title: Evaluation and management of the patient with difficult-to-control or resistant hypertension.
abstract: High blood pressure is often difficult to control. Resistant hypertension is blood pressure above goal despite adherence to a combination of at least three antihypertensive medications of different classes, optimally dosed and usually including a diuretic. The approach to blood pressure that is apparently difficult to control begins with an assessment of the patient's adherence to the management plan, including lifestyle modifications and medications. White-coat hypertension may need to be ruled out. Suboptimal therapy is the most common reason for failure to reach the blood pressure goal. Once-daily fixed-dose combination pills may improve control through the synergism of antihypertensive agents from different classes and improved adherence. Truly drug-resistant hypertension is commonly caused by chronic kidney disease, obstructive sleep apnea, or hyperaldosteronism, all of which can lead to fluid retention. Higher doses of diuretics (or a change to a loop diuretic) are usually needed. Other strategies include adding an alpha blocker, alpha-beta blocker, clonidine, or an aldosterone antagonist (e.g., spironolactone). Particularly in patients with diabetes or renal disease, combining a long-acting nondihydropyridine with a dihydropyridine calcium channel . blocker can also be considered. Obesity, heavy alcohol intake, high levels of dietary sodium, and interfering substances (especially nonsteroidal anti-inflammatory drugs) contribute to hypertension that is resistant or difficult to control.
authors.affiliation: Department of Family Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina 27599-7595, USA. anthony_viera@med.unc.edu
authors.forename: Anthony J
authors.initials: AJ
authors.lastname: Viera
authors.forename: Alan L
authors.initials: AL
authors.lastname: Hinderliter
mesh_terms: D000959:Antihypertensive Agents / Q000627:therapeutic use*; D004351:Drug Resistance; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000175:diagnosis* / Q000628:therapy*; D010349:Patient Compliance; D012307:Risk Factors
chemical_list: D000959:Antihypertensive Agents