Visual summary
True resistance is a diagnosis reached after verifying measurement, treatment delivery, and reversible contributors.
Text version
Apparent resistance has several causes
Persistent hypertension despite treatment may reflect true resistant disease, inadequate dosing, measurement error, nonadherence, substances, or secondary causes. Confirming the pattern prevents unnecessary testing and escalation.
Recognize clues to a secondary cause
Early or abrupt onset, hypokalemia, renal decline, episodic symptoms, sleep apnea features, or disproportionate severity can guide evaluation. Normal potassium does not exclude primary aldosteronism.
Verify the regimen and pressure
Use accurate office and out-of-office readings, review all medications and substances, and assess adherence and volume status. Confirm that the regimen includes suitable agents at tolerated doses before labeling true resistance.
Test and treat selectively
Evaluate aldosterone-related disease, renal parenchymal or vascular disease, sleep apnea, and other causes as indicated. Optimize diuretic therapy and consider additional agents with potassium and kidney monitoring according to the clinical phenotype.
Applied case: renal artery stenosis
Case 20 asks whether imaging-confirmed stenosis explains the presentation and whether intervention is likely to help. Most management decisions require more than anatomy; recurrent pulmonary edema or selected high-risk scenarios merit specialist discussion.
Keep devices in perspective
Renal denervation may fit selected patients after shared decision-making and expert assessment. It does not replace adherence review or investigation of secondary causes. Routine renal artery stenting should not be assumed superior to good medical therapy.
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