|Hypertension is a common, undertreated disease and a major risk factor for cardiovascular, cerebrovascular and renal disease. As many as 20-30% of hypertensive patients have resistant hypertension, defined as uncontrolled blood pressure despite 3 or more antihypertensive drugs including a diuretic, typically combined with a calcium-channel blocker and an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. Patients with resistant hypertension can often be controlled by adding a mineralocorticoid receptor antagonist and/or vasodilating beta-blocker. A significant number of patients will have a treatable secondary cause of resistant hypertension such as obesity, sleep apnea, renal insufficiency, primary aldosteronism or renal artery stenosis. For patients whose hypertension is refractory to preferred antihypertensives, use of third-line antihypertensives such as sympatholytics or vasodilators may be effective but consideration should be given to investigational device-based antihypertensive therapies. Renal artery angioplasty/stenting can be useful in selected cases of renal artery stenosis, while renal sympathetic denervation holds promise for resistant essential hypertension.
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