Table 4. Approach to Management of the Patient with Resistant Hypertension

Assess adherence to therapy	• Ask about adherence to the treatment plan
	• Ensure adherence to medications is as simple as possible (eg, once daily dosing regimens, generics, fixed-dose combination pills)
Rule out measurement error and white coat effect	• Repeat office measurement of BP making sure cuff size is correct (too small a cuff will overestimate BP) and proper technique is followed
	• Consider out-of-office monitoring (Figure 1)
Consider associated comorbidities	• Address chronic kidney disease if present
	• Emphasize weight loss if patient is overweight
	• In older patients with coronary artery disease, a low diastolic BP may limit degree to which systolic BP can be reduced
Reconsider secondary causes	• Test for primary aldosteronism
	• Consider testing for obstructive sleep apnea
	• Consider rarer causes such as Cushing's syndrome, coarctation of the aorta, pheochromocytoma, and hyperparathyroidism
Address volume overload and interfering substances	• Emphasize reducing dietary sodium; consider consulting nutrition specialist to assist
	• Discontinue or reduce medications, supplements, and other agents (eg, alcohol) that interfere with BP control (Table 3)
Intensify therapy	• Options for intensifying pharmacologic therapy (assumes patient already on low-dose thiazide diuretic, an ACEI or ARB, a long-acting calcium channel blocker, and possibly a beta-blocker): - Increase dose of diuretic (or change HCTZ to chlorthalidone) or change to a loop diuretic for those with GFR <30 mL/min - If no contraindications, add spironolactone as first-choice (starting at 12.5 mg daily); eplerenone (starting at 25 mg daily), or amiloride (starting at 2.5 mg daily) are alternatives - Use a vasodilating β-blocker (eg, carvedilol) - Add a calcium channel blocker from the alternate class (eg, add a nondihydropyridine if already on a dihydropyridine) - Add clonidine or guanfacine
Consult hypertension specialist	For directory of hypertension specialists, see http://www.ash-us.org/HTN-Specialist/HTN-Specialists-Directory.aspx

ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin II receptor blocker; BP, blood pressure; GFR, glomerular filtration rate; HCTZ, hydrochlorothiazide.