Treatment-resistant or difficult-to-control high blood pressure
When is high blood pressure resistant to treatment?
High blood pressure is considered treatment-resistant if the target value agreed with the doctor cannot be achieved despite treatment with three different blood pressure medications.
What could be causing this?
About 30% of cases of high blood pressure classified as treatment-resistant are due to secondary hypertension. In these cases, the high blood pressure is caused by another medical condition or by medication. The cause therefore needs to be identified. If another medical condition is present, it must be treated first. Any other medications being taken must also be reviewed and changed if necessary.
Likewise, the type or combination of antihypertensive medications used to date and the dosing schedule may be the reason why blood pressure has not been lowered sufficiently. Depending on any other conditions the patient may have, the antihypertensive medications must be selected from the appropriate drug classes, and the dosing schedule must be drawn up taking into account how long the medications remain effective (half-life).
Pseudoresistance
However, there are also factors that make blood pressure appear difficult to control even though there is no true treatment resistance. This is referred to as pseudoresistance.
White coat hypertension
Blood pressure readings can therefore be higher during a visit to the doctor than in normal everyday life, which is known as white coat hypertension. A 24-hour blood pressure measurement or regular self-measurements of blood pressure at home can provide greater clarity. See also “White coat hypertension”.
Measurement errors
However, home blood pressure measurements can also be a source of pseudoresistance if measurement errors result in falsely elevated readings. See also “Errors when measuring blood pressure”.
Lack of treatment adherence
Another common reason why high blood pressure appears resistant to treatment is poor adherence (see also “Adherence and compliance - treatment adherence“) by the person affected. If the lifestyle changes discussed with the doctor-and these are of the utmost importance-are not followed, or if the medication prescribed for high blood pressure is not taken or is not taken according to the medication schedule provided, it is not surprising if blood pressure decreases inadequately or not at all. This was also demonstrated by a Canadian study in which participants with apparent treatment-resistant hypertension had to take their medication under supervision. As a result, the readings fell in all participants. Around one-third even reached the normal range. Half of the participants had already experienced a cardiovascular event attributable to high blood pressure. Unfortunately, however, not even this was sufficient motivation to take the medication regularly and as prescribed.
What can you do about difficult-to-control high blood pressure?
Reviewing and, if necessary, improving your lifestyle is also fundamental when high blood pressure is difficult to control. The good news is that everyone can take action themselves and perhaps make further adjustments to their diet, physical activity and stress reduction, or reduce their alcohol and nicotine intake. It should go without saying that medication must be taken regularly as prescribed by the doctor.
If secondary hypertension is present, the underlying condition must be treated in order to bring the blood pressure under control.
If blood pressure remains unaffected by all efforts to lower it despite optimal adherence, several pharmacological or surgical procedures are still available to bring it closer to normal levels, such as renal denervation (see also "High blood pressure and kidneys") or the implantation of a special pacemaker (see also "Pacemakers for people with hypertension"). However, which option is suitable for the person concerned must be discussed individually with the treating physician.
Sources:
- https://aerztezeitung.at/2017/oaz-artikel/medizin/therapieresistente-hypertonie-pseudoresistenz-priv-doz-michael-rudnicki-univ-prof-bruno-watschinger/
- https://www.pharmazeutische-zeitung.de/die-resistenz-die-keine-ist/
- https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2735985
- https://www.patienten-information.de/patientenleitlinien/bluthochdruck
- https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2815018
- https://www.pharmazeutische-zeitung.de/spironolacton-am-wirksamsten-145440/
- https://www.patienten-information.de/patientenblaetter/bluthochdruck-nichtansprechen
- https://www.hochdruckliga.de/pressemitteilung/neue-optionen-bei-therapieresistenz-zertifizierung-renale-denervierungszentren
- https://www.thieme-connect.com/products/ejournals/pdf/10.1055/a-1031-0612.pdf
- https://www.medical-tribune.de/medizin-und-forschung/artikel/die-therapieresistente-hypertonie-ist-manchmal-gar-keine
- https://www.rosenfluh.ch/media/arsmedici-dossier/2010/04-05/Therapieresistente_arterielle_Hypertonie.pdf
- https://idw-online.de/de/news681153
This article is from Tensana – the leading app since 2011, helping hundreds of thousands of people monitor their blood pressure every day.
Our content is based on carefully researched, evidence-based data and is continuously updated (as of 11/2025).
Author Sabine Croci is a qualified medical assistant with many years of experience in internal medicine and cardiology practices as well as outpatient care, and has headed the specialist editorial team at Tensana since 2015. Thanks to her extensive additional qualifications as an emergency medical technician, first responder, and in various areas of therapy and emergency care, she provides well-founded, practical, and reliably verified information.
Author Sabine Croci is a qualified medical assistant with many years of experience in internal medicine and cardiology practices as well as outpatient care, and has headed the specialist editorial team at Tensana since 2015. Thanks to her extensive additional qualifications as an emergency medical technician, first responder, and in various areas of therapy and emergency care, she provides well-founded, practical, and reliably verified information.
