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Management of Intractable Hypertension

'Intractable', 'refractory' and 'resistant' are synonyms which may be used to describe hypertensive patients in whom blood pressure control is unsatisfactory despite the concurrent administration of three or more conventional hypotensive agents (beta-blocker plus diuretic plus either prazosin, hydralazine or methyldopa) in the maximum tolerated dose. The level of arterial pressure which is deemed to be unsatisfactory varies from clinician to clinician: a diastolic pressure of 110mmHg or greater despite treatment is one arbitrary level (Mackay et al. 1981 a) but, since blood pressure normally varies with sex and rises with age (Hamilton et al. 1954), a more accurate though equally arbitrary definition could be blood pressure despite treatment of greater than one standard deviation above the ageand sex-related mean value for a normal outpatient population (Mackay et al. 1983). Patients with intractable hypertension are commonly referred to a specialist hypertension clinic, and their management may usefully be approached by considering the following reasons for poor control.