Resistant Hypertension in Adults: Evaluation and Treatment

Difficult-to-control hypertension is a common issue in primary care. Resistant hypertension is defined as a blood pressure (BP) measurement above goal despite the use of maximum or optimal dosages of three antihypertensive agents, including a diuretic. Before diagnosing resistant hypertension, family physicians should evaluate patients with difficult-to-control BP for comorbid conditions, medication nonadherence, white coat hypertension, secondary hyper-tension, and suboptimal therapy. Attention should be focused on ensuring accurate BP measurement technique in the office and confirmatory BP monitoring at home. Management of resistant hypertension should include evidence-based lifestyle interventions, adjustment of plans for social factors, and individualized medication regimens. A dihydropyridine calcium channel blocker, an angiotensin receptor blocker or angiotensin-converting enzyme inhibitor, and a thiazide diuretic should be part of the initial three-drug regimen. Therapy may be suboptimal if preferred antihypertensives are not used, medications are inadequately dosed, lifestyle factors are not addressed, comorbidities are improperly treated, or social factors are not recognized. In patients with resistant hypertension, a mineralocorticoid receptor antagonist is the preferred fourth-line option. Other antihypertensives to improve BP control should be considered based on patient factors and shared decision-making. For patients who are unable to tolerate medications or achieve adequate BP control, referral for interventional options (eg, renal sympathetic denervation, carotid baroreceptor amplification) should be considered.