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Cardiovascular prevention
Diagnosis and management of resistant hypertension
  1. James P Sheppard1,
  2. Una Martin2,
  3. Richard J McManus1
  1. 1 Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  2. 2 Institute of Clinical Sciences Birmingham, University of Birmingham, Birmingham, UK
  1. Correspondence to Professor Richard J McManus, Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford OX2 6GG, UK; richard.mcmanus{at}

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Learning objectives

  • To understand the definition, prevalence and prognosis of resistant hypertension.

  • To describe the methods for effective diagnosis of resistant hypertension.

  • To review the treatment options for resistant hypertension, including lifestyle advice, pharmacological treatment and surgical intervention.


High blood pressure (hypertension) is one of the most important risk factors for cardiovascular disease,1 2 which is a significant cause of morbidity and mortality worldwide.3 Recent surveys from developed countries suggest that the prevalence of hypertension ranges from 20% to 30%, with 51%–80% receiving treatment but only 27%–66% with adequate blood pressure control.4 One subset of uncontrolled hypertensives who do not respond to treatment are known as resistant hypertensives. This article will describe how resistant hypertension is defined, its prevalence and prognosis, methods to diagnose it effectively in routine practice and strategies to effectively manage patients diagnosed with the condition.

Definition of resistant hypertension

Resistant hypertension is generally defined as uncontrolled clinic blood pressure (>140/90 mm Hg) after treatment with three or more antihypertensives.5 In the UK, National Institute for Health and Care Excellence (NICE) guidelines specify that these three should include optimal doses of an ACE inhibitor (or an angiotensin receptor blocker), a calcium channel blocker and a diuretic.6 However, there are some circumstances which preclude resistant hypertension, which must be ruled out before a formal diagnosis can be made. The so-called ‘pseudoresistant’ hypertension can be caused by poor clinic blood pressure measurement technique, patient non-adherence to prescribed medication, patient intolerance to certain antihypertensive medications and white coat hypertension (where blood pressure appears high in the clinic but is controlled out-of-the-office on home or ambulatory measurements).5

Prevalence and prognosis

Most prevalence studies have been conducted in the USA using routine medical records and in that setting resistant hypertension is thought to be relatively common, affecting anywhere between 9% and 18% of patients with diagnosed hypertension (table …

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  • Contributors JPS and UM wrote the first draft. All authors subsequently refined the manuscript and approved the final version. RJMcM is the guarantor.

  • Competing interests JPS holds a Medical Research Council Strategic Skills postdoctoral fellowship. RJMcM holds an National Institute for Health Research (NIHR) Professorship and leads the self-management theme of the NIHR Oxford Collaborations for Leadership in Applied Health Research and Care (CLAHRC).

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Correction notice This paper has been amended since it was published Online First. Owing to a scripting error, some of the publisher names in the references were replaced with 'BMJ Publishing Group'. This only affected the full text version, not the PDF. We have since corrected these errors and the correct publishers have been inserted into the references.