[2019] 1.4.52 If blood pressure remains uncontrolled in people with resistant hypertension taking the optimal tolerated doses of 4 drugs, seek specialist advice. [2019] For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on step 4 treatment. Full details of the evidence and the committee's discussion are in evidence review G: step 4 treatment. 1.5 Identifying who to refer for same-day specialist review 1.5.1 If a person has severe hypertension (clinic blood pressure of 180/ 120 mmHg or higher), but no symptoms or signs indicating same-day referral (see recommendation 1.5.2), carry out investigations for target organ damage (see recommendation 1.3.3) as soon as possible: If target organ damage is identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM. If no target organ damage is identified, confirm diagnosis by: repeating clinic blood pressure measurement within 7 days, or considering monitoring using ABPM (or HBPM if ABPM is not suitable or not tolerated), following recommendations 1.2.6 and 1.2.7, and ensuring a clinical review within 7 days. [2019] 1.5.2 Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with: signs of retinal haemorrhage or papilloedema (accelerated hypertension) or life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury. 