Resistant hypertension is defined as persistently elevated blood pressure despite adherence to optimal doses of three antihypertensive medications, including a diuretic, from different classes.

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It is a challenging condition to manage and may require a comprehensive evaluation to identify and address underlying causes and contributing factors. Here’s an overview of resistant hypertension:

**Causes and Risk Factors:**

**Poor Medication Adherence**: Non-adherence to prescribed antihypertensive medications is a common cause of resistant hypertension.

**Secondary Hypertension**: Underlying medical conditions such as chronic kidney disease, primary aldosteronism, renovascular disease, obstructive sleep apnea, thyroid disorders, or pheochromocytoma may contribute to resistant hypertension.

**Lifestyle Factors**: Factors such as obesity, excessive salt intake, alcohol consumption, physical inactivity, and stress can contribute to resistant hypertension.

**Medication-related Factors**: Inappropriate dosing, drug interactions, inadequate selection of antihypertensive medications, or use of sympathomimetic drugs may contribute to treatment resistance.

**White Coat Hypertension or Masked Hypertension**: In some cases, blood pressure measurements obtained in clinical settings may not accurately reflect a patient’s true blood pressure status, leading to misdiagnosis of resistant hypertension.

**Evaluation and Management:**

**Comprehensive Evaluation**: Conduct a thorough evaluation to identify and address underlying causes and contributing factors, including history taking, physical examination, laboratory tests (renal function, electrolytes, urinalysis), imaging studies (renal ultrasound, renal artery Doppler, echocardiography), and specialized tests (aldosterone-renin ratio, sleep studies).

**Optimization of Medications**: Ensure adherence to prescribed medications, optimize doses, and consider adding or switching to different classes of antihypertensive medications, such as diuretics, ACE inhibitors, angiotensin II receptor blockers (ARBs), calcium channel blockers (CCBs), beta-blockers, or mineralocorticoid receptor antagonists (spironolactone, eplerenone).

**Lifestyle Modifications**: Emphasize lifestyle modifications such as weight loss, dietary modifications (DASH diet), sodium restriction, regular exercise, moderation of alcohol consumption, smoking cessation, stress reduction techniques, and adequate sleep.

**Treatment of Underlying Conditions**: Address underlying medical conditions contributing to resistant hypertension, such as obstructive sleep apnea, primary aldosteronism, renovascular disease, or thyroid disorders, through appropriate medical or surgical interventions.

**Referral to Hypertension Specialists**: Consider referral to hypertension specialists or multidisciplinary hypertension clinics for further evaluation and management of resistant hypertension, particularly in cases where optimal blood pressure control cannot be achieved despite comprehensive management efforts.

**Patient Education and Support**: Provide education and support to empower patients to actively participate in their care, adhere to lifestyle modifications and medication regimens, monitor blood pressure at home, recognize signs of hypertension-related complications, and seek prompt medical attention when needed.

**Regular Follow-Up**: Schedule regular follow-up visits to monitor blood pressure control, assess treatment response, adjust medications as needed, reinforce lifestyle modifications, and address any new or ongoing concerns.

Overall, the management of resistant hypertension requires a multidisciplinary approach, including lifestyle modifications, optimization of medications, evaluation and treatment of underlying causes, and regular monitoring to achieve optimal blood pressure control and reduce the risk of cardiovascular complications.