Measuring adherence to therapy in apparent treatment-resistant hypertension: a feasibility study in Irish primary care

Br J Gen Pract. 2019 Aug 29;69(686):e621-e628. doi: 10.3399/bjgp19X705077. Print 2019 Sep.


Background: Apparent treatment-resistant hypertension (aTRH) is defined as uncontrolled blood pressure (BP) in patients taking three or more antihypertensive medications. Some patients will have true treatment-resistant hypertension, some undiagnosed secondary hypertension, while others have pseudo-resistance. Pseudo-resistance occurs when non-adherence to medication, white-coat hypertension (WCH), lifestyle, and inadequate drug dosing are responsible for the poorly controlled BP.

Aim: To examine the feasibility of establishing non-adherence to medication, for the first time in primary care, using mass spectrometry urine analysis. Operationalisation would be established by at least 50% of patients participating and 95% of samples being suitable for analysis. Clinical importance would be confirmed by >10% of patients being non-adherent.

Design and setting: Eligible patients with aTRH (n = 453) in 15 university research-affiliated Irish general practices were invited to participate.

Method: Participants underwent mass spectrometry urine analysis to test adherence and ambulatory BP monitoring (ABPM) to examine WCH.

Results: Of the eligible patients invited, 52% (n = 235) participated. All 235 urine samples (100%) were suitable for analysis: 174 (74%) patients were fully adherent, 56 (24%) partially adherent, and five (2%) fully non-adherent to therapy. A total of 206 patients also had ABPM, and in total 92 (45%) were categorised as pseudo-resistant. No significant associations were found between adherence status and patient characteristics or drug class.

Conclusion: In patients with aTRH, the authors have established that it is feasible to examine non-adherence to medications using mass spectrometry urine analysis. One in four patients were found to be partially or fully non-adherent. Further research on how to incorporate this approach into individual patient consultations and its associated cost-effectiveness is now appropriate.

Keywords: hypertension; primary care; pseudo-resistance; treatment adherence; urinalysis.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Antihypertensive Agents / therapeutic use*
  • Antihypertensive Agents / urine
  • Blood Pressure Monitoring, Ambulatory*
  • Feasibility Studies
  • Female
  • Humans
  • Hypertension / drug therapy*
  • Hypertension / physiopathology
  • Ireland
  • Male
  • Mass Spectrometry
  • Medication Adherence*
  • Middle Aged
  • Primary Health Care*
  • Urinalysis
  • White Coat Hypertension / diagnosis*


  • Antihypertensive Agents