When blood pressure remains above goal on three antihypertensive agents — including a diuretic at maximally tolerated doses — or is controlled only with four or more medications, the clinical picture meets the definition of resistant hypertension. This specific scenario calls for a structured reassessment of current therapy.
Resistant hypertension is defined as blood pressure above goal despite treatment with three antihypertensive medications with complementary mechanisms of action, including a diuretic at maximally tolerated doses, or blood pressure at goal but requiring four or more medications. Identifying this pattern is the first step toward targeted management.
Management involves optimizing the existing antihypertensive combination — with particular attention to the diuretic component, specifically whether a thiazide-like agent is in use — alongside a careful review of all current medications to identify and remove those with interfering effects on blood pressure. The complete agent selection, substitution criteria, and sequencing are provided in the full protocol.
The primary goal in this setting is blood pressure control to:
DOI: 10.1161/CIR.0000000000001356
Resistant hypertension is defined as BP above goal despite treatment with 3 antihypertensive medications with complementary mechanisms of action, including a diuretic at maximally tolerated doses or BP at goal but requiring ≥4 medications (Figure 8).
In adults with resistant hypertension, a more detailed evaluation for secondary causes, to include careful review of all medications and removal of those with interfering effects on BP, is beneficial for lowering BP and simplifying treatment.
Replacing thiazide-type diuretics (eg, HCTZ or bendroflumethiazide) with thiazide-like diuretics (eg, chlorthalidone and indapamide) may offer additional BP reduction and cardiovascular protection among patients with previous MI or stroke.
Based on the current BP goal of <130/80 mm Hg, the prevalence of resistant hypertension is approximately 8.5% to 20% among hypertensive US adults.
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