Consider the following causes for apparently resistant blood pressure: inaccurate measurement, antagonising substances such as non-steroidal anti-inflammatory drugs, aggravating conditions such as obesity or sleep apnoea, suboptimal treatment regimens, non-compliance. When apparent resistance remains unexplained or when there are clues suggesting white coat hypertension, consider this and arrange for multiple measurements by self monitoring, visits to or by nurses or health visitors, or ambulatory monitoring. If hypertension is still unexplained, or for patients who fit specific patterns of higher risk, consider a selective, sequential evaluation for secondary causes of hypertension, starting with relatively common conditions, such as renovascular causes and renal parenchymal disease. Work closely with patients to identify preferred and feasible solutions for correcting any cause that is found. Consider referral of patients with severe or persistently resistant hypertension to a centre specialising in its diagnosis and treatment.
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