OBJECTIVES: Hypertension is a modifiable risk factor for damage to organs including the heart, brain and kidneys, but can be uncontrolled (uHTN) or resistant despite treatment (trHTN). Comparison of evidence-based clinical practice guidelines (CPGs) could identify opportunities to optimize treatment for individuals.

METHODS: A targeted literature review of CPGs covering uHTN and trHTN in China, France, Germany, Japan, Italy, Spain, UK and US. A 2021 systematic review was updated searching 2020-2024 for new/updated CPGs. Definitions, investigations, blood pressure targets and therapeutic management strategies were extracted into a piloted data extraction tool.

RESULTS: Ten CPGs from Europe (1), Asia (4), UK (1) and US (n=4) were included from 1,410 records: CPGs covering Europe and Asia were adopted by multiple geographies. Recommendations varied by CPGs: differing US guidelines existed for primary and secondary care settings, whereas others were setting agnostic. Broadly, comorbid groups (diabetes, kidney & heart disease) were used to identify populations with lower targets, varying from 140/90 to 125/75 across CPGs. No CPGs explicitly defined uHTN beyond individuals not achieving recommended target blood pressure.

Six of the seven CPGs covering the management of trHTN defined it as inability to achieve therapeutic targets whilst on maximally tolerable doses of three different antihypertensive classes. Half recommended confirmatory ambulatory blood pressure and adherence testing, and half encouraged screening for secondary causes (e.g. aldosteronism). Management of trHTN was recommended in a specialist clinic and spironolactone was specifically recommended as a fourth agent in five CPGs.

CONCLUSIONS: As target blood pressure varies across guidelines and the populations covered within them, variation in characteristics and prevalence of uHTN and trHTN, numbers of individuals requiring specialist management in hypertension clinics, and the resources required for testing for secondary causes will occur. It is important that practitioners refer to the most relevant CPGs to define uHTN and trHTN.