Resistant High Blood Pressure

What is “Resistant Hypertension”?

A recent article by Dr Malik summaries what we currently do.

Hypertension causes a large disease burden.  It accounts for 62% of strokes and 49% of all cases of heart disease. The aim is to define which group would benefit from specialist therapy. The aim is to get the BP <140/90 is clinic. In addition, if there is renal disease and diabetes, the treatment target is lower, and thus those not meeting the target are more prevalent.

Prevalence is about 8% of the total population. In fact 20% of hypertensives are not adequately controlled in the UK. It could be as high as 35% in other populations. Resistant Hypertension is present in at least 2% of the hypertensives.



BP Agents Additional criteria
International Guidelines Clinic BP >140/90 Three agents including a diuretic
NICE UK guidelines Clinic BP >140/90 ACEI/ARB plusCCB plusThiazide diuretic 24 HR BP >135/85 (thus excluding white coat effect)


Risk factors for Resistant Hypertension include:

  • Demographic:
    • Age>75
    • Female
    • Black
    • Comorbidity
      • Obesity
      • Diabetes mellitus
      • Atherosclerosis
      • Target organ damage
      • Higher baseline Blood pressure/longer duration of High blood pressure
      • High sodium intake
      • Aortic stiffening


Step one in diagnosis is to exclude other causes:

Pseudo-resistant Hypertension

  1. White coat effect
  2. Patient compliance (side effects, cost, understanding (memory/explanation), complicated dosing)
  3. Physician factors (poor technique in measuring blood pressure, inadequate dosing, poor combinations)



  • 24 Hour BP monitor to exclude white coat effect
  • Discussion with patient to exclude
    • Diet:
      • Excess sodium intake
      • Excess alcohol intake
      • Weight loss advice/DASH diet
      • Liquorice, herbal supplements (bitter orange)
  • Drugs
    • Cocaine/amphetamine use
    • Combined contraceptive pill (HRT is not relevant)
    • Steroids
    • Erythropoietin/tacrolimus/ciclosporin
    • Steroids
    • Secondary HT screen
      • Basic screen for complications
        • ECG
        • Echocardiography
        • Urine for protein and blood
        • Basic blood tests for renal disease
        • Fundoscopy
  • Glucose/Hba1C for diabetes
  • Plasma Renin/Aldosterone to check for rare adrenal tumors
  • Urine catecholamines to check for rare adrenal tumors
  • HT screen MRI-for Renal artery stenosis/Coarctation/Adrenal adenoma
  • Non-pharmacological


Address diet sodium/calories/alcohol

Recommend weight loss and exercise

Involve patient in a treatment plan

  • Pharmacological
    • After A+C+D therapy consider spironolactone 25-50mg od

If side effects with Spironolactone, the consider epleronone

  • Monitor Potassium levels after 2 weeks
  • If still not responsive then
    • Betablockers
    • Alpha Blockers
    • MethylDOPA
    • Hydralazine
    • Minoxidil

Device Therapy

Two techniques are available for severe resistant hypertension:

  • Renal artery Denervation (RDN)
  • Carotid baroreflex activation (CBA)

If you would like to discuss blood pressure with the team please contact us. We offer renal denervation therapy.

Posted on 29 May 2013
Author: LCC
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