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)
Copyright statement: Croatian Cardiac Society
Copyright: 2025, Croatian Cardiac Society
Date received: 24 October 2025
Date: 14 November 2025
Publication date: December 2025
Publication date: December 2025
Volume: 21
Issue: 1-2
Page: 11
Publisher ID: CC 2026 21_1-2_11
DOI: 10.15836/ccar2026.11