Resistant hypertension: Causes and strategy to manage and treat resistant high blood pressure

resistant hypertensionResistant hypertension (high blood pressure) is diagnosed when a person has made the appropriate lifestyle changes in order to reduce their blood pressure or have taken at least two different types of blood pressure-lowering medications, and yet their blood pressure has not improved. Essentially, resistant hypertension refers to blood pressure that is difficult to treat and that may result from an underlying cause.

Possible causes for resistant hypertension include abnormalities in hormones controlling blood pressure, accumulation of artery-clogging plaque in the vessels that provide nutrients to the kidneys, sleep problems like sleep apnea, obesity, or high alcohol consumption.

Resistant hypertension causes


Knowing why your particular hypertension is not responding to treatment can be frustrating, as there are a number of things that may cause it to be difficult to adequately treat. With your cooperation and proper medical testing, the cause may reveal itself, making it easier to form a treatment plan that works for you.

The following are the three most common causes of resistant hypertension:

  • Patient non-compliance with treatment
  • Secondary hypertension (commonly due to an overactive adrenal gland)
  • Fluid retention (commonly due to kidney failure)

There are many other factors that may contribute to a diagnosis of resistant hypertension, including:

  • Misdiagnosis (pseudo-resistance)
  • Occult secondary causes of hypertension
  • Volume overload
  • Obesity
  • Cigarette smoking
  • Excess alcohol intake
  • Sleep apnea
  • Interfering medications
  • Suboptimal combinations of antihypertensive

These various secondary causes are the most likely routes of investigation your physician will take to find out why you may not be responding to the initial treatment plan. It would be ideal if the causes mentioned above were found to be the culprit as they can be easily remedied, but that may not be the case.

The most common cause and the bane of any physician is non-compliance to an outlined medical treatment. This is when a treatment plan is prescribed to the patient, and either they are not willing to follow through or they are passively defiant. While this notion may make the patient appear to be the bad guy, the circumstances may be a bit more complicated than this. Pharmaceutical medications typically require strict adherence for them to perform optimally, and some patients simply forget to take them medication or have trouble fitting them into their schedules. Another probable reason is side effects, as a lot of manufactured medication come with some sort of drawback that discourages the patient from using them regularly, whether consciously or unconsciously.

It is important to discuss potential problems with medication non-compliance, as working together with your doctor can help you find a more suitable treatment option that.

Understanding potential causes of resistant hypertension

False resistance

This is a scenario where the patient never actually has high blood pressure and only appears to have it in a clinical situation: known as white-coat hypertension. Classified as a temporary spike in blood pressure when at the doctor’s office or any other clinical setting, it may make it seem like you have uncontrolled blood pressure.

If you believe this could be the reason for your high blood pressure, talk to your doctor about home monitoring or ambulatory monitoring of your blood pressure to give better real world results.

Other possible reasons for false resistance include an incorrect method of obtaining blood pressure readings, commonly seen when incorrect blood pressure cuff sizes are used when making a reading. Also, chronically damaged arteries and blood vessels may lead to blood pressure to appear falsely raised (pseudo-hypertension) as seen in atherosclerosis. This may require a more invasive way to accurately measure your blood pressure by inserting a device directly into the vein.

Retaining fluid

This happens when the body is retaining too much water. It can occur due to overconsumption of sodium, kidney dysfunction, or even cardiovascular issues. Taking a diuretic medication helps release this extra fluid from the system.

Lifestyle issues

Many lifestyle habits contribute to increased blood pressure: cigarette smoking, obesity, and drinking too often are just some of the factors the contribute to increased blood pressure. Often the simplest solution is the best one. Quitting unhealthy habits, modifying diet, and increasing exercise are excellent lifestyle changes that not only help decrease and regulate blood pressure but also promotes overall health and wellbeing.

Symptoms of Resistant hypertension

While having high blood pressure in itself doesn’t necessarily present any immediate symptoms, there are instances where blood pressure may reach extremely high levels. This is called hypertensive crisis and can produce the following symptoms,

  • Headaches
  • Anxiety
  • Shortness of breath
  • Chest pain
  • Nosebleeds

It is important to note that dizziness is not a symptom of high blood pressure, but is a symptom of low blood pressure, as enough blood is not reaching the brain.

Managing resistant hypertension patients

A review of articles on resistant hypertension uncovered new ways for physicians to help patients with hard-to-treat high blood pressure. Researcher Dr. Raj Padwal and colleagues wrote, “We found few randomized controlled trials (RCTs) and no systematic reviews to guide decision-making. Thus, we have made management recommendations based primarily on expert consensus, unless otherwise specified.”

The study found that before targeting resistant hypertension, physicians should rule out pseudo-resistance, which consists of higher blood pressure when visiting a doctor (known as the white coat effect), failure to take medications as instructed, and inaccurate blood pressure readings.

The study recommends the following for improving treatment of resistant hypertension:

  • Optimizing current medications and improving adherence.
  • Counseling patients on reduced salt intake, lower alcohol use, exercise, and a healthy weight.
  • Treating obstructive sleep apnea with a CPAP device.
  • Adding drugs when current ones are ineffective.
  • Referring patients to hypertension specialists.

The researchers recommend that more studies need to be conducted on resistant hypertension in order to better understand this condition and improve treatments.

Strategy to help manage resistant hypertension


Resistant hypertension may be difficult to treat, but it’s still important that patients partake in the healthy lifestyle habits to help reduce high blood pressure, along with taking at least three different medications.

Lifestyle choices for treating hypertension include eating a healthy diet, reducing sodium and alcohol intake, controlling your weight, exercising, not smoking, reducing stress, and treating any sleep conditions such as sleep apnea.

Related: What is systolic and diastolic blood pressure?

Author Bio

Mohan Garikiparithi got his degree in medicine from Osmania University (University of Health Sciences). He practiced clinical medicine for over a decade before he shifted his focus to the field of health communications. During his active practice he served as the head of the Dept. of Microbiology in a diagnostic centre in India. On a three-year communications program in Germany, Mohan developed a keen interest in German Medicine (Homoeopathy), and other alternative systems of medicine. He now advocates treating different medical conditions without the use of traditional drugs. An ardent squash player, Mohan believes in the importance of fitness and wellness.


Related Reading:

High blood pressure and erectile dysfunction (ED): How it affects your sex life

What causes low and high blood pressure after exercise?

Popular Stories