Feature Article

Refractory hypertension: overcoming hard to control blood pressure

Rob MacGinley, John Amerena



Refractory hypertension must be carefully differentiated from hypertension caused by other treatable conditions or poor compliance. Once diagnosed, it can be treated with several pharmacological options and specialist assistance.

Key Points

  • Refractory hypertension, defined as blood pressure that remains high despite lifestyle modification and three antihypertensive medications, appears to be increasing in prevalence.
  • Refractory hypertension must be differentiated from otherwise poorly controlled hypertension by examining lifestyle factors (including hypertension-inducing drugs), treatment compliance and potential secondary causes of hypertension, such as renal disease and obstructive sleep apnoea.
  • An important diagnostic tool for diagnosing true refractory hypertension versus white coat hypertension is 24-hour blood pressure monitoring.
  • Treatment of refractory hypertension comprises strict diet and lifestyle modifications along with more aggressive pharmaceutical measures, such as maximising diuretic therapy, using combination therapies and considering use of novel therapies. Referral of patients to a specialist hypertension clinic and regular biochemical monitoring may be required.