Resistant hypertension
Resistant hypertension is blood pressure that remains above target despite three optimally dosed antihypertensives including a diuretic, or that requires four or more drugs. Evaluation excludes pseudoresistance and secondary causes, and treatment optimizes the regimen, emphasizes a mineralocorticoid antagonist, and addresses lifestyle and adherence.
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What this article covers
- Overview
Definition: resistant hypertension is blood pressure that remains above goal despite adherence to three optimally dosed antihypertensive agents of different classes including a diuretic, or…
- Epidemiology
A notable minority of treated hypertensives.
- Risk factors
Obesity, high dietary sodium, and excess alcohol.
- Pathophysiology
Volume overload: inadequate or mismatched diuretic therapy leaves patients volume-expanded, a common driver.
- Clinical features
Persistently high blood pressure despite therapy.
- Differential diagnosis
Pseudoresistance: apparent resistance from poor measurement technique, white-coat effect, or nonadherence, distinguished by normal out-of-office (ambulatory or home) readings and confirmation of…
- Diagnosis
Establish by confirming above-target blood pressure on an optimal three-drug regimen after excluding pseudoresistance: the diagnostic basis is documenting persistent elevation with correct technique…
- Management
First-line, exclude pseudoresistance and optimize the existing regimen: confirm adherence and technique, remove interfering substances, and ensure a correctly chosen and dosed diuretic…
- Complications
Elevated risk of stroke, heart failure, and chronic kidney disease.
- Prognosis
Higher cardiovascular risk than controlled hypertension.
- Prevention
Ensure adherence and correct measurement.
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Related articles
- Essential hypertension
Essential (primary) hypertension is chronically elevated blood pressure without an identifiable secondary cause, the overwhelming majority of hypertension. It is a leading modifiable driver of stroke, heart failure, and kidney disease, and management combines lifestyle change with staged pharmacotherapy to a target usually below 130/80 mmHg.
- Secondary hypertension
Secondary hypertension is high blood pressure from an identifiable, often correctable cause, such as primary aldosteronism, renal or renovascular disease, obstructive sleep apnea, or endocrine tumors. It should be suspected with resistant, early-onset, or abrupt hypertension, and identifying the cause can cure or greatly improve control.
- Hypertensive emergency
Hypertensive emergency is severe hypertension (usually above 180/120 mmHg) with acute target-organ damage such as encephalopathy, stroke, acute heart failure, myocardial ischemia, aortic dissection, or acute kidney injury. It requires controlled intravenous blood pressure reduction, with the target and pace determined by the specific end-organ involved.