The management of resistant hypertension

Resistant hypertension (RH) can be defined as repeated resting clinic blood pressure readings >140/90mmHg in patients with known hypertension, despite triple pharmacological therapy including a diuretic. In population terms RH is uncommon but is challenging to treat. Evidence of end-organ damage (for example, left ventricular hypertrophy, proteinuria) is often present in patients with RH and is an indicator of long-term suboptimal treatment. Confirmation of RH must comprise exclusion of a 'white-coat' response, pseudohypertension and secondary hypertension. Discontinuation of drugs that raise blood pressure is another prerequisite. Appropriate and adequate strategies to tackle RH should be based alongside strict adherence to a variety of lifestyle measures. Concordance with these is pivotal to successful treatment. Increments in drug therapy should be guided if possible by assessment of renin, cardiac output and total peripheral resistance. In practice, the use of aldosterone antagonists such as spironolactone in RH has proven effective but may be limited by side-effects, notably hyperkalaemia. Management of RH should encompass evaluation of other population cardiovascular risk factors and their resolution. Advice from a local hypertension clinic, if available, can be valuable.