Objective: Cardiovascular diseases remain a major cause of death. Arterial hypertension is an important risk factor, and although it is frequently screened for, it is often suboptimally treated. By implementing a structured care pathway for treatment-resistant hypertension, we aimed to improve diagnosis and treatment of these patients and identify patients at high risk for developing cardiovascular and renal complications. Design and method: Patients were referred to the hypertension clinic because of treatment-resistant hypertension despite 3 classes of antihypertensive drugs, or for hypertension diagnosed before the age of 40. All patients received 24 h ambulatory blood pressure monitoring (ABPM) and screening lab tests. Patients with inadequately treated hypertension (>130/80 mmHg/24 h) were evaluated via a structured pathway with a multidisciplinary approach including cardiac and renal ultrasound, nutritional education and additional screening for secondary causes of hypertension. Results: In the first year after implementing our structured care pathway, 51 patients were referred: 28 for hypertension diagnosed before the age of 40 and 23 for treatment-resistant hypertension. Mean age was 51 (range 17–81). 55% were overweight or obese, 16% smoked, 25% had diabetes and 22% used lipid-lowering drugs. ABPM identified 45 patients (88%) with inadequately treated hypertension. Their treatment regimen was intensified. Screening for secondary hypertension suggested primary hyperaldosteronism in 3 patients. Fibromuscular dysplasia was diagnosed in 1 patient. Patients with treatment-resistant hypertension were on average taking 3,3 different classes of antihypertensive drugs, with ACEi/ARB being used by 96% of patients, and calcium-antagonist by 78%. Cardiac ultrasound revealed left ventricular hypertrophy in 17 patients (33%). 4 patients had renal insufficiency (eGFR<45 ml/min/1,73m2), 3 had proteinuria. In patients with treatment-resistant hypertension, the median 10 year risk of cardiovascular death (SCORE risk charts) was 4,25% (range 1–30%). The median 10 year risk of cardiovascular morbidity (Framingham general CVD risk score) was 26,18% (range 7,12–62,6%). Conclusions: Implementing a structured care pathway for treatment-resistant hypertension including ABPM is an important tool to identify patients requiring antihypertensive treatment optimization and to diagnose patients with secondary hypertension. Furthermore, it can identify patients with end-organ damage and a high cardiovascular disease risk.