Current Hypertension Reports

, 21:67 | Cite as

Resistant Hypertension Management: Comparison of the 2017 American and 2018 European High Blood Pressure Guidelines

  • Guido Grassi
  • David A. Calhoun
  • Giuseppe Mancia
  • Robert M. CareyEmail author
Resistant Hypertension (L Drager, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Resistant Hypertension


Purpose of Review

To compare European and American guidelines for the diagnosis, evaluation, and management of resistant hypertension.

Recent Findings

Resistant hypertension is defined as high blood pressure that remains above goal with the use of 3 or more antihypertensive agents, commonly a renin-angiotensin blocker (either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker), a long-acting calcium channel blocker, and thiazide or thiazide-like diuretic. Resistant hypertension is common, with a recent analysis indicating that it affects approximately 17–19% of adult Americans with hypertension. Pseudocauses of apparent resistant hypertension, including inaccurate blood pressure measurement, white coat effect, undertreatment, and poor medication adherence, must be excluded in order to confirm true resistant hypertension. Evaluation of resistant hypertension requires identifying and treating secondary causes of hypertension, including obstructive sleep apnea, primary aldosteronism, and renal artery stenosis. Treatment of resistant hypertension includes a combined use of lifestyle modification and prescription of effective multiple-drug combinations. Preferential use of a long-acting thiazide-like diuretic, either chlorthalidone or indapamide, and a mineralocorticoid receptor blocker, most commonly spironolactone, is recommended if needed to achieve blood pressure control.


Aside for small exceptions, European and American guidelines agree in terms of recommendations for diagnosing, evaluating, and treating resistant hypertension.


Resistant hypertension Pseudoresistance White coat effect Adherence Aldosteronism Spironolactone 


Funding Information

David Calhoun’s research was supported by the National Institutes of Health (R01 HL113004) and the American Heart Association Strategically Focused Research Network (AHA 5SFRN2390002). Robert M. Carey’s research is supported by the National Institutes of Health (R01 HL 128189 and P01 HL 074940).

Compliance with Ethical Standards

Conflict of Interest

The authors declare no conflicts of interest relevant to this manuscript.

Human and Animal Rights and Informed Consent

All reported studies/experiments with human subjects or animals performed by the authors have been previously published and complied with all applicable ethical standards (including the Helsinki declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines).


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Guido Grassi
    • 1
  • David A. Calhoun
    • 2
  • Giuseppe Mancia
    • 1
  • Robert M. Carey
    • 3
    Email author
  1. 1.Department of Internal Medicine, Clinica MedicaUniversity of Milano-BicoccaMilanItaly
  2. 2.Vascular Biology and Hypertension ProgramUniversity of Alabama at BirminghamBirminghamUSA
  3. 3.Department of MedicineUniversity of Virginia Health SystemCharlottesvilleUSA

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