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Resistant hypertension should trigger a structured search for reversible causes rather than automatic addition of more medications. Primary aldosteronism is especially important because it is common, underdiagnosed and associated with cardiovascular and renal complications beyond the effect of blood pressure alone. Screening with an aldosterone-to-renin ratio is appropriate in selected high-risk patients, while confirmatory testing and adrenal imaging or venous sampling are used according to the suspected subtype. Obstructive sleep apnea, renal parenchymal disease, renovascular disease, thyroid disorders and medication effects are other important contributors. For internists, the first step is confirmation of true resistance using validated measurements and adherence review. Dietary sodium, obesity, NSAIDs, oral contraceptives, steroids and sympathomimetics can all complicate management. Once secondary causes are considered, spironolactone remains an evidence-based fourth-line therapy for many patients without contraindications. This diagnostic approach prevents years of uncontrolled blood pressure and reduces the risk of unnecessary polypharmacy.
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Resistant hypertension should trigger a structured search for reversible causes rather than automatic addition of more medications. Primary aldosteronism is especially important because it is common, underdiagnosed and associated with cardiovascular and renal complications beyond the effect of blood pressure alone. Screening with an aldosterone-to-renin ratio is appropriate in selected high-risk patients, while confirmatory testing and adrenal imaging or venous sampling are used according to the suspected subtype. Obstructive sleep apnea, renal parenchymal disease, renovascular disease, thyroid disorders and medication effects are other important contributors. For internists, the first step is confirmation of true resistance using validated measurements and adherence review. Dietary sodium, obesity, NSAIDs, oral contraceptives, steroids and sympathomimetics can all complicate management. Once secondary causes are considered, spironolactone remains an evidence-based fourth-line therapy for many patients without contraindications. This diagnostic approach prevents years of uncontrolled blood pressure and reduces the risk of unnecessary polypharmacy.
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