Your BP is elevated. You don't want medication yet.

Sleep apnea is the most common identifiable cause of resistant hypertension. When breathing repeatedly stops during sleep, the body surges with adrenaline — raising blood pressure throughout the night and into the morning. CPAP therapy can reduce systolic pressure by 5–10 mmHg in people with significant sleep apnea. Ask about a sleep study if you snore, wake unrefreshed, or have been told you stop breathing at night.

Logan AG et al., J Hypertension 2001; JAMA Internal Medicine 2014

Ibuprofen (Advil, Motrin), naproxen (Aleve), and other NSAIDs cause sodium retention and blunt the effect of antihypertensives. Regular use of these over-the-counter pain relievers can raise systolic BP by 3–5 mmHg and is a common reason controlled hypertension becomes uncontrolled. Other culprits include decongestants (pseudoephedrine), oral contraceptives, stimulants, and some antidepressants. Review all medications — prescription and over-the-counter — with your doctor.

Snowden S et al., Lancet 2002; ACC Resistant Hypertension Statement

Overproduction of aldosterone — a hormone from the adrenal glands — causes sodium retention and is present in 5–12% of hypertensive patients referred to specialists, much higher than previously thought. It often presents as hypokalemia (low potassium) alongside high blood pressure. Diagnosed with a simple aldosterone-to-renin ratio blood test. When caused by a single adrenal adenoma, surgical removal can cure hypertension entirely.

Funder JW et al., J Clin Endocrinol Metab 2016 (Endocrine Society Guideline)

The kidneys regulate blood pressure through fluid balance and hormone production. Chronic kidney disease (CKD) both causes and is worsened by hypertension — the relationship runs both ways. ACE inhibitors and ARBs are particularly protective for kidney function in CKD, but dose adjustments are required as kidney function declines. Measuring creatinine and eGFR annually is standard monitoring in hypertension.

Whelton PK et al., ACC/AHA 2017 Guideline

White coat hypertension — elevated in the office, normal at home — affects 15–30% of diagnosed patients and may not require treatment. Masked hypertension — normal in the office, elevated at home — is equally common and more dangerous because it goes undetected. 24-hour ambulatory blood pressure monitoring or systematic home monitoring distinguishes them. A home average above 135/85 mmHg is considered hypertensive.

Pickering TG et al., Hypertension 2005; ESH 2023 Guideline

The most common cause of 'resistant' hypertension is not actually pharmacological — it is inconsistent medication taking. Pharmacokinetic testing (measuring drug levels in blood or urine) in resistant hypertension cohorts finds that 50–60% of patients have little or no detectable medication in their system. Simplifying regimens to once-daily combinations, pill organizers, and linking medication to a daily habit (meals, toothbrushing) are the most effective adherence interventions.

Ceral J et al., J Hum Hypertension 2011; ACC Resistant Hypertension Consensus 2018