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Int J Cardiol. 2014 Mar 1;172(1):17-22. doi: 10.1016/j.ijcard.2013.12.125. Epub 2014 Jan 4.

A guide for easy- and difficult-to-treat hypertension.

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Department of Nephrology and Hypertension, University Hospital Erlangen, Germany. Electronic address:
Cardiology Unit, Clinical and Molecular Medicine Department Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy; IRCCS Neuromed, Pozzilli, Italy.
Centre Hôpitalier des Univérsités Vaudois (CHUV), Division de physiopathologie clinique, Lausanne, Switzerland.
Hypertension Unit, Hospital 12 de Octubre, & Department of Public Health and Preventive Medicine, Universidad Autónoma, Madrid, Spain.


Although the blood pressure (BP) of many patients can be controlled using standard combinations, treatment of hypertension frequently represents a clinical challenge to the primary care physician. This article will review best practices for managing patients with easy- and difficult-to-treat hypertension, including preferred antihypertensive combinations, optimizing adherence and persistence, recognizing white-coat hypertension, and intensifying therapy for treatment-resistant patients. Each physician must decide based on his or her own level of experience at what point a patient becomes too challenging and would benefit from referral to a hypertension specialist for more intensive management and to complete the exclusion of secondary forms of arterial hypertension. With intensive pharmacotherapy, many patients with difficult-to-treat hypertension can achieve BP control. If it fails, interventional strategies (e.g., renal denervation) are a valid option to get BP controlled.


Hypertension; Renal denervation; Treatment algorithm

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