Synopsis
Confirm true resistant hypertension, identify pseudo-resistance and secondary causes, then add evidence-based step-4 treatment with safe biochemical monitoring.
- NICE resistant hypertension means BP remains above the person's age- and comorbidity-appropriate NICE target despite optimal tolerated ACE inhibitor or ARB plus calcium-channel blocker plus thiazide-like diuretic, with elevation confirmed by ABPM or HBPM before step 4.
- Before step 4, confirm elevated BP with ABPM or HBPM, assess postural BP and discuss adherence.
- Exclude pseudo-resistance: wrong cuff/technique, white-coat effect, missed doses, under-dosing, excess salt/alcohol and pressor medicines/substances.
Key red flags
Onset under 40, rapid change or extensive organ damage prompts specialist secondary-cause assessment.
Investigation priorities
Confirm sustained out-of-office hypertension and exclude white-coat resistance.
Management branches
Clinic BP remains above target on three-drug treatment.
- First: repeat correct seated and standing BP, check cuff/device and obtain ABPM or HBPM.
- Next: reconcile prescriptions, actual dosing, adverse effects, cost/access, salt/alcohol and all pressor substances in a non-judgemental interview.
Key medicines
Spironolactone25 mg orally once daily initially; increase to 50 mg once daily if needed and tolerated.
DoxazosinImmediate-release: 1 mg orally once daily initially, titrated to 2–4 mg once daily; maximum 16 mg/day.