6 Reasons Prescribed Blood Pressure Medications May Prove Ineffective

Resistant hypertension, defined as blood pressure persistently above 130/80 mm Hg despite the use of three antihypertensive medications, including a diuretic, at optimal doses, affects approximately 10-15% of hypertensive patients[1]. This clinical challenge requires a meticulous approach to ensure effective management.

### Potential Causes of Resistant Hypertension

Potential reasons for resistant hypertension include pseudoresistance factors such as medication nonadherence, improper blood pressure measurement, white coat hypertension, and interfering medications. Secondary causes may involve primary hyperaldosteronism, kidney disease, hormonal imbalances, sleep apnea, and lifestyle factors like excess salt intake, obesity, alcohol use, and stress[1][3][5].

### Treatment of Resistant Hypertension

To confirm true resistance, it is essential to exclude pseudoresistance by ensuring adherence, proper measurement, and ruling out white coat effect through ambulatory or home monitoring. The optimal treatment approach includes the use of three drugs from different classes at maximum tolerated doses: angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs), calcium channel blockers, and diuretics targeting volume excess.

In some cases, a mineralocorticoid receptor antagonist (MRA) like spironolactone may be considered as a fourth-line agent. However, monitoring for hyperkalemia and kidney function is crucial. Additional agents such as alpha-blockers or beta-blockers may be added but are generally less effective than spironolactone[2].

New therapies, such as Aprocitentan, an endothelin receptor antagonist, have recently been approved as a novel treatment option showing efficacy and safety for resistant hypertension[2]. Addressing secondary causes, such as primary aldosteronism, kidney disease, and sleep apnea, is critical for improving control. Lifestyle modifications, including reducing salt intake, weight loss, limiting alcohol, and managing stress, are also essential.

Advanced interventions like renal denervation, which targets overactive sympathetic nerves in select patients, are emerging options[3].

### Addressing White Coat Hypertension and Medication Interactions

Managing anxiety, arriving early, taking deep breaths, and sitting quietly before blood pressure readings can help with 'white coat hypertension'. Other drugs like pain relievers (NSAIDs), oral contraceptives, and nasal decongestants can interfere with blood pressure control.

### The Role of Hypertension Specialists

If high blood pressure isn't responding to medication, a patient may be referred to a hypertension specialist recognized by the American Society of Hypertension. These specialists investigate difficulties in controlling blood pressure and create personalized treatment plans for attacking stubborn hypertension.

### Lifestyle Factors and Dietary Considerations

Being overweight, inactive, or a smoker can contribute to high blood pressure and should be addressed to lower it. Dr. George Thomas, a hypertension specialist, recommends the low sodium DASH diet for patients with hypertension, consisting of fruits, vegetables, whole grains, lean protein, and an ideal goal of no more than 1.5 grams of sodium each day[4]. Registered dietitians can help patients manage their sodium intake by teaching them how to spot sodium in nutrition labels.

In summary, managing resistant hypertension requires a systematic approach to exclude pseudoresistance, identify and treat secondary causes, optimize pharmacological therapy including newer agents like Aprocitentan, and reinforce lifestyle changes to improve blood pressure control and reduce cardiovascular risk[1][2][3]. The Cleveland Clinic, a non-profit academic medical center, is one such institution dedicated to providing comprehensive care for patients with resistant hypertension.

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