Intended for healthcare professionals

Clinical Review

Resistant hypertension

BMJ 2012; 345 doi: (Published 20 November 2012) Cite this as: BMJ 2012;345:e7473
  1. Aung Myat, British Heart Foundation clinical research training fellow1,
  2. Simon R Redwood, professor of interventional cardiology1,
  3. Ayesha C Qureshi, specialist registrar in cardiology2,
  4. John A Spertus, director of cardiovascular education and outcomes research3,
  5. Bryan Williams, professor of medicine4
  1. 1British Heart Foundation Centre of Research Excellence, Cardiovascular Division, Rayne Institute, St Thomas’ Hospital, King’s College London, London SE1 7EH, UK
  2. 2London Deanery, Stewart House, London WC1B 5DN, UK
  3. 3Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO 64111, USA
  4. 4Institute of Cardiovascular Science, University College London, London WC1E 6BT, UK
  1. Correspondence to: B Williams bryan.williams{at}
  • Accepted 1 November 2012

Summary points

  • Resistant hypertension is defined as high blood pressure that remains uncontrolled despite treatment with at least three antihypertensive agents (one of which is usually a diuretic) at best tolerated doses. A diagnosis of true resistant hypertension should be made only after a thorough assessment to exclude apparent or pseudo-resistant hypertension

  • Post hoc analyses of large scale trials of antihypertensive drugs plus retrospective cross sectional observational studies point to a prevalence of resistant hypertension of 10-20% of the general hypertensive population

  • Patients with resistant hypertension are almost 50% more likely to experience an adverse cardiovascular event compared with patients with blood pressure controlled by three or fewer antihypertensive agents

  • Studies indicate that 5-10% of resistant hypertension patients have an underlying secondary cause for their elevated blood pressure—a prevalence significantly greater than that of the general hypertensive population

  • No clinical trials have compared the effectiveness of specific drug regimens for the treatment of resistant hypertension. The best available evidence supports the use of low dose spironolactone as the preferred fourth drug if the patient’s blood potassium level is ≤4.5 mmol/L. With higher blood potassium levels, intensification of thiazide-like diuretic therapy should be considered

  • Renal sympathetic denervation therapy, as a device based intervention, could potentially stimulate a paradigm shift in the management of resistant hypertension

The disease burden attributable to arterial hypertension is substantial, accounting for or contributing to 62% of all strokes and 49% of all cases of heart disease, culminating in an estimated 7.1 million deaths a year; equivalent to 13% of total worldwide deaths.1 Although most cases of hypertension can be effectively treated with lifestyle changes or drugs, or both, hidden within this population lies a cohort at the extreme end of the cardiovascular risk spectrum—those with hypertension that is resistant to treatment.

The aim of this review is …

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