Resistant Hypertension

What is resistant hypertension?

The resistant hypertension definition is blood pressure that stays high (140/90 millimeters of mercury or mmHg and above) — even when you take three or more blood pressure medicines. These typically include maximum doses of:

• One diuretic (water pill).
• One calcium channel blocker.
• One angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB).

Hypertension (high blood pressure) is a major health issue that puts you at risk of cardiovascular (heart and blood vessel) diseases.

Healthcare providers may consider a resistant hypertension diagnosis after six months of unsuccessful treatment.

Clinical studies are looking into procedures that may help people with resistant hypertension in the future.

How common is resistant hypertension?

About 29% of adults in the U.S. have high blood pressure. About 12% of them fall in the resistant hypertension group.

What are the symptoms of resistant hypertension?

Some people can go years without even knowing they have hypertension. But untreated high blood pressure is dangerous to your health. Although you may not always feel the symptoms of hypertension, some people notice headache, chest pressure or shortness of breath.

You and your healthcare provider should monitor your blood pressure numbers regularly, especially as you get older. You can also measure them at home with a good, inexpensive electronic monitor. You can find one at most drug stores or online.

What causes resistant hypertension?

Resistant hypertension causes range from lifestyles to medicines to other conditions.

Lifestyle and what you eat

The following can all play a role in developing both hypertension and resistant hypertension:

• A body mass index (BMI) greater than 25.
• Physical inactivity.
• Foods high in salt.
• Heavy alcohol intake.

Drugs and medications

A variety of medications, including prescription and over-the-counter (OTC) drugs, can make it harder to manage blood pressure.

Examples include:

• Painkillers, especially NSAIDs (nonsteroidal anti-inflammatory drugs) like ibuprofen and naproxen.
• Nasal decongestants.
• Oral contraceptives (birth control pills).
• Ginseng, licorice or other herbal products.

Secondary causes

Sometimes, treatable secondary causes may be the source of your resistant hypertension.

Examples of secondary causes that raise your blood pressure include:

• Primary hyperaldosteronism, when your adrenal glands make too much of certain hormones.
• Renal artery stenosis, a narrowing of the arteries to your kidneys.
• Chronic kidney disease (CKD).
• Sleep apnea.
• Pheochromocytoma, a tumor in your adrenal gland (less common).
• Aortic narrowing (less common).
• Cushing syndrome, an overproduction of some steroid hormones (less common).

What are the risk factors for resistant hypertension?

You’re more likely to have resistant hypertension if you:

• Have chronic kidney disease.
• Have diabetes.
• Are African American.
• Were assigned male at birth (AMAB).

What are the complications of resistant hypertension?

Compared to people with high (but regulated) blood pressure, people with hard-to-treat, resistant hypertension have a higher risk of:

• Stroke.
• Kidney disease.
• Heart failure.

How is resistant hypertension diagnosed?

To diagnose resistant hypertension, your healthcare provider will gather information about you. They’ll want to make sure:

• Your blood pressure readings are accurate.
• You’re taking your prescribed medicines every day.
• You don’t have white coat syndrome.

Detailed medical history
Your provider may ask you:

• When your high blood pressure began.
• The steps you take when checking your blood pressure at home.
• Current drugs you take (including herbal medications and supplements) and if you take them as prescribed.
• Questions about possible secondary causes of your unmanaged hypertension.
• Questions about alcohol and tobacco use.

Physical exam
The physical exam will look for:

• Abnormal changes in your eye (a condition called hypertensive retinopathy).
• Abnormal sounds called bruits (vascular murmur) over some major arteries. These bruits may signal abnormal deposits of fatty tissue, also called plaques, in these blood vessels.

Lab tests

Lab tests may include:

• A urine test for protein.
• Blood tests to check your levels of blood creatinine, glucose and electrolytes like sodium and potassium.
• A blood test to screen for possible disease in the adrenal glands or kidneys.
• A test for thyroid disease because hypothyroidism can contribute to high blood pressure.

Imaging tests
These tests to check your adrenal gland, or to check for narrowing kidney arteries, may include:

• X-rays.
• Ultrasound.
• Computed tomography (CT) scans.

Also, your provider may ask you to undergo a sleep study to check for sleep apnea.

How do you fix resistant hypertension?

Resistant hypertension treatment may consist of lifestyle changes and medicines.

Lifestyle changes

Changes you can make include:

• Limiting salt (eating fewer than 2,400 milligrams per day) and alcohol.
• Limiting the use of NSAIDs for pain relief and using acetaminophen instead.
• Doing at least 30 minutes a day of aerobic activity, several days a week.

Medicines

Treatment for resistant hypertension may be as simple as making sure you’re following instructions for taking medicine. In about 40% of resistant hypertension cases, medications aren’t working because people aren’t taking them correctly. For the drugs to work, you have to take them every day at the correct dose, and the correct number of times per day.

If you have trouble taking your medicine correctly, talk to your provider. They may ask about side effects that keep you from taking all of your doses. If you have side effects from one drug, your provider may prescribe a different one. They may switch you to medicines that you only need to take once a day. Don’t stop taking any medications before talking to your provider.

If you’ve been taking your medication correctly and still have resistant hypertension, your provider may add another medication. Some people need to take four or five kinds of blood pressure medicines.

The most common classes of blood pressure medicines are:

• Diuretics.
• Calcium channel blockers.
• ACE inhibitors/angiotensin receptor blockers (ARBs).

Depending on your potassium level, your provider may need to double your diuretic dose or add a fourth type of medication — an aldosterone antagonist like spironolactone — to regulate your blood pressure. Your provider may also choose a beta-blocker.

Side effects of the treatment

Every medicine can have side effects. High blood pressure medicine side effects may include:

• Dizziness.
• Headache.
• Frequent need to pee.
• Constipation (trouble pooping).
• Dry cough.
• Tiredness.

How can I lower my risk of resistant hypertension?

To keep your high blood pressure from becoming resistant to treatment:

• Follow your provider’s instructions for taking your blood pressure medicines.
• Stay at a weight that’s healthy for you.
• Exercise 150 minutes each week (split into three to five sessions).
• Cut down the amount of salt you eat.
• Limit how much alcohol you drink.
• Get enough sleep every night.

What can I expect if I have resistant hypertension?

Most people with resistant hypertension can manage their blood pressure with medication. In addition to prescribing medication, your provider might need to try some different approaches, like replacing one diuretic with a stronger one or having you take one of your non-diuretic medicines at night.

Outlook for resistant hypertension

People who have resistant hypertension are at a higher risk of:

• Heart failure.
• Heart attack.
• Stroke.
• Kidney disease.
• Death.

How do I take care of myself?

Living with high blood pressure is an all-day, every-day thing. Taking care of yourself includes:

• Taking your blood pressure medicines at the right times and in the right doses.
• Limiting how much salt and alcohol you eat and drink.
• Going to checkup appointments.
• Exercising regularly.
• Maintaining a weight that’s healthy for you.
• Checking your blood pressure at home.

What can’t I eat with resistant hypertension?

Salt raises your blood pressure, so it’s good to avoid it. But you may not be aware of which foods contain it. You may be surprised to learn that restaurant meals and processed foods have a lot of salt in them. Avoiding and/or limiting these foods will help you put less salt into your body.

When should I see my healthcare provider?

Contact your provider if:

• You’re having trouble taking the medicines your provider prescribed for you.
• Your blood pressure readings are high even when you take every medicine as prescribed.

When should I go to the ER?

A hypertensive crisis needs medical attention immediately.

When this happens, your blood pressure suddenly gets very high (180/120 mmHg), and you experience:

• Headaches.
• Pounding in your chest.
• Dizziness.
• Shortness of breath.

What questions should I ask my doctor?

You may want to ask your provider:

• Do you need to change my medicines?
• Which combination of blood pressure medicines is best for me?
• How often do you want me to check my blood pressure at home?
• How often do I need follow-up appointments with you?

A note from Cleveland Clinic

It gets frustrating when you take multiple medications and don’t see any improvements. Getting your blood pressure into a normal range can feel like a real struggle when three blood pressure medicines aren’t enough. An honest conversation with your provider will help you get to the bottom of this problem. It’s in your best interest to ask questions about anything that isn’t clear.