Resistant Hypertension

Definition: Blood pressure above goal despite three hypertension medications in three different classes or BP’s controlled with 4 or more medications. Refractory hypertension when uncontrolled despite maximal therapy.


Pseudo-Resistant Hypertension

  • white coat hypertension
  • inaccurate BP measurement
  • poor med compliance
  • suboptimal therapy
  • poor lifestyle and diet


If indicated, evaluate for:

  • primary aldosteronism
  • renal artery stenosis
  • chronic kidney disease
  • obstructive sleep apnea

Less commonly: pheochromocytoma, cushing’s disease, aortic coarctation


Pharmacological treatment

  • Standard 3 drug regimen
    • ACEI or ARB, long-acting CCB, long-acting thiazide
  • If eGFR <30, loop diuretic for long control
  • Add spironolactone if HTN is resistant despite 3 drug regimen.
    • Trial 12.5 mg QD and titrate up to but not above 50 mg/day
    • If patients cannot tolerate spironolactone, use eplerenone or amiloride
  • Add vasodilatory beta-blocker if still persistent.  Alternatives are guanfacine or clonidine.
  • If still persistent, then use hydralazine in women or minoxidil in men.

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