High blood pressure, or hypertension, is often called the ‘silent killer.’ While medication remains the primary treatment, for some, even optimal medication and lifestyle changes fail to bring blood pressure under control. This condition is termed resistant hypertension. It is defined as blood pressure that remains above 14090 mmHg despite the use of three or more antihypertensive medications, including diuretic at optimal doses.

Dr Sanjeev Gera, Director, Cardiac Sciences, Fortis Heart Institute, Noida, “Resistant hypertension is not just a numbers problem, it is a sign that something deeper is causing the blood pressure to remain high. A complex evaluation that includes revisiting lifestyle choices, medication adherence, and screening for secondary causes can help uncover the root of the problem. Identifying these underlying factors, not only help in keeping the blood pressure under control, but also significantly reduce the risk of heart attack, stroke, and other serious complications. Timely interventions that combine lifestyle modifications with advanced medical therapy can change the outcome for these individuals and prevent long term complications.” 

Dr Amit Sharma, Interventional Cardiologist at Health First Cardiac Centre, Vile Parle, Mumbai, “Resistant hypertension is a warning sign that the individual is at a higher risk for heart attack, stroke or kidney disease. While medication remains the primary treatment, for some, even optimal medication and lifestyle changes fail to bring blood pressure under control. For those who continue to struggle despite these efforts, advanced therapies like renal denervation offer new hope. Managing hypertension beyond the pills requires both personal commitment and evolving medical innovation.”  

Dr Guruprasad S, HOD, Department of Electrophysiology, Gleneagles Hospitals, Chennai, said, “Many patients with resistant hypertension do not even realize that they  suffer from resistant hypertension, because they think they are giving their best, following instructions, eating well, and exercising regularly, which they genuinely do. We often see patients on multiple medications with persistent high blood pressure readings but fail to identify the underlying causes. For them, it is not just about adding another pill. They need a structured evaluation that considers both lifestyle modifications and emerging medical interventions. Managing blood pressure is not one-size-fits-all, it is personal.”  

Following are some factors that one should not overlook while managing resistant hypertension 

Obstructive Sleep Apnea

OSA is a major yet often under looked contributor to resistant hypertension. OSA leads to intermittent hypoxia and increased sympathetic nervous system activity during sleep, both of which drive persistent elevation of blood pressure.2 Treating this, can significantly improve blood pressure in affected individuals. 

Lifestyle Factors 

Lifestyle factors play a significant role in resistant hypertension. Excessive dietary salt intake is especially common and can diminish the effects of antihypertensive medications. Obesity is another important contributor, as it is associated with increased sympathetic activity, insulin resistance, and sodium retention.

Primary Aldosternoism & Hormonal Disorders 

Disorders of hormone regulation, especially overproduction of aldosterone by the adrenal glands are common causes. These conditions often go undiagnosed but can be identified with targeted testing and treated with specific medications.

Chronic Kidney Disease(CKD) 

Chronic kidney disease is both a cause and a consequence of resistant hypertension. Damaged kidneys disrupt fluid and hormone balance in turn promoting resistant hypertension. Early detection and management of kidney disease are critical for breaking this vicious cycle.

Non-Adherence To Medications 

Studies reveal that 50% of hypertension patients become non-adherent to their medications within a year, often skipping doses when they feel better or encounter side effects.4 Non-adherence to medications remains a significant barrier in managing blood pressure, especially for those with resistant hypertension, as even missing a few doses can affect long-term control.  

The next step in treatment – Renal Denervation 

For patients whose blood pressure remains uncontrolled despite addressing these factors, modern therapies like Renal Denervation (RDN) may be useful. RDN is a minimally invasive catheter-based procedure that targets the overactive sympathetic nerves in the renal arteries that play a key role in regulating blood pressure. By acting on the renal arteries, RDN offers a sustained drop in blood pressure for those with resistant hypertension, who have exhausted other options.

Resistant hypertension is a complex condition that demands a thorough search for hidden causes and a willingness to embrace new solutions. The key is to not give up, explore all available options, and take control of your blood pressure.