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No commercial re-use. See rights and permissions. Published by BMJ." /> <meta name="DC.AccessRights" content="restricted" /> <meta name="DC.Description" content="Resistant hypertension is a condition where blood pressure levels remain elevated above target despite changes in lifestyle and concurrent use of at least three antihypertensive agents, including a long-acting calcium channel blocker (CCB), a blocker of the renin-angiotensin system (ACE inhibitor or angiotensin receptor blocker) and a diuretic. To be diagnosed as resistant hypertension, maintaining adherence to therapy is required along with confirmation of blood pressure levels above target by out-of-office blood pressure measurements and exclusion of secondary causes of hypertension. The key management points of this condition include lifestyle changes such as reduced sodium and alcohol intake, regular physical activity, weight loss and discontinuation of substances that can interfere with blood pressure control. It is also recommended that current treatment be rationalised, including single pill combination treatment where antihypertensive drugs should be provided at the maximum tolerated dose. It is further recommended that current drugs be replaced with a more appropriate and less difficult treatment regimen based on the patient鈥檚 age, ethnicity, comorbidities and risk of drug鈥揹rug interactions. The fourth line of treatment for patients with resistant hypertension should include mineralocorticoid receptor antagonists such as spironolactone, as demonstrated in the PATHWAY-2 trial and meta-analyses. Alternatives to spironolactone include amiloride, doxazosin, eplerenone, clonidine and beta-blockers, as well as any other antihypertensive drugs not already in use. New approaches under research are selective non-steroidal mineralocorticoid receptor antagonists such as finerenone, esaxerenone and ocedurenone, selective aldosterone synthase inhibitors such as baxdrostat, and dual endothelin antagonist aprocitentan." /> <meta name="DC.Contributor" content="Miguel Camafort" /> <meta name="DC.Contributor" content="Reinhold Kreutz" /> <meta name="DC.Contributor" content="Myeong-Chan Cho" /> <meta name="article:published_time" content="2024-11-01" /> <meta name="article:section" content="Education in Heart" /> <meta name="citation_title" content="Diagnosis and management of resistant hypertension" /> <meta name="citation_abstract" lang="en" content="<p>Resistant hypertension is a condition where blood pressure levels remain elevated above target despite changes in lifestyle and concurrent use of at least three antihypertensive agents, including a long-acting calcium channel blocker (CCB), a blocker of the renin-angiotensin system (ACE inhibitor or angiotensin receptor blocker) and a diuretic. To be diagnosed as resistant hypertension, maintaining adherence to therapy is required along with confirmation of blood pressure levels above target by out-of-office blood pressure measurements and exclusion of secondary causes of hypertension. The key management points of this condition include lifestyle changes such as reduced sodium and alcohol intake, regular physical activity, weight loss and discontinuation of substances that can interfere with blood pressure control. It is also recommended that current treatment be rationalised, including single pill combination treatment where antihypertensive drugs should be provided at the maximum tolerated dose. It is further recommended that current drugs be replaced with a more appropriate and less difficult treatment regimen based on the patient鈥檚 age, ethnicity, comorbidities and risk of drug鈥揹rug interactions. The fourth line of treatment for patients with resistant hypertension should include mineralocorticoid receptor antagonists such as spironolactone, as demonstrated in the PATHWAY-2 trial and meta-analyses. Alternatives to spironolactone include amiloride, doxazosin, eplerenone, clonidine and beta-blockers, as well as any other antihypertensive drugs not already in use. New approaches under research are selective non-steroidal mineralocorticoid receptor antagonists such as finerenone, esaxerenone and ocedurenone, selective aldosterone synthase inhibitors such as baxdrostat, and dual endothelin antagonist aprocitentan.</p>" /> <meta name="citation_journal_title" content="Heart" /> <meta name="citation_publisher" content="BMJ Publishing Group Ltd and British Cardiovascular Society" /> <meta name="citation_publication_date" content="2024/11/01" /> <meta name="citation_mjid" content="heartjnl;110/22/1336" /> <meta name="citation_id" content="110/22/1336" /> <meta name="citation_public_url" content="https://heart.bmj.com/content/110/22/1336" /> <meta name="citation_abstract_html_url" content="https://heart.bmj.com/content/110/22/1336.abstract" /> <meta name="citation_full_html_url" content="https://heart.bmj.com/content/110/22/1336.full" /> <meta name="citation_pdf_url" content="https://heart.bmj.com/content/heartjnl/110/22/1336.full.pdf" /> <meta name="citation_issn" content="1355-6037" /> <meta name="citation_issn" content="1468-201X" /> <meta name="citation_journal_abbrev" content="Heart" /> <meta name="citation_doi" content="10.1136/heartjnl-2022-321730" /> <meta name="citation_pmid" content="38135468" /> <meta name="citation_volume" content="110" /> <meta name="citation_issue" content="22" /> <meta name="citation_article_type" content="Other" /> <meta name="citation_section" content="Education in Heart" /> <meta name="citation_firstpage" content="1336" /> <meta name="citation_lastpage" content="1342" /> <meta name="citation_author" content="Miguel Camafort" /> <meta name="citation_author_institution" content="Hypertensi贸n Unit. 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To be diagnosed as resistant hypertension, maintaining adherence to therapy is required along with confirmation of blood pressure levels above target by out-of-office blood pressure measurements and exclusion of secondary causes of hypertension. The key management points of this condition include lifestyle changes such as reduced sodium and alcohol intake, regular physical activity, weight loss and discontinuation of substances that can interfere with blood pressure control. It is also recommended that current treatment be rationalised, including single pill combination treatment where antihypertensive drugs should be provided at the maximum tolerated dose. It is further recommended that current drugs be replaced with a more appropriate and less difficult treatment regimen based on the patient鈥檚 age, ethnicity, comorbidities and risk of drug鈥揹rug interactions. The fourth line of treatment for patients with resistant hypertension should include mineralocorticoid receptor antagonists such as spironolactone, as demonstrated in the PATHWAY-2 trial and meta-analyses. Alternatives to spironolactone include amiloride, doxazosin, eplerenone, clonidine and beta-blockers, as well as any other antihypertensive drugs not already in use. New approaches under research are selective non-steroidal mineralocorticoid receptor antagonists such as finerenone, esaxerenone and ocedurenone, selective aldosterone synthase inhibitors such as baxdrostat, and dual endothelin antagonist aprocitentan." /> <meta name="og-title" property="og:title" content="Diagnosis and management of resistant hypertension" /> <meta name="og-url" property="og:url" content="https://heart.bmj.com/content/110/22/1336" /> <meta name="og-site-name" property="og:site_name" content="Heart" /> <meta name="og-description" property="og:description" content="Resistant hypertension is a condition where blood pressure levels remain elevated above target despite changes in lifestyle and concurrent use of at least three antihypertensive agents, including a long-acting calcium channel blocker (CCB), a blocker of the renin-angiotensin system (ACE inhibitor or angiotensin receptor blocker) and a diuretic. To be diagnosed as resistant hypertension, maintaining adherence to therapy is required along with confirmation of blood pressure levels above target by out-of-office blood pressure measurements and exclusion of secondary causes of hypertension. The key management points of this condition include lifestyle changes such as reduced sodium and alcohol intake, regular physical activity, weight loss and discontinuation of substances that can interfere with blood pressure control. It is also recommended that current treatment be rationalised, including single pill combination treatment where antihypertensive drugs should be provided at the maximum tolerated dose. It is further recommended that current drugs be replaced with a more appropriate and less difficult treatment regimen based on the patient鈥檚 age, ethnicity, comorbidities and risk of drug鈥揹rug interactions. The fourth line of treatment for patients with resistant hypertension should include mineralocorticoid receptor antagonists such as spironolactone, as demonstrated in the PATHWAY-2 trial and meta-analyses. Alternatives to spironolactone include amiloride, doxazosin, eplerenone, clonidine and beta-blockers, as well as any other antihypertensive drugs not already in use. 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author-affiliates-corresp article" > <div class="pane-content"> <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div xmlns:xhtml="http://www.w3.org/1999/xhtml" class="contributors"><ol class="contributor-list" id="contrib-group-1"><li class="contributor" id="contrib-1"><a href="http://orcid.org/0000-0002-8669-6410" class="bmjj-markup-orcid-logo" target="_blank">http://orcid.org/0000-0002-8669-6410</a><span class="name">Miguel Camafort</span><a id="xref-aff-1-1" class="xref-aff" href="#aff-1">1</a><span class="xref-sep">,</span><a id="xref-aff-2-1" class="xref-aff" href="#aff-2">2</a>, </li><li class="contributor" id="contrib-2"><span class="name">Reinhold Kreutz</span><a id="xref-aff-3-1" class="xref-aff" href="#aff-3">3</a><span class="xref-sep">,</span><a id="xref-aff-4-1" class="xref-aff" href="#aff-4">4</a>, </li><li class="last" id="contrib-3"><span class="name">Myeong-Chan Cho</span><a id="xref-aff-5-1" class="xref-aff" href="#aff-5">5</a></li></ol><ol class="affiliation-list"><li class="aff"><a id="aff-1" name="aff-1"></a><address> <sup>1</sup> <span class="institution">Hypertensi贸n Unit. Internal Medicine Department</span>, <span class="institution">Hospital Clinic de Barcelona</span>, <span class="addr-line">Barcelona</span>, Spain </address></li><li class="aff"><a id="aff-2" name="aff-2"></a><address> <sup>2</sup> <span class="institution">CIBEROBN</span>, <span class="institution">Instituto de Salud Carlos III</span>, <span class="addr-line">Madrid</span>, Spain </address></li><li class="aff"><a id="aff-3" name="aff-3"></a><address> <sup>3</sup> <span class="institution">Charite Medical Faculty Berlin</span>, <span class="addr-line">Berlin</span>, Germany </address></li><li class="aff"><a id="aff-4" name="aff-4"></a><address> <sup>4</sup> <span class="institution">Institut f眉r Klinische Pharmakologie und Toxikologie</span>, <span class="institution">Berlin Institute of Health at Charite</span>, <span class="addr-line">Berlin</span>, Germany </address></li><li class="aff"><a id="aff-5" name="aff-5"></a><address> <sup>5</sup> <span class="institution">Cardiology</span>, <span class="institution">Chungbuk National University Hospital</span>, <span class="addr-line">Cheongju</span>, Korea </address></li></ol><ol class="corresp-list"><li class="corresp" id="corresp-1"><span class="corresp-label">Correspondence to</span> Dr Miguel Camafort; <span class="em-link"><span class="em-addr">camafort{at}clinic.cat</span></span> </li></ol></div></div></div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-bmjj-learning-test col-narrow-12" > <div class="pane-content"> <p class="learning-link hidden-xs"><a href="https://learning.bmj.com/course-mapping?id=10.1136/heartjnl-2022-321730" target="_blank"><img src="/sites/default/modules/jnl_template_bmjj/plugins/content_types/images//logo-learning-take-the-test.png" alt="BMJ Learning - Take the Test"></a></p> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-highwire-markup abstract-with-bc" > <div class="pane-content"> <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" id="content-block" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div class="article abstract-view "><span class="highwire-journal-article-marker-start"></span><div class="section abstract" id="abstract-1"><h2>Abstract</h2><p id="p-1">Resistant hypertension is a condition where blood pressure levels remain elevated above target despite changes in lifestyle and concurrent use of at least three antihypertensive agents, including a long-acting calcium channel blocker (CCB), a blocker of the renin-angiotensin system (ACE inhibitor or angiotensin receptor blocker) and a diuretic. To be diagnosed as resistant hypertension, maintaining adherence to therapy is required along with confirmation of blood pressure levels above target by out-of-office blood pressure measurements and exclusion of secondary causes of hypertension. The key management points of this condition include lifestyle changes such as reduced sodium and alcohol intake, regular physical activity, weight loss and discontinuation of substances that can interfere with blood pressure control. It is also recommended that current treatment be rationalised, including single pill combination treatment where antihypertensive drugs should be provided at the maximum tolerated dose. It is further recommended that current drugs be replaced with a more appropriate and less difficult treatment regimen based on the patient鈥檚 age, ethnicity, comorbidities and risk of drug鈥揹rug interactions. The fourth line of treatment for patients with resistant hypertension should include mineralocorticoid receptor antagonists such as spironolactone, as demonstrated in the PATHWAY-2 trial and meta-analyses. Alternatives to spironolactone include amiloride, doxazosin, eplerenone, clonidine and beta-blockers, as well as any other antihypertensive drugs not already in use. New approaches under research are selective non-steroidal mineralocorticoid receptor antagonists such as finerenone, esaxerenone and ocedurenone, selective aldosterone synthase inhibitors such as baxdrostat, and dual endothelin antagonist aprocitentan.</p></div><ul class="kwd-group"><li class="kwd">hypertension</li><li class="kwd">pharmacology</li></ul><span class="highwire-journal-article-marker-end"></span></div><span class="related-urls"></span></div></div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-dfp-pane oas-ads oas-ads-mid pull-right" > <div class="pane-content"> <div id="dfp-ad-mpu-wrapper" class="dfp-tag-wrapper"> <div id="dfp-ad-mpu" class="dfp-tag-wrapper"> <script type="text/javascript"> googletag.cmd.push(function() { googletag.display("dfp-ad-mpu"); }); </script> </div> </div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-custom pane-1" > <div class="pane-content"> <p><a href="https://doi.org/10.1136/heartjnl-2022-321730" target="_new">https://doi.org/10.1136/heartjnl-2022-321730</a></p> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-highwire-altmetrics" > <h2 class="pane-title">Statistics from Altmetric.com</h2> <div class="pane-content"> <div data-badge-details="right" data-badge-type="medium-donut" data-doi="10.1136/heartjnl-2022-321730" data-hide-no-mentions="true" class="altmetric-embed"></div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-bmjj-jumplinks" > <div class="pane-content"> <div class="highwire-list-wrapper"><div class="highwire-list"><ul></ul></div></div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-custom pane-2 permissions-box" > <h2 class="pane-title">Request Permissions</h2> <div class="pane-content"> <p>If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. 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class="panel-separator"></div><div class="panel-pane pane-highwire-markup footnotes" > <div class="pane-content"> <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div xmlns:xhtml="http://www.w3.org/1999/xhtml" class="section fn-group" id="fn-group-1"><h2>Footnotes</h2><ul><li class="fn-other" id="fn-6"><p id="p-45"><span class="fn-label">X</span> @MiguelCamafort</p></li><li class="fn-other" id="fn-7"><p id="p-46"><span class="fn-label">Contributors</span> MC, RK and M-CC contributed equally to the conception or design of the work, data collection, data analysis and interpretation, drafting the article, critical revision of the article, and final approval of the version to be published.</p></li><li class="fn-other" id="fn-8"><p id="p-47"><span class="fn-label">Funding</span> The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.</p></li><li class="fn-conflict" id="fn-9"><p id="p-48"><span class="fn-label">Competing interests</span> None declared.</p></li><li class="fn-other" id="fn-10"><p id="p-49"><span class="fn-label">Provenance and peer review</span> Commissioned; externally peer reviewed.</p></li><li class="fn-other" id="fn-11"><p id="p-50"><span class="fn-label">Author note</span> References which include a * are considered to be key references.</p></li></ul></div></div></div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-panels-mini pane-jnl-template-bmjj-challenge article-login" > <h2 class="pane-title">Read the full text or download the PDF:</h2> <div class="pane-content"> <div class="panel-display three-layout " id="mini-panel-jnl_template_bmjj_challenge"> <div class="panel-row-wrapper row"> <div class="left-wrapper col-narrow-12 col-normal-4"> <div class="panel-panel panel-region-left"> <div class="inside"><div class="panel-pane 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