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Definition, risk factors, and evaluation of resistant hypertension

David A Calhoun, MD
Raymond R Townsend, MD
Section Editors
George L Bakris, MD
William B White, MD
Deputy Editor
John P Forman, MD, MSc


Patients with persistent hypertension despite multiple medications are at high risk for adverse cardiovascular events and are more likely than those with controlled hypertension to have a secondary (ie, identifiable) cause, which is usually at least in part reversible.

The definition, prevalence, risk factors, and evaluation of resistant hypertension will be reviewed here. Specific causes of secondary hypertension will be briefly mentioned. The treatment and prognosis of resistant hypertension, indications for referral to a hypertension specialist, and how one identifies patients who should be screened for secondary hypertension are discussed elsewhere. (See "Treatment of resistant hypertension" and "Evaluation of secondary hypertension".)


Resistant hypertension — Resistant hypertension is defined by the 2017 American College of Cardiology/American Heart Association (ACC/AHA) hypertension guideline and by the 2013 European Societies of Hypertension and Cardiology (ESH/ESC) statement as blood pressure that remains above goal in spite of concurrent use of three antihypertensive agents of different classes [1,2]. Thus, patients whose blood pressure is controlled with four or more medications should be considered to have resistant hypertension.

If tolerated, one of the three agents should be a diuretic, and all agents should be prescribed at optimal doses (ie, 50 percent or more of the maximum recommended antihypertensive dose) [3]. Goal blood pressure is presented separately. (See "What is goal blood pressure in the treatment of hypertension?" and "Antihypertensive therapy to prevent recurrent stroke or transient ischemic attack" and "Treatment of hypertension in patients with diabetes mellitus", section on 'Goal blood pressure' and "Antihypertensive therapy and progression of nondiabetic chronic kidney disease in adults", section on 'Blood pressure goal'.)

Although patients with resistant hypertension may have elevations in both systolic and diastolic pressures, isolated systolic hypertension is common. In the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT) of over 33,000 hypertensive patients treated with different antihypertensive drugs, only 67 percent of participants attained a systolic blood pressure below 140 mmHg, whereas 92 percent attained a diastolic pressure below 90 mmHg [4]. Treatment of older adults with isolated systolic hypertension that is resistant to therapy may be more difficult since intensification of the therapeutic regimen may lead to unacceptably low diastolic pressures. (See "Treatment of hypertension in older adults, particularly isolated systolic hypertension", section on 'Resistant hypertension' and "Treatment of hypertension in older adults, particularly isolated systolic hypertension".)

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Literature review current through: Nov 2017. | This topic last updated: Nov 27, 2017.
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