Table 1.

A 7 step plan for evaluation and management of treatment resistant hypertension (2).

1. Confirm treatment resistance by checking that the patient's office blood pressure is ≥140/90 mmHg despite taking ≥3 blood pressure medications at optimal doses, preferably including a diuretic.

2. To exclude pseudoresistance, check if the patient is adherent to an optimal treatment regimen and whether their out-of-office blood pressure is elevated.

3. Identify and address lifestyle factors that contribute to hypertension, such as obesity, physical inactivity, excess alcohol consumption, and high salt intake.

4. Discontinue or reduce interfering substances, including NSAIDs, sympathomimetics, oral contraceptives, erythropoietin, and non-prescription weight loss supplements containing ephedra.

5. Screen for secondary hypertension causes, including obstructive sleep apnea, primary aldosteronism, chronic kidney disease, renal artery stenosis, and pheochromocytoma.

6. To optimize pharmacologic treatment, consider enhancing diuretic therapy and using alpha1 and beta1 adrenoceptor blockade in patients with an otherwise optimal regimen, while avoiding combining beta-blockade with non-dihydropyridine CCB.

7. If the patient's blood pressure remains uncontrolled after six months or if there are known or suspected secondary causes of hypertension, it is recommended to refer them to a hypertension specialist for definitive evaluation and treatment.