People tend to see blood pressure (BP) as two numbers, but the heart doesn't. When BP stays high for a long time, the heart has to work harder to pump blood through the body. Over time, that extra pressure can damage blood vessels and increase the risk of heart disease, heart attack, stroke and kidney disease. The concern is even greater when BP remains uncontrolled despite treatment.

Studies show that patients with resistant hypertension (BP is more than or equal to 140/90 mmHg despite being on at least three medications) face a two- to six-fold higher risk of heart attack, stroke, end-stage kidney disease, and death than people whose blood pressure is controlled.

This is a bigger issue in India than many people realise. The latest NFHS-6 data show that 19.4% of Indian women and 22.1% of Indian men aged 15 years and above have elevated BP or are taking medication to control it. An analysis of more than 1.7 million Indians found that only 8.5% of people with hypertension had their BP under control, highlighting how much of a challenge effective control remains.

So what happens when someone is taking their medicines, watching their diet and staying active, but the numbers still refuse to come down?

Controlling high blood pressure is not always a simple matter of taking another tablet or trying harder with lifestyle changes. When BP remains high despite appropriate treatment, we need to step back and ask whether there is an underlying reason why it is proving so difficult to control.

Lifestyle changes continue to matter. Cutting back on salt, maintaining a healthy weight, staying physically active, limiting alcohol, avoiding tobacco, and getting adequate sleep can all support better BP control. But healthy habits are not a guarantee that every person's BP will respond in the same way. Persistently high readings despite genuine effort should therefore be a reason for a clinical review.

Hidden hormonal driver of hypertension

The reasons for difficult-to-control hypertension can vary. Doctors may check the following:

  • Are the medicines being taken as prescribed?
  • Is BP being measured correctly?
  • Are factors such as excess salt, obesity, sleep apnoea, kidney disease or other medicines contributing to this rise?
  • Is there some other underlying cause, e.g., a hormonal driver?

A hormone that can cause persistently increased blood pressure is aldosterone, which helps the body regulate salt and water. When too much aldosterone is produced, the body can retain more sodium and water, contributing to higher BP. It can also contribute to changes in the blood vessels and organs over time. This is why understanding what is driving a patient's hypertension can matter, particularly when standard treatment is not enough.

For a long time, an uncontrolled BP reading led to adjusting the dose or adding another medicine. Those steps remain important. But hypertension care is also moving towards a more individualised approach. Instead of looking only at the number, doctors are increasingly asking what the mechanism behind it could be. Innovative treatments that target specific biological pathways, including aldosterone production, reflect this shift.

Once it is understood why a patient's blood pressure is difficult to control, doctors can make more informed decisions about the next step. The goal is to get a better reading at the next visit, and to reduce the long-term burden that uncontrolled blood pressure places on the heart and other organs.

Patients should not judge their heart health only by how they feel. High BP can have no obvious symptoms while quietly increasing the strain on the heart. Know the numbers, take prescribed medicines, and don't ignore persistently high readings. If BP remains uncontrolled despite treatment, speak to the doctor about what could be driving it. This World Heart Day, check your BP and take the next step to protect your heart.

(Dr. Prof. J. C. Mohan, Chairman, Institute of Heart and Vascular Disorders, Jaipur Golden Hospital, New Delhi)



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