Uncontrolled and Apparent Treatment Resistant Hypertension in the United States, 1988 to 2008
Open accessAbstract
Background—: Despite progress, many hypertensive patients remain uncontrolled. Defining characteristics of uncontrolled hypertensives may facilitate efforts to improve blood pressure control. Methods and Results—: Subjects included 13 375 hypertensive adults from National Health and Nutrition Examination Surveys (NHANESs) subdivided into 1988 to 1994, 1999 to 2004, and 2005 to 2008. Uncontrolled hypertension was defined as blood pressure ≥140/≥90 mm Hg and apparent treatment-resistant hypertension (aTRH) when subjects reported taking ≥3 antihypertensive medications. Framingham 10-year coronary risk was calculated. Multivariable logistic regression was used to identify clinical characteristics associated with untreated, treated uncontrolled on 1 to 2 blood pressure medications, and aTRH across all 3 survey periods. More than half of uncontrolled hypertensives were untreated across surveys, including 52.2% in 2005 to 2008. Clinical factors linked with untreated hypertension included male sex, infrequent healthcare visits (0 to 1 per year), body mass index <25 kg/m 2 , absence of chronic kidney disease, and Framingham 10-year coronary risk <10% ( P <0.01). Most treated uncontrolled patients reported taking 1 to 2 blood pressure medications, a proxy for therapeutic inertia. This group was older, had higher Framingham 10-year coronary risk than patients controlled on 1 to 2 medications ( P <0.01), and comprised 34.4% of all uncontrolled and 72.0% of treated uncontrolled patients in 2005 to 2008. We found that aTRH increased from 15.9% (1998–2004) to 28.0% (2005–2008) of treated patients ( P <0.001). Clinical characteristics associated with aTRH included ≥4 visits per year, obesity, chronic kidney disease, and Framingham 10-year coronary risk >20% ( P <0.01). Conclusion—: Untreated, undertreated, and aTRH patients have consistent characteristics that could inform strategies to improve blood pressure control by decreasing untreated hypertension, reducing therapeutic inertia in undertreated patients, and enhancing therapeutic efficiency in aTRH.
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Among treated adults with hypertension, prevalent apparent treatment-resistant hypertension occurs in approximately 12% to 15% of population-based samples.
“Among treated adults with hypertension, prevalent aTRH occurs in ≈12% to 15% of population-based13–16 and 15% to 18% of clinic-based reports.17–20”
From Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association (2018) · cites this paper as [13]
Chronic renal insufficiency is a well-established cause of heightened salt sensitivity of blood pressure and has been repetitively linked to apparent treatment-resistant hypertension.
“Further indirect evidence can be derived from large population studies in which chronic renal insufficiency, a well-established cause of heightened salt sensitivity of BP, has been repetitively linked to aTRH.13,38,152”
From Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association (2018) · cites this paper as [13]
Among hypertensive adults, body mass index ≥30 kg/m2 approximately doubles the risk for apparent treatment-resistant hypertension.
“Recent findings from the NHANES (National Health and Nutrition Examination Survey) of 13 375 hypertensive adults demonstrate that body mass index (BMI) ≥30 kg/m2 approximately doubles the risk for aTRH.13”
From Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association (2018) · cites this paper as [13]
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- Authors
- Egan, B. M., Zhao, Y., Axon, R. N., Brzezinski, W. A., & Ferdinand, K. C.
- Affiliations
- Emory University (US)
- Venue
- Circulation
- Published
- 2011-08-30
- Volume
- 124
- Issue
- 9
- Pages
- 1046-1058
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- PMC
- PMC3210066
- OpenAlex
- W1984845078
- Cited by
- 599
- References
- 42
- Citations by year
- 2026: 6 · 2025: 8 · 2024: 28 · 2023: 26 · 2022: 19 · 2021: 22 · 2020: 33 · 2019: 34 · 2018: 44 · 2017: 37 · 2016: 55 · 2015: 55 · 2014: 76 · 2013: 93 · 2012: 55
- FWCI
- 50.59
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Circulation (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Heart, Lung, and Blood Institute (R34HL105880, R01HL091841, R01 HL07080684)
- National Institute of Diabetes and Digestive and Kidney Diseases (R01DK067615)
- National Institute of Neurological Disorders and Stroke (R01-NS058728, U01NS058728)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Disease Prevention
- Health Sciences › Nursing › Nutrition and Dietetics › Sodium Intake and Health
- Keywords
- apparent treatment-resistant hypertension, blood pressure control, antihypertensive medication use, therapeutic inertia, health care utilization, obesity, chronic kidney disease
- MeSH terms
- Antihypertensive Agents, Drug Resistance, Female, Humans, Hypertension, Kidney Diseases, Male, Middle Aged, Nutrition Surveys, Obesity, Risk, United States, Comorbidity, Body Mass Index, Prevalence
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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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