Resistant hypertension is defined as blood pressure that remains above the therapeutic goal despite concurrent use of at least three antihypertensive agents of different classes, including a diuretic, with all agents administered at maximum or maximally tolerated doses. It is also diagnosed if blood pressure control requires four or more antihypertensive drugs. Diagnosis requires excluding apparent treatment-resistant hypertension, which is often due to non-adherence to treatment. Resistant hypertension is associated with major cardiovascular events, including heart failure, ischemic heart disease, stroke, and renal failure. Guidelines recommend lifestyle modification and antihypertensive drugs, typically including an ACE inhibitor or ARB, a calcium channel blocker, and a long-acting thiazide-type diuretic. If a fourth drug is needed, evidence supports adding a mineralocorticoid receptor antagonist. New agents, such as aldosterone synthase inhibitors and dual endothelin receptor antagonists, are under development. Renal denervation is the best-supported and only approved interventional device treatment for resistant hypertension. Resistant hypertension is a significant risk factor for cardiovascular complications, with higher rates in Black patients and those with diabetes. Diagnosis requires accurate blood pressure measurements and exclusion of white coat hypertension. Non-adherence accounts for 25-50% of apparent treatment-resistant hypertension. Screening for secondary causes of hypertension, such as primary aldosteronism, is essential. Primary aldosteronism is diagnosed through aldosterone and renin measurements and treated with surgical removal or spironolactone. Renal vascular hypertension is another cause, often due to atherosclerosis or fibromuscular dysplasia. Management includes lifestyle changes, medication optimization, and device-based interventions like renal denervation. Newer treatments include endothelin receptor antagonists, aldosterone synthase inhibitors, and non-steroidal mineralocorticoid antagonists. These agents offer potential benefits in resistant hypertension, particularly in patients with CKD. Angiotensinogen synthesis inhibitors and combinations of ARB with neprilysin inhibitors show promise. Devices like renal denervation are increasingly used, with recent approvals for catheter-based procedures. Overall, effective management of resistant hypertension requires a multidisciplinary approach, including lifestyle modifications, medication optimization, and emerging therapies.Resistant hypertension is defined as blood pressure that remains above the therapeutic goal despite concurrent use of at least three antihypertensive agents of different classes, including a diuretic, with all agents administered at maximum or maximally tolerated doses. It is also diagnosed if blood pressure control requires four or more antihypertensive drugs. Diagnosis requires excluding apparent treatment-resistant hypertension, which is often due to non-adherence to treatment. Resistant hypertension is associated with major cardiovascular events, including heart failure, ischemic heart disease, stroke, and renal failure. Guidelines recommend lifestyle modification and antihypertensive drugs, typically including an ACE inhibitor or ARB, a calcium channel blocker, and a long-acting thiazide-type diuretic. If a fourth drug is needed, evidence supports adding a mineralocorticoid receptor antagonist. New agents, such as aldosterone synthase inhibitors and dual endothelin receptor antagonists, are under development. Renal denervation is the best-supported and only approved interventional device treatment for resistant hypertension. Resistant hypertension is a significant risk factor for cardiovascular complications, with higher rates in Black patients and those with diabetes. Diagnosis requires accurate blood pressure measurements and exclusion of white coat hypertension. Non-adherence accounts for 25-50% of apparent treatment-resistant hypertension. Screening for secondary causes of hypertension, such as primary aldosteronism, is essential. Primary aldosteronism is diagnosed through aldosterone and renin measurements and treated with surgical removal or spironolactone. Renal vascular hypertension is another cause, often due to atherosclerosis or fibromuscular dysplasia. Management includes lifestyle changes, medication optimization, and device-based interventions like renal denervation. Newer treatments include endothelin receptor antagonists, aldosterone synthase inhibitors, and non-steroidal mineralocorticoid antagonists. These agents offer potential benefits in resistant hypertension, particularly in patients with CKD. Angiotensinogen synthesis inhibitors and combinations of ARB with neprilysin inhibitors show promise. Devices like renal denervation are increasingly used, with recent approvals for catheter-based procedures. Overall, effective management of resistant hypertension requires a multidisciplinary approach, including lifestyle modifications, medication optimization, and emerging therapies.