Approaches for the Management of Resistant Hypertension in 2020

  • Wilbert S. AronowEmail author
Resistant Hypertension (L Drager, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Resistant Hypertension


Purpose of Review

Resistant hypertension is diagnosed if the blood pressure (BP) is not controlled despite optimum doses of 3 first-line classes of antihypertensive drugs including a thiazide diuretic or if adequate BP control needs 4 or more antihypertensive drugs from different classes.

Recent Findings

Pseudohypertension and white coat hypertension must be excluded. Poor patient compliance, inadequate doses of antihypertensive drugs, poor office BP measurement technique, and having to pay for costs of drugs are factors associated with pseudoresistant hypertension. Secondary hypertension must be excluded and treated. Therapy of resistant hypertension includes improving compliance with use of medication, detection, and treatment of secondary hypertension, use of lifestyle measures, and treatment of obesity and other comorbidities. Switching the patient from hydrochlorothiazide to a longer acting thiazide-type diuretic such as chlorthalidone may improve BP control. The beneficial effects of thiazide diuretics are reduced when the glomerular filtration rate is reduced to less than 40 mL/min/1.73 m2. These patients should be treated with a loop diuretic such as furosemide every 12 h. If a fourth antihypertensive drug is needed to control blood pressure in persons treated with adequate doses of antihypertensive drugs from different classes including a thiazide-type diuretic, a mineralocorticoid receptor antagonist should be added to the therapeutic regimen. Further research is needed on investigational drugs and device therapy for treating resistant hypertension.


Clinical trials are indicated for the treatment of resistant hypertension by sacubitril/valsartan and also by firibastat.


Resistant hypertension Antihypertensive drugs Diuretics Mineralocorticoid receptor antagonists Lifestyle measures Device therapy for hypertension 


Compliance with Ethical Standards

Conflict of Interest

Dr. Aronow has no conflicts of interest to disclose. This author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or drugs or devices discussed in this manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by the author.


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Authors and Affiliations

  1. 1.Department of CardiologyWestchester Medical Center and New York Medical CollegeValhallaUSA
  2. 2.Department of MedicineWestchester Medical Center and New York Medical CollegeValhallaUSA

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