Treating Resistant Hypertension

Failure to control blood pressure mostly due to one cause

Aneroid sphygmomanometer (blood pressure gauge)
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Resistant hypertension is a term used to describe high blood pressure which does not respond to treatment. It is a problem that can cause extreme anxiety for those who have been trying to control their blood pressure as well as frustration for doctors whose patients are not taking their drugs as prescribed.

Causes of Resistant Hypertension

Resistant hypertension is defined as blood pressure that remains well above the target goals despite the use of optimal, three-drug therapy.

Because hypertension can be difficult to treat and usually requires multi-drug therapy, resistance cannot officially be declared until such time as a three-drug combination fails.

There are many things that can cause resistant hypertension. While some may be related to co-existing disorders or diseases, others may be caused by the treated individuals themselves. A doctor will typically focus on the three most common causes when investigating resistant hypertension:

  • Poor or inconsistent dosing
  • Secondary hypertension, usually from overactive adrenal glands
  • Fluid retention, often the result of kidney failure

Investigations will typically involve blood and imaging tests, a physical exam, and a review of the person’s self-reported medication use (including missed doses, dosing schedule, and side effects).

Addressing Patient Noncompliance

The most common cause of resistant hypertension—and the most difficult to treat—is what doctors refer to as patient noncompliance.

This is where an individual is not taking his or her medications as prescribed and is either skipping doses, dosing inconsistently, or experiencing lengthy gaps in treatment.

The term "noncompliant" is not meant to suggest that the person is necessarily to blame. In many cases, it may be due to circumstances beyond the individual’s control that make the treatment either impractical or intolerable.

The goal of the doctor, therefore, is not to issue warnings but to identify the barriers that are keeping that person from taking the drugs as prescribed.

These barriers can include everything from depression and family issues to copay problems and polypharmacy (too many drugs). Until these fundamental issues are addressed and resolved, it may be near-impossible to achieve the goals of therapy.

In some cases, a social worker or counselor may need to be brought in to help with any emotional problems the person may be experiencing. At other times, efforts will need to be made to address medication cost concerns (including fighting insurance or enrolling in drug assistance programs).

Sometimes, all it takes is a simple change of medication to alleviate symptoms that may, up until this time, have gone unreported.

Treating Resistant Hypertension

The treatment of resistant hypertension usually focuses on correcting the underlying problems, both physical and functional. This may involve:

  • Correcting and monitoring drug adherence on an ongoing basis
  • Finding friends or family members who can assist with daily drug-taking
  • Addressing lifestyle factors such as obesity, alcohol, and dietary salt
  • Avoiding or limiting the use of nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, and Tylenol (acetaminophen)

It is also important to ensure that the resistant hypertension isn’t something else. This may include pseudohypertension (a false high blood pressure reading due to the calcification of blood vessels) or white coat hypertension (high blood pressure that only occurs in the doctor's office).


Yaxley, J. and Thambar, S. "Resistant hypertension: an approach to management in primary care." Journal of Family Medicine and Primary Care. 2015; 4(2):193-199.