Saudi Heart Association Position Statement on the Management of Uncontrolled and Resistant Hypertension

Background: Despite advances in antihypertensive therapy, blood pressure control remains suboptimal globally and in Saudi Arabia, where uncontrolled hypertension continues to contribute significantly to disease burden. Resistant hypertension represents a high-risk phenotype associated with increased cardiovascular and renal morbidity. Methods: This Saudi Heart Association position statement was developed by a multidisciplinary expert panel using a structured consensus approach and a comprehensive, non-systematic review of the literature. Evidence on epidemiology, pathophysiology, diagnosis, and management of uncontrolled and resistant hypertension was critically appraised to formulate clinically applicable recommendations. Results and conclusions: Uncontrolled and resistant hypertension are driven by complex mechanisms including activation of the renin–angiotensin–aldosterone system, sympathetic overactivity, endothelial dysfunction, and coexisting conditions such as obesity, chronic kidney disease, and obstructive sleep apnea. Accurate diagnosis requires exclusion of pseudo-resistance and secondary causes using standardized blood pressure assessment and out-of-office monitoring. Management should follow a stepwise approach, beginning with lifestyle optimization and foundational triple therapy, followed by pharmacologic intensification with aldosterone-directed therapy or phenotype-guided treatment as needed. Device-based therapies may be considered in selected patients. Emerging treatments targeting key mechanistic pathways, including endothelin signaling and aldosterone synthesis, offer promising future options. This position statement provides a practical stepwise framework to improve identification, optimize management, and enhance clinical outcomes in patients with uncontrolled or resistant hypertension.