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Resistant Hypertension

Resistant Hypertension: New developments

Risk Factors:-

• Old Age
• Obesity
• Reduced Renal Functions
• High Aldosterone level
• Hypertension of long duration
• Isolated Systolic Hypertension
• Framingham risk score>20%
• Target oragan damage like LVH, Microalbuminuria

Diagnosis & Treatment recommendations:

STEP-1 Confirm Treatment Resistance

• Blood pressure>140/90 or 130/80 mm of Hg. In Diabetic patient or with CKD
• Patient taking 3 or more anti-hypertensive at optimal dose including Diuretic
• Patient requiring 4 or more anti-hypertensive to achieve optimum goal of control

STEP-2 Exclude Pseudoresistance

• Confirm whether patient was adherent to prescribed regimen
• Exclude white-coat effect

STEP-3 Identify & reverse contributing life style factors

• Obesity
• Physical Inactivity
• Excessive alcohol consumption
• High salt, low fibre diet

STEP-4 Discontinue or minimize interfering substances

• Decongestants, Diet pills
• Stimulants
• Ephedrine
• Licorice

STEP-5 Screen for secondary causes of Hypertension

• Primary Aldosteronism
• Renal Artery Stenosis
• Cushing’s Syndrome
• Aortic Coarctation

STEP-6 Pharmacological Treatment

• Maximise Diuretics, add mineralocorticoid receptor antagonist
• Combined different agents with different mechanism
• Minoxidil in CKD

STEP-7 Refer to Specialist

• Refer for known or suspected secondary cause of hypertension
• Refer if uncontrolled for 6 months after revising therapy

Second-line antihypertensive medications

• Beta-blockers
• Alpha-1 blockers
• Clonidine. Moxonidine, Methyldopa
• Hydrallazine, Minoxidil
• Spironolactone
• Aliskerin

Non-Pharmacological Approach

• Dietary salt restriction
• Weight loss
• Moderate alcohol intake
• Increase physical activity


• Despite availability of many antihypertensive medications, resistant hypertension is very common which increases Cardiac morbidity & mortality.
• 24 hour ambulatory BP monitoring is useful determining true resistant hypertension.
• Combination of 3 drugs is ideal to treat resistant hypertension.
• If 3 drug regimen fails, add second line antihypertensive medications.
• Life style changes needed.