Resistant Hypertension
Conditions We Treat
Resistant Hypertension
Blood pressure that defies three or more medications often has a renal or endocrine cause. Finding it — and treating it — is what we do.
What is resistant hypertension?
Resistant hypertension is defined as blood pressure that remains above goal despite the use of three or more antihypertensive medications at optimal doses — including a diuretic. It affects an estimated 10–15% of all hypertensive patients and carries a significantly elevated risk of heart attack, stroke, kidney failure, and death.
The majority of resistant hypertension cases have an identifiable cause. The most common is primary aldosteronism — overproduction of the hormone aldosterone by the adrenal glands — which is present in up to 20% of resistant hypertension cases and is routinely missed in primary care. Other causes include renal artery stenosis, obstructive sleep apnea, chronic kidney disease, and pheochromocytoma.
Before labeling hypertension as truly resistant, we also evaluate for pseudoresistance: white-coat effect, medication non-adherence, and suboptimal drug regimens. True resistant hypertension requires a systematic diagnostic workup — not simply adding a fourth medication.
Common Causes
How we approach resistant hypertension
Rule out pseudoresistance first
White-coat hypertension, medication non-adherence, and suboptimal drug selection account for many "resistant" cases. We confirm true resistance before pursuing a secondary cause workup.
Screen for primary aldosteronism
Aldosterone-to-renin ratio testing is the first step. If positive, adrenal CT and adrenal vein sampling identify whether one or both adrenal glands are overproducing — which determines whether surgery or medication is the right treatment.
Evaluate for renal artery stenosis
Renal duplex ultrasound or CT angiography identifies significant stenosis. Revascularization — stenting or surgery — can dramatically improve blood pressure control in the right patient.
Optimize the medication regimen
True resistant hypertension often responds to the addition of a mineralocorticoid receptor antagonist (spironolactone or eplerenone) — even without confirmed aldosteronism. We build regimens based on mechanism, not trial and error.
Frequently asked questions
What is resistant hypertension?
Resistant hypertension is blood pressure that remains above goal despite the use of three or more antihypertensive medications at optimal doses — including a diuretic. It is not simply "hard to control" blood pressure; it is a specific clinical entity with identifiable causes.
What is the most common cause of resistant hypertension?
Primary aldosteronism — overproduction of the hormone aldosterone by the adrenal glands — is present in up to 20% of resistant hypertension cases. It is the most common secondary cause and is routinely missed in primary care.
Why does resistant hypertension matter?
Uncontrolled hypertension is the leading modifiable risk factor for stroke, heart attack, heart failure, and kidney failure. Patients with resistant hypertension have a significantly higher risk of cardiovascular events than those with controlled hypertension.
Can resistant hypertension be cured?
In some cases, yes. Primary aldosteronism caused by a single overactive adrenal gland can be cured with surgery. Renal artery stenosis can be treated with revascularization. In other cases, the goal is optimal control with the right combination of medications.
Related conditions
Resistant hypertension has a cause. We find it.
Our nephrologists specialize in secondary hypertension evaluation. Accepting new patients in Newport Beach.