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There are no good trials on betablockers in hypertension other than with Atenolol. Atenolol is not a true once a day drug and should be used bd or even tds. Atenolol is also renally cleared and thus can cause more bradycardia in the elderly.

ESC definition of resistant hypertension is failure to reach goal despite triple therapy including a diuretic in an adequate dose. Hydrochlorothiazide should be up to 50mg daily. Note even in clinical trials, 30-40% of participants had resistant hypertension.

Causes of resistant hypertension- non-compliance, white-coat effect, interfering substances (NSAIDs, salt, excess alcohol, steroids, cyclosporin ...), psychological stressors, weight gain.

Should measure BP with 2mmHg accuracy in both arms, sitting and standing.
Ensure have checked bloods, urine, ECG.

Accronym RADIO4- for check list

R- Resistance- check home BP or ambulatory BP
A- Adherence (can be difficult when patients on several drugs and when on drugs that require multiple daily dosing)
D- Drug interferers
I- Interfering substances
O4- OSA, Optimize therapy, secOndary causes of hypertension

Note:
OSA is associated with increased aldosterone levels.
Optimize therapy includes exercise, low salt intake, low alcohol intake, potassium supplements

Use a thiazide diuretic unless GFR is less than 40ml/min and then consider using Frusemide. Chlorthialidone 12.5mg to 25mg can be used (thiazide) but this is rarely used now. Hydrocholorothiazide seems to be favoured.

Some combinations work better- A+C or B+D to start. that is ACEi/ARB with calcium channel blockers; beta-blockers with diuretics. (see ESC guidelines, note British Hypertension Society Guidelines are slightly different).

Amiloride may be as effective as spirinolactone and without problems with gynaecomastia.

In the ASCOT trial, unpublished data to date found that the betablocker group did not benefit from statin therapy- if this is the case than it is a very strong case against beta-blockers in hypertension. There is a general recommendation that beta-blockers are relegated for use in those with specific indications for these agents.