Authors

• Nikolina Bukal Ćaleta — General Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia — ORCID: 0000-0002-7655-6078
• Marijana Kovačević — General Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia
• Ivana Stanušić — General Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia
• Iva Dumančić — General Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia
• Josipa Meter — General Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia
• Ana Kovačević — General Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia
• Maja Franić — General Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia

Keywords

resistant hypertension, guidelines

DOI

Full Text

Both guidelines; ESC 2024 and ACC/AHA 2025 confirming true resistant hypertension as the official values of blood pressure (BP) >140/90 mmHg despite 3 or more BP-lowering medications at maximally tolerated doses including diuretic, by excluding pseudo-resistance (improper measurement, white coat effect, poor adherence, suboptimal regimen/dosing) and causes of secondary hypertension (primary aldosteronism, renal artery stenosis, obstructive sleep apnea, drug/substance contributors, thyroid disease, Cushing, chronic kidney disease etc.). New ACC/AHA guidance expands recommendation to screen more broadly for primary aldosteronism in patients with resistant hypertension (including many without hypokalemia). Out-of-office BP measurement (HBPM/ABPM) is strongly recommended. Both favor the usual 3-drug foundation (ACEi/ARB + calcium channel blocker +thiazide-like diuretic). If blood pressure remains uncontrolled on these, mineralocorticoid receptor antagonist (MRA) spironolactone (or eplerenone if spironolactone not tolerated), is the preferred fourth-line agent in many patients with cautions for renal function and hyperkalemia (ESC Class IIa). If spironolactone is not tolerated, alternatives include amiloride or a beta-blocker depending on indications. After confirming true resistant hypertension, excluding secondary causes, optimizing the therapy and adding spironolactone as preferred 4th-line, refer to specialist centers for complex causes and consider renal denervation (RDN) only as a specialized shared-decision option after thorough evaluation. ESC 2024 now permits consideration of renal denervation for selected patients with resistant uncontrolled hypertension after shared decision-making and specialist assessment and it is not recommended in severe CKD (eGFR <40) or secondary hypertension. (Class IIb) (1) ACC/AHA materials discuss RDN as an emerging option but the 2025 ACC/AHA update centers on standardized pharmacologic and diagnostic pathways in primary care. (2)

Literature

1. McEvoy JW, McCarthy CP, Bruno RM, Brouwers S, Canavan MD, Ceconi C, et al. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. Eur Heart J. 2024 October 7;45(38):3912–4018. https://doi.org/10.1093/eurheartj/ehae178
2. Jones DW, Ferdinand KC, Taler SJ, Johnson HM, Shimbo D, Abdalla M, et al. Peer Review Committee Members. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2025 November 4;86(18):1567–678. https://doi.org/10.1016/j.jacc.2025.05.007