The authoritative definition is as follows: when blood pressure is still above the target level after applying sufficient doses of three reasonable antihypertensive drugs (including diuretics) based on lifestyle improvement, or when at least four drugs are needed to bring blood pressure up to the standard, it is called refractory hypertension (or intractable hypertension), accounting for about 15% to 20% of hypertensive patients. Don’t look at this definition is very simple, but there are a lot of connotations inside. First of all, it is not easy to improve the lifestyle, which includes a light diet, quit smoking and limit alcohol, proper exercise, weight control, reduce stress, psychological balance and other aspects. Patients may want to ask themselves what they have not done enough? Are you consuming too much oil and salt in your diet? Do you always quit smoking halfway? Is not always sitting in the office lazy to move, so that the weight with blood pressure and skyrocketing? Is too much work pressure to make the mental tension, excessive pursuit of perfection to sleepless nights? As the saying goes, the journey of a thousand miles begins with the first step, hurry up to control the mouth, open the legs! Second, many patients hearsay, the adverse effects of drugs overly magnified, resulting in psychological tension, panic, but ignore the important therapeutic value of drugs and high blood pressure on their own silent harm. If you refuse or delay the start of medication for fear of “lifelong medication” until complications arise, it will be too late to regret. The most common irrational clinical use of drugs are fear of diuretics, beta-blockers on the impact of glucose and lipid metabolism and prefer not to use or not to adhere to the medication and a series of pseudo-“refractory hypertension” caused by insufficient doses. In addition, pseudo-refractory hypertension also includes improper measurement methods (e.g., incorrect posture during measurement, not using larger cuffs for thicker upper arms), white coat hypertension, still taking antagonistic antihypertensive medications (e.g., oral contraceptives, adrenal steroids, cocaine, licorice, ephedra, etc.), chronic pain, and chronic anxiety. The fact remains that there are still many patients who do not have any of these causes and whose blood pressure is still difficult to control, and it is time to initiate a screening procedure for secondary hypertension with a specialist. Common secondary hypertension includes renal and endocrine hypertension. Renal hypertension is subdivided into renal substantial and renal arterial hypertension. Renal hypertension can progress rapidly. Once a young man in his 20s went to the doctor because of blurred food and near blindness, and once he measured his blood pressure 260/130 mmHg, his proteinuria could reach 10 g/day. There was also a young man of the same age who visited the clinic because of nausea and loss of appetite, the patient was pale and his blood pressure was barely measured to the upper limit, highly suspicious of uremia, and once tested, as expected, creatinine was over 1000umol/l! Renal arterial hypertension often prefers young women and older men. Sudden loss of control of blood pressure, murmur in the abdomen, unexplained rise in creatinine or excessive difference in blood pressure in the extremities must be highly suspected of renal artery stenosis. Once the diagnosis is clear, balloon dilation or stent placement will often play a decisive role. Endocrine hypertension is mainly concentrated in the adrenal glands, with cortisolism, pheochromocytoma and primary aldosteronism. If you suddenly have a round face like a full-moon baby, urinate a lot at night, have weakness in the limbs and have high and low blood pressure, you should be highly suspicious! You may want to do an adrenal ultrasound first, large adenomas can generally be found, small hyperplasia or nodules or something can only be found by CT or something. Of course, hyper- or hypothyroidism can also affect blood pressure, but it’s not usually that “intractable”. In short, refractory hypertension is not really that difficult to treat, as long as we work closely with the doctor and patient and persevere, most blood pressure can be lowered.