with out-of-office assessments.7
Patient Case
Mr. Johnson is a 58-year-old Black male with a history of type 2 diabetes, obesity (BMI 34), and obstructive sleep apnea. He presents for a routine primary care visit where his blood pressure is 152/92 mmHg. He admits he has not been taking his lisinopril regularly because of a bothersome cough and often forgets his evening hydrochlorothiazide dose. He also eats most of his meals from fast-food restaurants and has little time for exercise because of his work schedule. He has not had his CPAP machine checked in over a year.
Risk Factors for Hypertension
Hypertension develops through a complex interaction of modifiable and non-modifiable risk factors. Notably, nearly 1 in 5 patients with hypertension has three or more risk factors, which compounds their overall cardiovascular risk.9
Non-modifiable factors include older age (≥65 years), family history, and certain ethnic backgrounds. In particular, Black, Pacific Islander, and Hispanic populations experience a disproportionately higher prevalence of hypertension and its complications.7,10,11 In addition, patients with diabetes mellitus face a significantly higher risk, with studies finding that approximately 71% of patients with diabetes will develop hypertension.12 Another key risk factor is obstructive sleep apnea (OSA), which is present in more than 80% of adults with resistant hypertension and underscores the importance of screening for sleep disorders in difficult-to-control hypertension cases.13
Social determinants of health also play a large role in the development of hypertension. A recent study identified that numerous factors, including poverty, food insecurity, poor housing, limited access to green spaces, transportation barriers, structural racism, psychosocial stress, and adverse childhood experiences, can dramatically impact hypertension risk and outcomes.14 These factors promote unhealthy behaviors, increase chronic stress and inflammation, and limit access to preventive health care, collectively driving disparities across the life course.14 Mechanistic evidence finds that psychosocial stress alters neuroendocrine and inflammatory pathways, further predisposing disadvantaged groups to hypertension and CVD.14
In contrast, modifiable lifestyle-related risk factors provide healthcare teams and patients with an opportunity for prevention. Aggressively addressing weight, diet, physical activity, alcohol, and smoking behaviors can reduce the risk of cardiovascular events by up to 15%.15 Hypertension risk rises sharply with overweight/obesity and abdominal adiposity, sedentary behavior, diets high in sodium and fat but low in potassium, excess alcohol use, and tobacco smoking.7,10,11 Pharmacists on the care team can assist by identifying medications that may contribute to a patient’s risk of secondary hypertension (Table 2).
Table 2
Medications that May Cause Secondary Hypertension
| Mechanism | Examples |
|---|---|
| Volume Expansion / Fluid Retention | Corticosteroids (glucocorticoids, mineralocorticoids) NSAIDs (chronic use) Sodium-containing antacids Erythropoietin Cyclosporine, tacrolimus |
| Hormonal Effects | Oral contraceptives (higher estrogen doses) Glycyrrhizin (black licorice → mimics mineralocorticoid activity) |
| Sympathetic Nervous System Activation | Decongestants (phenylephrine, pseudoephedrine) Stimulants (methylphenidate, amphetamines, weight-loss drugs) |
| Neuropsychiatric / Metabolic Effects | Antidepressants (TCAs, SSRIs, MAOIs) Atypical antipsychotics (clozapine, olanzapine) |
| Direct Vascular / Endothelial Effects | Angiogenesis inhibitors (bevacizumab) Tyrosine kinase inhibitors (sunitinib, sorafenib) |
An active area of research is the role of salt sensitivity in blood pressure regulation.16-18 This phenomenon, more common in Black patients, older adults, and those with chronic kidney disease, diabetes, or metabolic syndrome, is an exaggerated blood pressure response to dietary sodium intake.16-18 Recent large-scale genetic studies from the United Kingdom identified over 100 loci linked to blood pressure regulation, including variants at the NADPH oxidase 4 (NOX4) locus.16-18 This gene influences both vasodilation and the production of reactive oxygen species in vascular and renal tissues, providing mechanistic insight into salt-sensitive hypertension, which affects an estimated 50–60% of hypertensive patients.16-18 Currently, methods for clinically measuring salt sensitivity are limited to research settings.16-18 However, simplified and cost-effective approaches are under investigation, with the potential to transform future hypertension management.16-18
Screening for Hypertension
The U.S. Preventive Services Task Force (USPSTF) recommends that all adults aged 18 years and older be screened for hypertension.19 Screening frequency depends on age and risk status. Adults aged 40 years and older or those at increased risk, including individuals who are Black, overweight or obese, or who have had elevated blood pressure in the past, should be screened semiannually.19 In contrast, younger adults (18–39 years) with no additional risk factors and consistently normal prior readings may be screened annually.19
Screening should begin with an office, clinic, or pharmacy-based measurement using a validated device. However, because single in-office measurements may over- or underestimate true blood pressure, the USPSTF emphasizes that confirmation with out-of-office monitoring is essential.19 The gold standard for assessing blood pressure is ambulatory blood pressure monitoring (ABPM), which can identify both white-coat and masked hypertension.19 Home blood pressure monitoring (HBPM) with validated devices is an acceptable alternative when ABPM is not feasible.19 This two-step approach ensures accurate diagnosis and avoids overtreatment.
Managing Hypertension
The goals of hypertension management are straightforward and vital: achieve blood pressure control while reducing the long-term risks of cardiovascular disease, kidney damage, and heart failure.20 Current US guidelines emphasize a target blood pressure of <130/80 mm Hg for most adults, though individualization remains essential, particularly for older adults or patients with multiple comorbidities.7 The ultimate objective is to reduce morbidity and mortality from stroke, myocardial infarction, renal failure, and other complications of uncontrolled hypertension.7
Effective management requires a dual approach. First, the healthcare team should recommend and reinforce nonpharmacological interventions, including weight reduction, sodium restriction, regular physical activity, moderation of alcohol intake, and smoking cessation.7 Lifestyle changes provide additive benefits even when medications are necessary. Second, pharmacologic therapy tailored to the patient's comorbidities, tolerability, and risk profile.7 Health team members play a crucial role in patient education and support, reminding patients of their individualized targets and encouraging adherence.
Nonpharmacologic Therapy
All patients with hypertension need to adopt lifestyle modifications that directly address the risk factors listed above. These include incorporating a heart-healthy diet (such as the DASH diet), increasing potassium intake and reducing sodium intake, limiting alcohol consumption, engaging in regular physical activity, and maintaining a healthy weight.7 Lifestyle modifications alone have the potential to mean SBP by about 5 mm Hg in patients with HTN and by 2 to 3 mm Hg in patients without HTN.21
The ideal diet plan for HTN focuses on healthier eating, reduced sodium intake, and increased potassium intake.21 Reducing dietary sodium by 1,000 mg can lower SBP by 3 mm Hg, and increasing potassium intake by 0.6 g/day can result in a 1 mm Hg reduction in SBP.21 The Dietary Approaches to Stop Hypertension (DASH) diet and the Mediterranean diet are commonly recommended, and both have evidence to decrease the risk of HTN.21 These diets emphasize fruits, vegetables, whole grains, olive oil, nuts, and seeds, while promoting consumption of less red meat, sodium, and saturated and total dietary fat. These diets also encourage acceptable alcohol consumption (two or fewer drinks daily for men and one or fewer drinks daily for women).21 Careful adherence can result in lower SBP, with overall reductions up to 11 mm Hg, allowing for better BP control.7,21
As physical inactivity is a major risk factor for HTN, increasing exercise is critical. Exercise can reduce SBP by an average of 5 to 8 mm Hg and DBP by 3 mm Hg.23,24 The guidelines recommend at least 150 minutes per week of moderate-intensity physical activity, such as brisk walking.7 Often, when patients think about exercise, they think about aerobic exercises (e.g., cycling, dancing, swimming, running) and may feel overwhelmed by the idea of starting an intensive exercise regimen.23,24 However, evidence indicates that dynamic resistance exercise and static isometric exercises can also improve BP. Patients may find that starting slowly with low-intensity workouts and setting goals to gradually increase helps build endurance and strength.7,23,24
Weight loss can lead to hypertension reversal if patients lose enough weight, but it is a significant challenge for many patients.25 Modest weight loss can have a positive impact on BP; a 2- to 4-kg (2.2 to 8.8 pound) reduction in weight has been shown to decrease SBP by 3 to 8 mm Hg.25 The typical formula for weight loss involves reducing caloric intake and increasing physical activity; however, success varies from patient to patient. (Increasingly, researchers are finding that this formula may be overly simplified.)25 Ideally, experts recommend a gradual weight loss approach, with a weekly goal of 1 to 2 kg (2.2 to 4.4 pounds).7,25
Smoking cessation and moderating or discontinuing alcohol use are also important.20 Within pharmacy settings, technicians often have more time than pharmacists to assist patients in finding smoking cessation products. Reviewing these products and understanding their differences can prepare technicians to effectively answer questions.
Pharmacologic Therapy
Any decision to begin pharmacologic treatment of hypertension must be individualized and patient-centered. From a guideline perspective, clinicians should initiate pharmacologic therapy based on the patient’s risk for atherosclerotic cardiovascular disease (ASCVD) and hypertension stage (see Table 3 below) if lifestyle modifications alone do not help patients achieve a normal blood pressure.7 The ACC’s website includes an ASCVD Pooled Cohort Equations calculator that can be downloaded as a mobile phone application.7 Many electronic medical record systems embed this tool in their clinical information systems.
ACC’s ASCVD Pooled Cohort Equations Calculator: https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/ |
|---|
The ACC considers patients to be at an "elevated" risk if the Pooled Cohort Equations-predicted risk is at least 10%.7 The ACC has validated this calculator for US adults aged 40 to 79 years who are not taking concurrent statin therapy. For patients older than 79, the 10-year ASCVD risk generally exceeds 10%, and prescribers should instead use an SBP threshold of 130 mm Hg to start antihypertensive drug treatment.7 In all patients, prescribers need to consider predicted CVD risk in conjunction with BP to guide antihypertensive drug therapy.26-28
Table 3
Guideline Recommendations for
Antihypertensive Treatment Initiation7,26-28
| Classification | Treatment |
|---|---|
| Normal | Healthy lifestyle habits (prevention) |
| Elevated | Nonpharmacologic interventions (lifestyle modification) |
| Stage I | CVD risk < 10%: Use nonpharmacologic interventions CVD risk > 10%: Use nonpharmacologic interventions and add antihypertensive(s) |
| Stage II | Use nonpharmacologic interventions and add antihypertensives (s); consider two antihypertensives as initial therapy |
| ABBREVIATION: CVD = cardiovascular disease | |
Notably, many studies have identified that the extent of blood pressure reduction is more important than the choice of medication for overall risk reduction.29 While the ACC/AHA guideline recommends thiazide diuretics, calcium channel blockers, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers as first-line therapies, the choice of medication should be specific to patient preference, comorbidities, and potential for allergies or drug interactions.29 Additionally, use of once-daily medications may simplify treatment and improve adherence.29 Table 4 lists medications and describes the common adverse drug reactions (ADRs) associated with them.31-33 Clinicians should check a patient’s blood pressure every two to four weeks after starting medication.7
Table 4
Initial Therapy: Thiazide Diuretics, Calcium Channel Blockers,
and Angiotensin-Converting Enzymes, Angiotensin Receptor Blockers7,20,31-33
| Medication Class and Approved Medications* | Potential Class Adverse Events and Counseling Points* |
|---|---|
Angiotensin-converting enzyme inhibitors
|
|
Angiotensin Receptor Blockers
|
|
Calcium Channel Blockers
|
|
Thiazide Diuretics
|
|
Many medications used today have been available for many years and are inexpensive. For this reason, treating HTN early is not only smart but also cost-effective.34 Clinicians often choose to start hydrochlorothiazide (HCTZ) or chlorthalidone, which rarely cause adverse effects. By increasing urine production and excretion through the kidneys, these drugs can decrease blood volume and lower BP. Efficacy evidence is stronger for chlorthalidone and indapamide than for HCTZ, but in practice, HCTZ use is more common.34
Approximately one-third of patients will need three or more antihypertensive drugs, and recent trends in prescribing have explored the idea of earlier use of combination pills.37 Up-titrating monotherapy is often ineffective, time-consuming, and frustrating for prescribers and patients.37 Several studies have found that early use of a drug combination can reduce BP more quickly and effectively, and results indicate a higher proportion of patients achieve targets with favorable cardiovascular outcomes.37 One randomized, placebo-controlled, double-blind, crossover trial (N = 55 participants with untreated HTN) used a "quadpill” which contained irbesartan 37.5 mg, amlodipine 1.25 mg, hydrochlorothiazide 6.25 mg, and atenolol 12.5 mg.38 Patients treated with the quadpill attained an average reduction in SBP of 19 mm Hg and in-office BP of 22/13 mm Hg.38 All participants reached a target of less than 140/90 mm Hg during the quadpill arm compared to 33% of placebo-treated participants.38
Patients with stage II HTN should begin therapy with two medications from different classes.7,20 ACE inhibitors and ARBs are effective treatments for HTN, and prescribers often use them for patients with underlying heart disease, diabetes, or kidney disease.7 ACE inhibitors block the conversion of angiotensin I to angiotensin II, decreasing BP and reducing sodium and fluid retention. ARBs block angiotensin II, decreasing BP and improving blood flow. ACE inhibitors and ARBs are usually well-tolerated but may cause cough, dizziness, and hyperkalemia.20 Calcium channel blockers (CCB) are also effective. These agents block the entry of calcium into cardiac and vascular cells, decreasing BP and improving blood flow. Both classes may cause dizziness, fatigue, and gastrointestinal disturbances.20
Various combinations include ACE inhibitors, ARBs, or calcium channel blockers with thiazide diuretics. Prescribers should individualize the drugs in combination therapy based on the patient’s specific needs, tolerability, and potential adverse effects, especially with drugs associated with electrolyte disturbances. They should also avoid using two drugs with the same (or similar) mechanisms of action.20
Table 5
Additional drugs for Hypertension7,20,37-48
| Medication Class and Approved Medications* | Potential Class Adverse Events and Counseling Points* |
|---|---|
Alpha1 antagonists
|
|
Beta-blockers (cardioselective)
|
|
Beta-blockers (non-cardioselective)
|
|
Beta-blockers (third-generation β-adrenoreceptor antagonists)
|
|
Central alpha2 agonists
|
|
Direct vasodilators
|
|
Loop diuretics
|
|
Mineralocorticoid receptor antagonists
|
|
Potassium-sparing diuretics
|
|
*Taken from References 37-48
Continued Uncontrolled Hypertension
Despite the availability of safe, effective, and affordable antihypertensive medications, nearly three out of four patients continue to have uncontrolled hypertension in the United States. This treatment gap highlights a multifactorial problem that involves both healthcare system limitations and patient-related barriers.49,50,51
Prescriber-related barriers. Clinical inertia remains a major contributor to poor hypertension control. Clinicians may prescribe suboptimal doses, fail to escalate therapy when blood pressure remains elevated, or continue a regimen despite inadequate response. In some cases, the chosen medication may not align with the patient’s comorbidities, race/ethnicity, or individual response, further reducing effectiveness. Lack of timely follow-up and fragmented care models can compound these issues.
Patient-related barriers. Even when effective medications are prescribed, outcomes are often limited by low adherence. Studies show that about 12% of patients never fill their initial antihypertensive prescription, and among those who do, average adherence falls below 50% within one year. Contributing factors include adverse effects, complex regimens requiring multiple daily doses, and competing life priorities. Cost and limited healthcare access—especially in rural or underserved communities—are major obstacles. Additionally, failure to adopt lifestyle modifications such as reducing sodium intake, increasing physical activity, and achieving weight loss can blunt the effects of therapy.
When both prescriber and patient barriers converge, the consequences can be severe. Uncontrolled hypertension significantly increases the risk of myocardial infarction, stroke, chronic kidney disease, and premature death. Importantly, these outcomes are largely preventable with consistent and guideline-directed care. Pharmacists, as accessible and trusted healthcare professionals, are uniquely positioned to identify these barriers, provide patient education, support adherence strategies, and collaborate with prescribers to optimize patient care and therapy.
Return to Patient Case
The care team—including his primary care physician, pharmacist, nurse, dietitian, and social worker—meets to develop an interprofessional plan. The physician discusses switching his ACE inhibitor to an ARB, the pharmacist provides adherence counseling and recommends a once-daily fixed-dose combination, the nurse demonstrates proper home blood pressure monitoring, the dietitian reviews sodium reduction strategies, and the social worker connects him with a local food assistance program and smoking cessation resources.
On the Hypertension Horizon
In June 2025, the FDA approved Widaplik, a novel single-pill triple combination containing telmisartan, amlodipine, and indapamide for the treatment of hypertension in adults.52 This approval reflects the growing emphasis on fixed-dose combinations to simplify regimens, improve adherence, and achieve earlier, more aggressive blood pressure control. Reinforcing this paradigm shift, the new 2025 U.S. hypertension guidelines—jointly issued by the American College of Cardiology (ACC), American Heart Association (AHA), and eleven other professional organizations stress the importance of initiating treatment promptly and intensifying therapy when needed, while continuing to emphasize foundational lifestyle interventions.53 The guidelines also highlight the connection between hypertension and cognitive decline, underscore the importance of careful blood pressure management in pregnancy, and recommend a move toward personalized risk-based care using the newer PREVENT risk calculator in place of the long-utilized pooled cohort equations (PCE).53 This shift reflects a broader vision that integrates precision risk assessment with streamlined single-pill therapies.
Looking forward, several agents in development may soon expand the therapeutic landscape. Baxdrostat, a selective aldosterone synthase inhibitor, has demonstrated significant blood pressure reductions in early studies for managing treatment-resistant hypertension.54 Similarly, lorundrostat, another aldosterone synthase inhibitor, has shown promising efficacy in patients with uncontrolled and treatment-resistant hypertension.55
Hypertension Intervention: An Interprofessional Care Team Approach
Hypertension management is most effective when it is approached as an interprofessional effort, with each member of the healthcare team contributing unique expertise. Physicians and advanced practice providers (APPs) play a central role in diagnosing hypertension, initiating treatment, and tailoring therapy to comorbidities and patient characteristics. Pharmacists complement this work by reviewing regimens for drug–drug interactions, monitoring for adverse effects, and recommending dose adjustments or therapeutic substitutions when treatment response is inadequate. Nurses reinforce these efforts by routinely checking blood pressure during visits, documenting side effects, and providing essential follow-up between physician encounters, while technicians and medical assistants support workflow by accurately collecting vital signs, reconciling medications, and providing refill reminders.
Patient education is a shared responsibility across the team. Pharmacists and nurses collaborate to counsel patients about proper medication use, adherence strategies, and management of side effects. Dietitians provide targeted guidance on reducing sodium intake, achieving healthy weight loss, and adopting practical dietary changes, while respiratory therapists and sleep specialists evaluate and reinforce management of comorbid conditions such as obstructive sleep apnea, which can undermine blood pressure control. Technicians can expand this educational reach by encouraging blood pressure screenings for patients over 40 and assisting patients in interpreting nutrition labels for sodium content.
Accurate blood pressure monitoring at home is another area where teamwork is critical. Nurses and pharmacists demonstrate proper technique, including sitting quietly before the measurement, correctly positioning the cuff, and maintaining consistent conditions. Pharmacists can verify device accuracy and encourage patients to use logs or device memory to track results, while prescribers may order ambulatory blood pressure monitoring in cases of suspected nocturnal dipping, morning surges, or unexplained variability. Care coordinators and case managers ensure that home readings are accurately integrated into the medical record, allowing the entire team to make informed decisions.
Sustained lifestyle modification requires consistent reinforcement from multiple disciplines. Physicians and dietitians guide weight management and exercise planning, while pharmacists and nurses adjust therapy as blood pressure falls with successful weight loss. For some patients, physicians may consider referral for bariatric surgery, which has been shown to produce durable reductions in blood pressure and long-term cardiovascular risk.
Finally, interprofessional care extends beyond clinical interventions to address systemic barriers. Social workers and case managers provide critical support by assisting patients with concerns about costs, insurance coverage, and transportation, which often impede consistent care. Across all disciplines, team members share the responsibility of motivating patients, celebrating progress, and adjusting strategies to sustain long-term control. When clinicians, pharmacists, nurses, dietitians, and support staff collaborate in this way, hypertension care becomes more consistent, patient-centered, and effective, reducing the risks of cardiovascular events, kidney disease, and stroke.
Summary
Hypertension is a highly prevalent but often underdiagnosed and undertreated condition that affects nearly half of U.S. adults and remains a leading modifiable risk factor for cardiovascular morbidity and mortality. Current guidelines define hypertension as blood pressure ≥130/80 mmHg, with diagnosis requiring confirmation through out-of-office measurements such as ambulatory or home blood pressure monitoring. Risk factors include both non-modifiable contributors, such as age, race, and genetics, and modifiable factors, including obesity, poor diet, physical inactivity, alcohol use, and tobacco use. Social determinants of health further drive disparities in hypertension prevalence and outcomes.
Effective management requires a dual approach: nonpharmacologic interventions such as sodium reduction, weight loss, regular exercise, and smoking cessation, alongside pharmacologic therapy tailored to comorbidities and patient needs. First-line medications include ACE inhibitors, ARBs, calcium channel blockers, and thiazide diuretics, with combination therapy often needed for Stage 2 hypertension. Interprofessional collaboration is critical, with physicians, pharmacists, nurses, dietitians, and social workers working together to improve screening, enhance adherence, and address barriers to care. By leveraging team-based care and evidence-based strategies, clinicians can improve blood pressure control, reduce cardiovascular risk, and alleviate the substantial individual and societal burden of hypertension.
References
Centers for Disease Control and Prevention. Facts about hypertension. CDC. January 28, 2025. Accessed January 26, 2026. https://www.cdc.gov/high-blood-pressure/data-research/facts-stats/?CDC_AAref_Val=https://www.cdc.gov/bloodpressure/facts.htm
GBD 2015 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1659-1724.
Cheema AAA, Ibrahim M, Zia A, et al. Trends in hypertension- and dementia-related mortality in the United States: An observational analysis from 1999 to 2020. Medicine (Baltimore). 2025;104(51):e46611. doi:10.1097/MD.0000000000046611
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