Vivian Fonseca, MD, FRCP

Panelists discuss how improving adherence requires both individual strategies like smartphone reminders and smart medication monitoring devices, as well as population-level interventions including reducing sodium content in processed foods and harmonizing hypertension guidelines to address the epidemic of poorly controlled blood pressure.

Optimizing Patient Adherence and Targeting the Root Causes of Treatment Resistance 

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Modern adherence improvement strategies leverage smartphone technology and digital health tools to address the fundamental challenge of medication-taking persistence. Smart medication caps, phone alarms, and remote monitoring systems provide objective data about patient medication-taking behavior while enabling more targeted interventions. These technological solutions must be implemented thoughtfully, recognizing that opening a pill bottle doesn’t guarantee medication consumption, but they provide valuable conversation starters between patients and providers.

Addressing resistant hypertension requires population health approaches targeting root causes, particularly dietary sodium reduction through food industry regulation. International examples from the UK demonstrate that reducing sodium content in processed foods can achieve meaningful population-level blood pressure improvements. Public health initiatives must balance individual choice with protective policies, similar to approaches used for clean water and food safety, recognizing that personal responsibility alone cannot address the epidemic of poor blood pressure control.

The future of hypertension management lies in addressing underlying causes rather than simply adding medications indefinitely. This includes governmental leadership in food policy, health care system redesign for chronic disease management, and individual education about lifestyle modifications. The goal is creating environments where patients who want to maintain good health can do so without being undermined by unhealthy food systems, while preserving individual choice and autonomy in health care decisions.

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Panelists discuss how newer therapies will likely be incorporated into guidelines with improved reimbursement structures over time, similar to the evolution seen with lipid-lowering medications, making advanced treatments more accessible for patients with uncontrolled blood pressure.

Integration of Newer Agents Into Future Guidelines

Future hypertension guidelines will likely incorporate newer therapeutic options like endothelin receptor antagonists and renal denervation more prominently as evidence accumulates. The field is moving toward more precision-based approaches, attempting to match specific patient phenotypes with optimal therapeutic interventions rather than universal treatment algorithms. This evolution requires better characterization of patient subgroups and their differential responses to various antihypertensive mechanisms.

Health care reimbursement structures will need to evolve to support newer, more expensive antihypertensive therapies, similar to the progression seen with lipid-lowering medications beyond statins. Current barriers to accessing advanced therapies like endothelin receptor antagonists or renal denervation procedures will likely diminish as guidelines incorporate these options and demonstrate their cost-effectiveness. Payers will increasingly recognize that leaving patients on inadequate generic therapy with blood pressures in the 130-140 mm Hg range is not appropriate long-term management.

The integration of newer agents into clinical practice faces challenges beyond regulatory approval and guideline inclusion. Clinicians need education about appropriate patient selection, timing of advanced therapies, and combination strategies. The field must address both the development of novel therapeutic options and the health care delivery systems needed to implement them effectively, ensuring that innovation translates into improved population-level blood pressure control rates.

Panelists discuss how follow-up strategies should include monthly visits initially with more frequent monitoring for high-risk situations, emphasizing home blood pressure monitoring and utilizing team-based care approaches with optimal visit intervals of 4 to 6 weeks to avoid both therapeutic inertia and overadjustment.

Lab Monitoring or Follow-Up Strategies With New Agents

Resistant hypertension management requires strategic follow-up scheduling with most patients seen within 4 to 6 weeks after medication changes. The A-TIME study demonstrated that 2-week intervals are too frequent, leading to excessive changes and reduced adherence, while 3-month intervals are inadequate for optimal control. High-risk patients, particularly those with elevated potassium levels or kidney disease, may require laboratory monitoring within 1 to 2 weeks when starting medications affecting electrolyte balance.

Home blood pressure monitoring represents a cornerstone of resistant hypertension management, providing more accurate assessment than office readings affected by white coat effects. Proper cuff sizing and patient education are essential for reliable home monitoring data. Remote patient monitoring technologies and team-based care approaches, including clinical pharmacists and physician extenders, help overcome access barriers and therapeutic inertia that commonly plague resistant hypertension management.

Successful resistant hypertension management requires systematic approaches to prevent patient loss to follow-up, which contributes significantly to treatment resistance. Health care teams must implement systems to identify and reengage patients who miss appointments, as prescription persistence requires multiple successful interactions over years. Virtual care options have expanded access for patients with transportation or mobility barriers, though individual patient preferences for in-person versus virtual visits should guide delivery methods.

Panelists discuss how shared decision-making requires explaining the rationale for blood pressure control, addressing patient fears about medications, and utilizing newer drug classes like endothelin receptor antagonists that offer a “clean slate” approach for patients who have had negative experiences with traditional therapies.

Shared Decision-Making With Patients Who Have Failed Multiple Agents

Effective resistant hypertension management requires robust shared decision-making processes, particularly for patients frustrated by multiple treatment failures. Clinicians must help patients understand the explanatory model linking blood pressure control to cardiovascular risk reduction, moving beyond pill-taking compliance to genuine health outcome focus. Many apparent treatment resistance cases actually reflect medication fears or concerns rather than true pharmacological resistance.

Patient adherence often suffers from preconceived notions about specific medication classes based on personal experiences or anecdotal reports. New therapeutic options like endothelin receptor antagonists provide “clean slate” opportunities without patient preconceptions, while renal denervation offers alternatives for medication-averse patients. Clinicians should explore patient concerns systematically and provide balanced information about both treatment benefits and consequences of uncontrolled hypertension.

Modern patients frequently consult online resources, including “Dr Google” and AI platforms, requiring clinicians to address misinformation proactively. Health care providers must balance acknowledging potential medication adverse effects while emphasizing the greater long-term risks of uncontrolled hypertension. Effective communication involves explaining how short-term medication concerns pale compared with long-term cardiovascular consequences, using patient-friendly language and incorporating diabetes educators or other health care team members when appropriate.

Vivian Fonseca, MD, FRCP

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