Prevalence of Apparent Treatment-Resistant Hypertension in the United States

Abstract

In 2018, the American Heart Association published a Scientific Statement on resistant hypertension. We compared the prevalence of apparent treatment-resistant hypertension (aTRH) among US adults as defined in the 2018 and 2008 American Heart Association Scientific Statements using data from 4158 participants with hypertension, taking antihypertensive medication in the 2009 to 2014 National Health and Nutrition Examination Survey. Blood pressure (BP) was measured 3 times, and antihypertensive medication classes were identified through a pill bottle review. In both Scientific Statements, aTRH was defined as uncontrolled BP while taking ≥3 classes of antihypertensive medication or taking ≥4 classes of antihypertensive medication regardless of BP level. Uncontrolled BP was defined as systolic/diastolic BP ≥140/90 mm Hg (≥130/80 mm Hg for those with diabetes mellitus or chronic kidney disease) in the 2008 Scientific Statement and systolic/diastolic BP ≥130/80 mm Hg (systolic BP ≥130 mm Hg only for low-risk adults ≥65 years of age) in the 2018 Scientific Statement. The prevalence of aTRH was 17.7% and 19.7% according to the 2008 and 2018 Scientific Statement definitions, respectively (Δ=2.0%; 95% CI, 1.5%-2.7%). Overall, 10.3 million US adults had aTRH according to the 2018 Scientific Statement. The most common 3-drug combination taken included an angiotensin-converting enzyme inhibitor, β-blocker, and thiazide diuretic. Using the 2018 definition, 3.2% of US adults with aTRH were taking a thiazide-like diuretic (chlorthalidone or indapamide), and 9.0% were taking a mineralocorticoid receptor blocker (spironolactone or eplerenone). In conclusion, the prevalence of aTRH is only modestly higher using the definition in the 2018 versus 2008 resistant hypertension Scientific Statement.

Keywords: adult; blood pressure; hypertension; prevalence; resistant hypertension; scientific statement.

Figure 1.

Distribution of US adults taking antihypertensive medication by number of antihypertensive drug classes they were taking and blood pressure levels. SBP: Systolic blood pressure, DBP: Diastolic blood pressure. Due to rounding, the numbers in the figure sum to 100.1% instead of 100%. A: These individuals have apparent treatment resistant hypertension according to the 2008 and 2018 American Heart Association Scientific Statement definitions. B: All of these individuals have apparent treatment resistant hypertension according to the 2018 American Heart Association’s Scientific Statement definition. Also, 2.3% of these individuals (i.e., those in this group with diabetes or chronic kidney disease) have apparent treatment resistant hypertension according to the 2008 American Heart Association’s Scientific Statement definition.

Figure 2.

Proportion of US adults with apparent treatment resistant hypertension according to the 2018 American Heart Association Scientific Statement on resistant hypertension taking chlorthalidone or indapamide (left panel) and spironolactone or eplerenone (right panel). aTRH: apparent treatment resistant hypertension, BP: blood pressure According to the 2018 American Heart Association Scientific Statement on resistant hypertension, uncontrolled blood pressure was defined as systolic blood pressure ≥ 130 mm Hg and diastolic blood pressure ≥ 80 mm Hg. For adults ≥ 65 years of age without diabetes, chronic kidney disease, history of cardiovascular disease or 10-year predicted risk ≥ 10% on the Pooled Cohort risk equations only systolic blood pressure ≥ 130 mm Hg is used to defined uncontrolled blood pressure. According to the 2018 American Heart Association Scientific Statement on resistant hypertension, controlled blood pressure was defined as systolic blood pressure <130 mm Hg and diastolic blood pressure < 80 mm Hg. For adults ≥ 65 years of age without diabetes, chronic kidney disease, history of cardiovascular disease or 10-year predicted risk ≥ 10% on the Pooled Cohort risk equations, controlled blood pressure was defined as systolic blood pressure < 130 mm Hg.