Introduction: Over 95% of high blood pressure (HBP) cases are classified as essential hypertension in the absence of a clear etiological factor. Failure to achieve therapeutic targets under three antihypertensives, including a diuretic, defines resistant hypertension. This most often hides a secondary cause, which once identified and treated significantly improves the evolution and prognosis of patients. Atherosclerotic renovascular disease is identified in approximately 2-5% of hyper-tensive patients, but it is difficult to say whether it is a cause of HBP or a consequence of common risk factors.

Case presentation: We present the case of a 75 years old male patient, with a history of HBP for about 10 years, associating permanent atrial fibrillation, being under chronic treatment at home with zofenopril, indapamide, carvedilol, rilmenidine, dabigatran, with good treatment adherence, complaining of palpitations and occipital headache in the context of high blood pressure. Clinically, within normal limits, except for high BP values (175/90 mmHg). ECG: atrial fibrillation with a medium rate of 60 bpm, right bundle branch block. Echocardiography: mild concentric LVH, moderate diastolic dysfunction, systolic function within normal limits. Blood tests were without pathological changes. Due to the persistently elevated blood pressure values, it was decided to add spironolactone and nifedipine to the treatment regimen, along with increasing the dose of zofenopril. A decrease in BP values was noticed, but they remained high. Slight increase in creatinine (from 1.05 mg/dl to 1.26 mg/dl) after adding spirono-lactone and increasing the dose of zofenopril suggested renovascular disease. Therefore, we investigated the possibility of a secondary renovascular hypertension. Although doppler ultrasound of the renal arteries was normal, it was recommended to perform an abdominal angio-CT that showed bilateral renal artery stenosis, a result later confirmed by renal artery angiography, with indication for percutaneous stent revascularization. After performing the revascularization procedure, the evolution was favorable, with the reduction of BP va-lues, and their control with minimal antihypertensive medication.

Particularity: The case particularity consists in a long standing resistant arterial hypertension classified from the beginning as essential hypertension and thus trea-ted for 10 years, without being investigated during this time a secondary cause. Thus, the question arises whether renal artery stenoses occurred over time, part of the atherosclerotic disease, in an elderly hypertensive patient or were present from the first diagnosis of hypertension. We want to emphasize the possibility of overlapping a secondary cause of hypertension in a known hypertensive patient and the importance of actively investigate it, especially when treatment resistance is present. Another particular element is that the ultrasound of the renal arteries could not exclude the presence of hemodynamically significant atheroscle-rotic stenosis, the clinical suspicion being in this case decisive in conducting further investigations.