Purpose of review: Evidence from clinical trials suggests that refractory hypertension is increasingly common. The underlying mechanisms are largely unknown but recent data have implicated increased aldosterone activity as an important mediator of resistance to routinely used antihypertensive agents.
Recent findings: Epidemiological studies have suggested a significant rise in the prevalence of primary aldosteronism among patients with hypertension. This reflects the increasing use of an aldosterone-to-renin ratio as a screening tool. Recent reports have demonstrated that relative aldosterone excess is common in individuals with refractory hypertension, and that the use of aldosterone antagonists leads to better blood pressure control in such patients.
Summary: These data highlight the potential role of aldosterone in the pathogenesis of hypertension. The syndrome of primary aldosteronism, however, encompasses a wide spectrum of disorders that will require better definition. Similarly, although aldosterone blockade is apparently beneficial in individuals with refractory hypertension, this evidence is not currently based on robust randomized, double-blind trial.