High blood pressure is one of the leading risk factors influencing the global burden of cardiovascular disease, resulting in increased incidence of all-cause and cardiovascular mortality, sudden death, stroke, coronary heart disease, heart failure, atrial fibrillation, peripheral artery disease, and renal insufficiency. Hypertension affects about 25% of adults around the world and is estimated to lead to over seven million deaths each year—that is, about 13% of the total number of deaths worldwide. Lifestyle changes are able to lower blood pressure and prevent the development of hypertension, and antihypertensive drug treatment has been shown to reduce blood pressure and cardiovascular complications in hypertensive patients. Despite current knowledge on the management of hypertension and the availability of numerous effective antihypertensive drugs and combinations of drugs, hypertension remains inadequately controlled in many patients and a number of them are considered to have so-called ‘resistant hypertension’.

The following issues will be discussed in this article on resistant hypertension: definition; prevalence; causes; target organ damage and cardiovascular complications; patient evaluation; and management. It is of note, however, that much of the knowledge on resistant hypertension is observational in nature, and that hard evidence is scarce, apart from a number of recent randomised controlled trials. This article will highlight new developments, with due respect for current generally accepted knowledge.