Evidence based management of hypertension - What to do when blood pressureis difficult to control

Consider the following causes for apparently resistant blood pressure: inac curate measurement, antagonising substances such as non-steroidal anti-infl ammatory drugs, aggravating conditions such as obesity or sleep apnoea, sub optimal treatment regimens, non-compliance When apparent resistance remains unexplained or when there are clues sugges ting white coat hypertension, consider this and arrange for multiple measur ements by self monitoring, visits to or by nurses or health visitors, or am bulatory monitoring If hypertension is still unexplained, or for patients who fit specific patt erns of higher risk, consider a selective, sequential evaluation for second ary causes of hypertension, starting with relatively common conditions, suc h 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 hyperte nsion to a centre specialising in its diagnosis and treatment.