44
Resistant Hypertension
Figure 10. Resistant Hypertension: Diagnosis, Evaluation,
and Treatment
Confirm treatment resistance
• Office SBP/DBP ≥130/80 mm Hg, and
• Patient prescribed ≥3 antihypertensive medications at optimal doses, including a
diuretic, if possible, or
• Office SBP/DBP <130/80 mm Hg but patient requires ≥4 antihypertensive
medications
Exclude pseudoresistance
• Ensure accurate office BP measurements
• Assess for nonadherence with prescribed regimen
• Obtain home, work, or ambulatory BP readings to exclude white coat effect
Identify and reverse contributing lifestyle factors
• Obesity • Physical inactivity
• Excessive alcohol ingestion • High-salt, low-fiber diet
Discontinue or minimize interfering substances NSAIDs
Screen for secondary causes of hypertension
• Primary aldosteronism (elevated aldosterone/renin ratio)
• CKD (eGFR <60 mL/min/1.73 m
2
)
• Renal artery stenosis (young female, known atherosclerotic disease, worsening
kidney function)
• Pheochromocytoma (episodic hypertension, palpitations, diaphoresis, headache)
• Obstructive sleep apnea (snoring, witnessed apnea, excessive daytime sleepiness)
• Sympathomimetic (e.g.,
amphetamines, decongestants)
• Stimulants
• Oral contraceptives
• Licorice
• Ephedra
Pharmacological treatment
• Maximize diuretic therapy
• Add a mineralocorticoid receptor antagonist
• Add other agents with different mechanisms of actions
• Use loop diuretics in patients with CKD and/or patients receiving potent
vasodilators (e.g., minoxidil)
Refer to specialist
• Refer to appropriate specialist for known or suspected secondary cause(s) of
hypertension
• Refer to hypertension specialist if BP remains uncontrolled after 6 mo of treatment
