8 (a) Patient-Related Problems. Adherence to antihyper- tensive treatment is of utmost importance for the eﬀective management of arterial hypertension. Both epidemiological and clinical data strongly indicate that patient adherence to antihypertensive therapy is poor [170–175]. Almost half of treated hypertensive patients discontinue drug administration during the ﬁrst year of treatment whereas long-term adherence rates are even lower. In addition, small studies in patients with resistant hypertension suggest that poor patient adherence represents one of the most common causes of treatment resistance [176, 177]. Detailed medical history, information by relatives, and use of speciﬁc questionnaires might help in iden- tifying patients with poor adherence; these methods can be easily applied by primary care physicians with obvious beneﬁts. The pursuit of improved patient adherence attracts great scientiﬁc interest. Modern technology is used with good results (electronic pill boxes, internet monitoring) but is not widely applied yet. Special programmes using close contact of health care professionals (doctors, nurses, and pharmacists) with patients seem also eﬀective but lack wide application as well. Finally, simpliﬁcation of dosing schedule and use of drugs with superior safety proﬁle may be of beneﬁt. (b) Physician-Related Problems. Physician inertia is an- other important factor contributing in treatment resistance. It has been shown that doctors are fre- quently reluctant to maximize drug therapy, either by adding antihypertensive drugs or by switching drug category, in order to achieve blood pressure goals [178–181]. Indeed, a gap between guideline recom- mendations and their implementation in everyday clinical practice has been recognized and represents a signiﬁcant obstacle in achieving satisfying blood pressure control rates [149, 150]. Another contribu- tor to treatment resistance is the use of inappropriate drug combinations or suboptimal doses of antihy- pertensive drugs. Indeed, a study of patients with resistant hypertension revealed that simple measures, such as increasing diuretic dosing or switching to appropriate diuretics, can result in significant blood pressure reductions [156]. In our opinion, however, the most important line of evidence suggesting physician inertia on treat- ment resistance, comes from recent studies reporting signiﬁcantly higher control rates of hypertension [182–185]. In these studies, various measures have been used to motivate physicians in achieving blood pressure goals, resulting in improved control rates. Therefore, physicians need to be the focus of future eﬀorts for the eﬀective management of resistant hypertension. (c) Blood Pressure Technique-Related Problems. The re- quirements for proper blood pressure measurement have been standardized [186] and incorporated in International Journal of Hypertension the guidelines for the management of arterial hyper- tension [149, 150]. However, the measurement of oﬃce blood pressure in clinical practice frequently deviates from the recommendations. Therefore, falsely elevated blood pressure levels may be recorded due to several reasons: inappropriate cuﬀ size, failure to comply with the recommendations regarding suﬃcient time before blood-pressure measurement, arm support at the heart level, assessment in a quiet room, triplicate recordings, and coﬀee intake or smoking before blood pressure measurement [187– 189]. The above mentioned factors may contribute to overestimation of blood pressure and “pseudoresis- tance”. Similarly, false elevations may be encountered in older patients, in whom adequate artery compres- sion may not be achieved due to marked arterial calciﬁcation. Therefore, it is essential to assure proper techniques of blood pressure measurement in order to limit the rates of pseudoresistance. Another important aspect of “resistance” is recog- nition of “white coat” hypertension. It has been noted that in 20–30% of patients with resistant hypertension, treatment resistance may be attributed to the “white coat” eﬀect [143, 190–192]. Target organ damage is less frequent in these patients, who actually do not suﬀer from “true” resistant hy- pertension. Therefore, either ambulatory or home blood-pressure monitoring should be performed in every patient with resistant hypertension, in order to exclude the “white coat” eﬀect and avoid unnecessary referrals. (ii) Exclusion of Drug-Induced Hypertension. As discussed in the ﬁrst section of this paper, several drugs may induce blood pressure elevations, with NSAIDs and oral contraceptives being the most common. Therefore, practicing physicians need to be very meticulous during medical history taking, in order to uncover the use of drugs inducing hypertension. The withdrawal of oﬀended drugs usually results to the return of blood pressure at previous levels. In the case, however, that the drug is considered essential for the treatment of comorbidities, the substitution to another drug with a more friendly proﬁle or the reduction of dose might be beneﬁcial. (iii) Reduction of Dietary Sodium Intake. Sodium intake is excessive in the Western world, mainly due to the “hidden salt” in processed foods. The average sodium intake is far higher than the recommended 2.4 grams per day, reaching even 10 g/day in patients with resistant hypertension [193]. Plasma volume expansion represents one of the cardinal characteristics of resistant hypertension. The important role of sodium restriction in patients with resistant hypertension is highlighted by the ﬁndings of a recent study. It was found that reductions in sodium intake are accompanied by signiﬁcant reductions in blood pressure levels in resistant hypertensives [194].