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there is evidence of HMOD or existing cardiac, cerebrovascular, or renal disease. Details on medical history and physical examination steps are summarized in the supplement (see Supplementary data online, Tables S2 and S3), as well as drugs or substances that may increase BP (see Supplementary data online, Table S4). 7.4.2 Drug adherence and persistence with treatment Adherence is defined as the extent to which a patient’s behaviour, e.g. with respect to taking medication, coincides with agreed recommendations from a healthcare provider. Persistence represents the amount of time from initiation to discontinuation of therapy.248 Adherence to medical therapies is especially suboptimal in asymptomatic conditions such as hypertension.249–254 Non-adherence to BP-lowering therapy correlates with a higher risk of CVD events.255,256 Objective methods to assess adherence, such as detecting prescribed drugs in blood or urine samples and directly observed treatment (witnessed pill intake during ABPM), have demonstrated their potential usefulness, particularly in the setting of apparently resistant hypertension.257 However, all methods for testing drug adherence have limitations. Non-adherence to BP-lowering therapy depends on many factors (Figure 11).253 Effective patient–physician communication is crucial to improve adherence.258,259 Single-pill combinations improve persistence in BP-lowering treatment and are associated with lower all-cause mortality.260 7.4.3 Routine and optional tests Routine tests include laboratory and clinical tests to detect increased CVD risk and relevant comorbidities (e.g. hyperlipidaemia and diabetes) (Table 8). Optional tests should be considered in the initial assessment if they are likely to change patient management, with the main rationale being to improve CVD risk stratification.170 As highlighted in Section 6, for adults with elevated BP who also have a 10-year estimated CVD risk of 5% to <10%, optional tests including those for HMOD may be considered if up-classification of risk on the basis of an abnormal test result could prompt initiation of BP-lowering therapy.31,170 Evidence of subclinical microvascular neurodegeneration and/or lacunar brain disease due to small-vessel pathology may also indicate HMOD.264 Table 7 Key illness representations and treatment beliefs: how these apply to communicating a hypertension diagnosis to the patient (note that gender influences these representations) Illness representation Example patient question Application to a hypertension diagnosis conversation Identity What is the disease/illness label and the related symptoms? The condition where your systolic BP is ≥140 and/or diastolic BP ≥90 mmHg is called hypertension. We classify systolic BP 120–139 or diastolic BP 70–89 mmHg as elevated BP. For most people, this has no noticeable signs or symptoms, therefore, we need to monitor your BP to assess how medications and behavioural changes are working. Control Is the illness controllable through medical intervention or behavioural change? Hypertension can usually be controlled with medication and behavioural changes such as dietary changes and regular physical activity. For some people we need to try a few different options before we get BP under control. Timeline Is this an acute or chronic problem? This is a serious long-term or chronic condition condition that will require long-term management. This means that it may need to be managed throughout life. Consequences What are the physical and psychosocial consequences? If hypertension is not controlled, then there is a risk of a serious acute cardiovascular disease event such as a stroke or heart attack; however, if it is managed through the right medical intervention and behavioural changes, then this risk can be reduced and the condition will have less consequences for your life. Causes What caused the condition? Multiple factors contribute to someone developing hypertension. These include both non-modifiable factors (e.g. genetics and age) and modifiable factors (e.g. diet, weight, and physical activity). We are best focusing on those things that we can control to reduce your BP. Treatment beliefs Example patient question Application to a hypertension diagnosis communication Necessity To what extent is treatment necessary? Taking BP-lowering medication every day is necessary to keep your BP under control and to help prevent a more serious health problem developing. Do you think that these medicines will help you? Concerns To what extent does treatment cause concern? Some patients have concerns about taking daily medications throughout their life, e.g. about side effects. Do you have any concerns about taking your BP medications every day? © ESC 2024 BP, blood pressure. Recommendation Table 7 — Recommendations for assessing adherence and persistence with treatment (see Evidence Table 16) Recommendation Classa Levelb Objective evaluation of adherence (either directly observed treatment or detecting prescribed drugs in blood or urine samples) should be considered in the clinical work-up of patients with apparent resistant hypertension, if resources allow.261–263 IIa B © ESC 2024 aClass of recommendation. bLevel of evidence. ESC Guidelines 3945 Downloaded from academic.oup.com/eurheartj/article/45/38/3912/7741010 by guest on 07 October 2026