Resistant Hypertension

• 📄 Leopold JA, Ingelfinger JR. Aldosterone and Treatment-Resistant Hypertension. New England Journal of Medicine. 2023;388(5):464-467. doi:10.1056/nejme2213559
• High BP despite concurrent use of three anti-hypertensive agents of different classes, one of which should be a diuretic
• “True” Resistant HTN is defined as “Failure to reach goal BP <130/80 mm Hg while documenting ingestion of three-drug antihypertensive regimen including an appropriate diuretic for kidney function, a CCB and a RAS blocker maximally dosed”

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Diagnosis

• All of the following need to be present before diagnosing someone as having TRUE resistant hypertension
  • Adherence with: Low Sodium Diet Intake and Medication
  • Good Sleep Quality (i.e., minimum of 6-7 hours of uninterrupted sleep a night)
  • Substitutions of drugs with greater effect within the Same Class i.e. ARBs and diuretics
  • Rule out all Secondary Causes of Hypertension
    • Before saying anyone is resistant must rule out the most common secondary cause of hypertension: Primary Hyperaldosteronism (prevalence is high and largely unrecognized)
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Management

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Footnotes

1. Vongpatanasin W. Resistant hypertension: a review of diagnosis and management. JAMA. 2014 Jun 4;311(21):2216-24. doi: 10.1001/jama.2014.5180. Erratum in: JAMA. 2014 Sep 17;312(11):1157. Dosage error in article text. PMID: 24893089. ↩

2. Azizi M, Vongpatanasin W, Fisher NDL, Mahfoud F, Amar L, Kirtane AJ. Diagnosis and Management of Resistant Hypertension: A Review. JAMA. 2026 Apr 28;335(16):1428-1439. doi: 10.1001/jama.2026.1221. PMID: 41870448. ↩ ↩²

3. Carey RM, Calhoun DA, Bakris GL, et al. Resistant hypertension: detection, evaluation, and management: a scientific statement from the american heart association. Hypertension. 2018;72(5). doi:10.1161/HYP.0000000000000084 ↩