Treatment-Resistant Hypertension: What It Means When Nothing Seems to Work

What Is Treatment-Resistant Hypertension?

Treatment-resistant hypertension means your blood pressure stays above your treatment goal even with three different types of blood pressure medications at appropriate doses, explains Matthew Weir, MD, a professor of medicine and the director of the division of nephrology at the University of Maryland in Baltimore.

• A thiazide or thiazide-like diuretic, often called a water pill, which helps the body remove extra salt and fluid.
• A long-acting calcium channel blocker, which helps blood vessels relax.
• An angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB), which acts on a hormone system that regulates blood pressure.

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Treatment-resistant hypertension describes how difficult your blood pressure is to control, not necessarily why it’s high, says Craig Basman, MD, the associate director of the structural and congenital heart program at Hackensack Meridian Health in New Jersey.

• Primary hypertension, also called essential hypertension, develops without an identifiable medical cause.

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   Genetics, aging, and lifestyle factors can contribute, Basman says.
• Secondary hypertension results from an identifiable cause, such as kidney disease, narrowed arteries supplying the kidneys, or a hormone disorder involving the adrenal or thyroid glands, Dr. Weir explains.

Someone with either primary or secondary hypertension can have treatment-resistant hypertension.

Causes of Treatment-Resistant Hypertension

When several medications fail to bring down your blood pressure, your care team looks for factors that could be contributing, says Payal Kohli, MD, a cardiologist in private practice in Aurora, Colorado, and an associate adjunct professor of medicine at Johns Hopkins University Ciccarone Center for the Prevention of Cardiovascular Disease in Baltimore and Duke University in Durham, North Carolina.

“Finding and treating those causes can often make blood pressure much easier to control,” Dr. Kohli says. These causes can include factors such as other medical conditions or dietary choices.

Primary Aldosteronism

Obstructive Sleep Apnea

Chronic Kidney Disease

Narrowed Kidney Arteries

Other Hormone Disorders

Medications and Supplements

Other contributors to high blood pressure include decongestants and certain supplements or herbal products, including licorice root, bitter orange, and yohimbine, Dr. Malik notes.

Excess Sodium, Obesity, or Alcohol

Kohli notes that excess sodium (salt), heavy alcohol use, and obesity can also make blood pressure more difficult to control.

Diagnosing Treatment-Resistant Hypertension

Diagnosing treatment-resistant hypertension is “a bit like detective work,” Kohli says.

Before confirming a treatment-resistant hypertension diagnosis, the care team checks for pseudoresistance, meaning when blood pressure appears resistant to treatment for another reason, Basman says. Possible explanations include inaccurate readings, the white-coat effect (when blood pressure is high in a medical office but controlled elsewhere), or a medication plan that needs adjusting or is difficult to follow as prescribed, he explains.

Step 1: Confirm That the Readings Are Accurate

• Use a home blood pressure monitor. Your care team can make sure that your home monitor is reliable and show you how to take and record readings consistently, Malik says.
• Wear a 24-hour ambulatory blood pressure monitor. This portable device automatically takes readings throughout the day and night to detect abnormal changes in your blood pressure.

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Step 2: Review Your Medications

A review of all your prescribed medications, including doses and your daily schedule, is part of the review process to make sure the treatment plan is appropriate, Kohli notes.

Your care team will also review side effects, supplements, and over-the-counter products that could affect blood pressure, says Malik.

“Medication adherence is not a judgment,” Malik says. “Blood pressure regimens can become complicated, expensive, or difficult to tolerate, so we need to understand what is actually happening before concluding that treatment has failed.”

Let your care team know about missed doses, side effects, or cost concerns so they can help you find a plan you can follow. Take your medication bottles or pictures of the labels to the appointment to make the review easier and more accurate.

Step 3: Look For an Underlying Cause

• Kidney Function Blood Tests Basman checks creatinine, a waste product that helps doctors assess how well your kidneys filter blood.
• Urine Tests This test detects signs of kidney disease, says Malik. A urinalysis can show protein, blood, or other abnormalities that may need further evaluation.

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• Electrolyte Tests These blood tests check minerals such as potassium, Basman says. Too much aldosterone can raise blood pressure and cause the body to lose potassium through urine.

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  A low potassium level may therefore prompt additional testing.
• Aldosterone and Renin Tests Weir measures these two hormones together to screen for excess aldosterone. High aldosterone alongside low renin can suggest primary aldosteronism, though your care team may need additional tests to confirm it.

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• Other Hormone Tests Thyroid tests may be recommended when appropriate, Malik notes. Kohli says checking for excess cortisol, which can raise blood pressure, may also be included.
• A Sleep Study Basman may recommend this test to check for sleep apnea. A sleep study records breathing, oxygen levels, and other measurements during sleep.

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   Depending on your situation, the study may take place at home or in a sleep lab.
• Kidney or Kidney Artery Imaging If your care team suspects narrowed kidney arteries, they may order a Doppler ultrasound, which measures blood flow.

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   An ultrasound to examine the kidneys may also be recommended.

Treatment and Management Strategies

Treatment for Underlying Causes

If your care team identifies a condition that’s contributing to high blood pressure, treating it is usually a priority. With an untreated underlying condition, Kohli says even the most appropriate blood pressure medication plan may not be effective.

Kidney disease, narrowed kidney arteries, and hormone conditions may each call for a different treatment approach.

Adjustments to Your Medications

After reviewing your list of medications, changes to decongestants and other medications or supplements that affect blood pressure may be made, says Malik. Basman recommends a discussion with your care team about alternatives if you regularly take NSAIDs.

Support Treatment With Daily Habits

Lifestyle changes don’t replace medication for treatment-resistant hypertension, but they’re an important part of treatment and may even reduce the number of medications needed, Kohli says. Work with your care team to set goals that fit your health and daily routine.

• Reduce sodium. Kohli recommends aiming for less than 1,500 to 2,000 milligrams (mg) of sodium a day, depending on your care team’s advice. Current guidelines recommend limiting sodium to less than 2,300 mg daily, ideally closer to 1,500 mg.

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   Restaurant meals, fast food, canned soups, deli meats, and processed foods can be major sources.

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   Check nutrition labels and compare products.
• Try the DASH eating plan. DASH stands for Dietary Approaches to Stop Hypertension.

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   It emphasizes vegetables, fruits, whole grains, beans, nuts, and low-fat dairy. Malik also recommends foods such as leafy greens, beets, and berries, which contain plant compounds that may help blood vessels relax.
• Be thoughtful about potassium. Potassium-rich foods, such as cantaloupe, kiwifruit, potatoes, and spinach, can help your body remove extra sodium through urine, which can lower blood pressure.

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   But Malik recommends asking your care team how much potassium is right for you if you have kidney disease or take medications that raise potassium levels. Too much potassium in the blood can cause dangerous heart rhythm problems.

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• Stay active and discuss weight goals. Kohli recommends at least 150 minutes of moderate-intensity activity each week, such as brisk walks, as your health allows. If weight loss is appropriate, your care team can help you develop a plan.
• Limit alcohol. Alcohol can raise blood pressure, so limiting or avoiding it is important, Kohli says. The American Heart Association recommends no more than two drinks per day for men and one drink per day for women.

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• Make time for sleep and stress relief. Pay attention to sleep and stress management with strategies such as paced breathing, meditation, yoga, or tai chi, Malik says.

Certain supplements, such as magnesium, omega-3 fatty acids, and aged garlic extract, may have some small benefits alongside treatment, Malik says, but others can raise blood pressure or interact with blood pressure medications. Even so, supplements are not a substitute for treatment. Talk with your care team before adding any to your routine.

Note: The U.S. Food and Drug Administration (FDA) does not approve supplements for safety or effectiveness. Talk to a healthcare professional about whether a supplement is the right fit for your individual health, and about any potential drug interactions or safety concerns.

Explore Renal Denervation When Appropriate

Work With a Hypertension Specialist

Kohli and Basman suggest asking for a referral to a hypertension specialist if:

• Your blood pressure stays uncontrolled despite several medications.
• You have side effects that make your medication plan hard to tolerate.
• Your provider suspects an underlying cause, such as a hormone or kidney problem.
• You developed high blood pressure at a young age, usually before age 30.
• You have signs of damage to the heart or kidneys.
• Your care team is considering renal denervation or another advanced treatment.

“Resistant doesn’t mean untreatable,” Kohli says. High blood pressure often causes no symptoms, and that can make taking several medications feel discouraging, she adds. But the goal is to protect your health over the long term by lowering the risk of heart attack, stroke, heart failure, kidney disease, and dementia.