Defining Resistant Hypertension

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Resistant hypertension affects approximately 10% to 15% of all hypertensive patients, representing roughly 10 million Americans with blood pressure remaining above 130/80 mm Hg despite 3 properly prescribed antihypertensive medications from different drug classes, including a diuretic. This condition represents a significant clinical challenge that specialists encounter frequently in practice, requiring systematic evaluation to distinguish true resistance from apparent resistance.

The critical distinction between true resistant hypertension and pseudoresistance cannot be overstated, as up to 50% of apparently resistant cases may actually represent pseudoresistance. The primary causes of pseudoresistance include medication nonadherence, improper blood pressure measurement techniques, and white coat hypertension. Health care providers must systematically address these factors through proper cuff sizing, patient positioning, adequate rest periods, and comprehensive out-of-office blood pressure monitoring using ambulatory monitoring or validated home devices.

Secondary causes of hypertension, particularly primary hyperaldosteronism, require active screening in resistant hypertension patients regardless of potassium levels. Current recommendations emphasize obtaining aldosterone-to-renin ratios in all patients with treatment-resistant hypertension, as 10% to 15% will have elevated aldosterone with suppressed renin. Additional secondary causes include mild autonomous cortisol secretion, pheochromocytoma, and medication interference from NSAIDs. Identifying these treatable causes can significantly improve blood pressure control and reduce cardiovascular risk.