Resistant hypertension is common. The reported rates vary considerably largely because not everyone with high blood pressure prescribed multiple antihypertensive drugs is truly resistant. Some are non adherent, some have a secondary cause for their hypertension, some have white coat hypertension and some will achieve target blood pressure levels with rationalization of their drug regimen, especially with more diuretic therapy.The sympathetic nervous system is a key regulatory system involved in the pathogenesis of hypertension. A large body of historical work in our laboratories and elsewhere showed that a proportion of people with hypertension have elevated sympathetic efferent activity. This is largely targeted to the kidney, causing sodium retention, increased vascular resistance and renin secretion. This evidence has underpinned the present vogue for renal denervation procedures. There is a need for rigorous trial design, comparisons with benchmark pharmacotherapy and better classification of patient groups that will benefit from renal denervation therapy. Extension of indications beyond that supported by trial data should be monitored and generally avoided. Before handing management of resistant hypertension over to the interventionists however there is evidence that pharmacological management could be improved with evidence-based regimens. In general therapy that targets renal tubular function including aldosterone antagonists has proven most effective in lowering blood pressure (BP) in people who remain hypertensive despite triple drug therapy.
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