Perceptions and practices of primary care physicians in the management of resistant hypertension

Introduction: Resistant hypertension poses significant management challenges in primary care, with varying practices influencing patient outcomes. We evaluated current practices of primary care physicians in Singapore in managing resistant hypertension and examined their concordance with local and international guidelines. Methods: An anonymised cross-sectional survey was conducted from July 2021 to October 2023, using a 26-item questionnaire distributed to primary care physicians across Singapore. The survey included physicians from both the public and private healthcare sectors, while specialists were excluded. The survey assessed their knowledge of the definitions, diagnostic criteria, treatment preferences and referral patterns for resistant hypertension. Results: A total of 85 respondents participated in the survey. Only 74% ( n = 63) of respondents correctly defined resistant hypertension as uncontrolled blood pressure (BP) (above 140/90 mmHg) despite concurrent use of three or more antihypertensives, including a diuretic. In addition, 53% ( n = 45) correctly defined uncontrolled hypertension as home BP exceeding 135/85 mmHg. The majority (69%, n = 59) of primary care physicians would consider referral to a specialist after a trial of three antihypertensives, whereas 13% ( n = 14) chose to continue management in primary care. Referrals were made mainly to Endocrinology (43%, n = 47) and Cardiology (35%, n = 39). Notably, few primary care physicians (27%, n = 23) considered the necessary work-up for secondary causes such as primary aldosteronism. Conclusion: This study identifies discrepancies between clinical practice and guidelines. The findings highlight a need to improve education on accurate definitions and guideline-based diagnosis of resistant hypertension, and develop clear national referral pathways for suspected secondary hypertension in primary care.