Characterization and treatment of resistant hypertension

Resistant hypertension is a common medical problem. It carries a significantly increased risk of end-organ damage and cardiovascular events compared with more easily controlled hypertension. Resistant hypertension is most often related to isolated systolic hypertension and is characterized by aldosterone excess and increased intravascular volume. Its diagnosis requires the exclusion of pseudoresistance. The etiology of resistant hypertension is almost always multifactorial. Common reversible contributing factors need to be identified and addressed. Secondary causes of hypertension, such as primary aldosteronism, parenchymal and vascular kidney disease, and obstructive sleep apnea, require investigation and effective treatment if present. Therapy for resistant hypertension should be based on use of rational drug class combinations at optimal doses, with particular attention to adequate diuretic use. The addition of an aldosterone antagonist may further improve blood pressure control.