JAMA Clinical Reviews Resistant Hypertension: Diagnosis and Management
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Mar 23, 2026 Michel Azizi, Professor of Vascular Medicine at Georges Pompidou University Hospital, offers clinical expertise on resistant hypertension. He defines true resistance versus white coat effects. He explains accurate home and ambulatory blood pressure measurement. He reviews lifestyle changes, medication sequencing including diuretics and mineralocorticoid antagonists, and emerging device and drug options.
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Always Rule Out White Coat Before Diagnosing Resistance
- Confirm apparent resistant hypertension by ruling out white coat effect before labeling it true resistance.
- Use home or 24-hour ambulatory monitoring; white coat occurs in ~30–40% of apparent resistant cases so out-of-office readings are essential.
How To Measure Home And Ambulatory Blood Pressure
- Instruct patients to measure home BP twice daily for at least 3 days (ideally 1 week) after 5 minutes rest, two readings 1 minute apart.
- Define home resistant BP as average ≥130/80 mmHg and ambulatory 24‑hour average ≥125/75 mmHg.
Check Adherence And Interfering Drugs First
- Verify medication adherence with a nonjudgmental conversation, pharmacy refill review, and, when needed, blood/urine drug levels.
- Also review full medication list to find BP‑raising drugs like NSAIDs or SNRIs that undermine control.