Visual summary
Before a fourth drug or device, prove sustained resistance, verify drug delivery, and identify treatable volume or secondary mechanisms.
Text version
Verify true resistance
Resistant hypertension is above-goal BP despite three appropriately selected, tolerated drugs, usually RAAS blocker + long-acting CCB + diuretic, or controlled BP requiring at least four drugs. Confirm home/ABPM elevation and exclude poor technique before labeling it true resistance.
Reconstruct the actual regimen
Review refill access, missed doses, dose adequacy, sodium intake, volume, NSAIDs, decongestants, stimulants, licorice, and alcohol. Ask without blame. A prescribed three-drug list is not evidence that three effective doses are reaching the patient.
Screen the likely secondary causes
Primary aldosteronism can occur with normal potassium; obtain aldosterone/renin testing using an appropriate preparation and interpretation plan. Assess CKD, sleep apnea, and renovascular disease when indicated. Episodic adrenergic symptoms or specific endocrine signs guide additional tests.
Optimize the volume and fourth-drug plan
Ensure the diuretic fits kidney function and congestion. Spironolactone is a common effective fourth agent in eligible patients, but potassium and kidney function can limit use. Arrange baseline and early laboratory follow-up rather than adding it to an unmonitored RAAS regimen.
Case 20: anatomy is not benefit
Renal artery narrowing on imaging does not prove it causes the BP or that stenting helps. Good medical therapy is central for most atherosclerotic disease. Recurrent flash pulmonary edema, rapidly declining function, or selected high-risk presentations justify specialist revascularization assessment.
Devices follow, not replace, evaluation
Renal denervation may be considered in selected patients through an expert shared-decision pathway. Verify anatomy, current device eligibility, secondary causes, and medication management. Explain that BP reduction, procedure risk, and long-term outcome evidence are separate questions.