In evaluating resistant hypertension, which steps are typically recommended?

• A. Assess adherence, evaluate secondary causes (sleep apnea, renal disease, endocrine disorders), optimize diuretic therapy (often with mineralocorticoid receptor antagonist), and consider specialist input.
• B. Increase salt intake.
• C. Stop all antihypertensive therapy.
• D. Only focus on lifestyle changes.

Answer: (A)

In evaluating resistant hypertension, the aim is to confirm true resistance and address factors that can be modified to lower blood pressure. Start by ensuring the patient is truly adherent to therapy and that blood pressure is measured correctly, since nonadherence or improper measurement can mimic resistance. Then search for secondary causes that are treatable—sleep apnea, kidney disease, and endocrine disorders are common culprits that, when identified and managed, can substantially improve BP. Next, optimize the antihypertensive regimen, especially diuretic therapy, because volume overload is a frequent driver of resistance; use a potent diuretic at an adequate dose, and in patients with reduced kidney function consider a loop diuretic. Add a mineralocorticoid receptor antagonist (such as spironolactone or eplerenone) when appropriate, as these have strong evidence for further lowering BP in resistant cases, with careful monitoring for potassium and kidney function. If blood pressure remains uncontrolled after these steps, seek specialist input for further evaluation and management. Removing therapy or focusing only on lifestyle changes won’t address true resistance, and increasing salt intake would worsen the problem.