Mayo Clinic Proceedings Home

Prevalence of Apparent Treatment-Resistant Hypertension in the United States According to the 2017 High Blood Pressure Guideline



      To evaluate the prevalence of apparent treatment-resistant hypertension (aTR-hypertension) in US adults with treated hypertension by using the nationally representative National Health and Nutrition Examination Survey (NHANES).

      Patients and Methods

      Nonpregnant US adults older than 20 years with a self-reported history of treated hypertension who had blood pressure measured in NHANES cycles 2007 to 2014 were included in this study. Study participants were stratified into 4 groups according to average blood pressure and antihypertensive medication use: well-controlled hypertension, undertreated hypertension, aTR-hypertension by the 2017 guideline, and aTR-hypertension by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guideline. National Health and Nutrition Examination Survey sample weights were used to estimate the national prevalence.


      From 2007 to 2014, 5512 participants with treated hypertension representing 46.7 million people nationally were included. Compared with JNC 7 guideline criteria, application of the 2017 high blood pressure guideline criteria increased the prevalence of aTR-hypertension in US adults with treated hypertension from 12.0% to 15.95%, identifying an additional 1.85 million individuals with aTR-hypertension nationally. Individuals newly reclassified as having aTR-hypertension were younger. However, the prevalence of thiazide diuretic use remained less than 70%, and that of mineralocorticoid antagonist use remained less than 10% regardless of the guideline definition.


      On the basis of the 2017 high blood pressure guideline, the prevalence of aTR-hypertension is 15.95% in US adults with treated hypertension. This represents an absolute increase of 4% (1.85 million additional individuals nationally) compared with the JNC 7 guideline definition, with a consistent increase across all subpopulations with treated hypertension.

      Abbreviations and Acronyms:

      aTR-hypertension (apparent treatment-resistant hypertension), BP (blood pressure), JNC 7 (Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure), NHANES (National Health and Nutrition Examination Survey)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Mayo Clinic Proceedings
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Benjamin E.J.
        • Blaha M.J.
        • Chiuve S.E.
        • et al.
        • American Heart Association Statistics Committee and Stroke Statistics
        Heart Disease and Stroke Statistics—2017 update: a report from the American Heart Association.
        Circulation. 2017; 135 ([published correction appears in Circulation. 2017]): e146-e603
        • Gu Q.
        • Dillon C.F.
        • Burt V.L.
        • Gillum R.F.
        Association of hypertension treatment and control with all-cause and cardiovascular disease mortality among US adults with hypertension.
        Am J Hypertens. 2010; 23: 38-45
        • Muntner P.
        • Carey R.M.
        • Gidding S.
        • et al.
        Potential US Population Impact of the 2017 ACC/AHA High Blood Pressure Guideline.
        Circulation. 2018; 137: 109-118
        • Persell S.D.
        Prevalence of resistant hypertension in the United States, 2003-2008.
        Hypertension. 2011; 57: 1076-1080
        • Egan B.M.
        • Zhao Y.
        • Axon R.N.
        • Brzezinski W.A.
        • Ferdinand K.C.
        Uncontrolled and apparent treatment resistant hypertension in the United States, 1988 to 2008.
        Circulation. 2011; 124: 1046-1058
        • Chobanian A.V.
        • Bakris G.L.
        • Black H.R.
        • et al.
        • National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
        • National High Blood Pressure Education Program Coordinating Committee
        The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.
        JAMA. 2003; 289 ([published correction appears in JAMA. 2003;290(2):197]): 2560-2572
        • Calhoun D.A.
        • Jones D.
        • Textor S.
        • et al.
        Resistant hypertension: diagnosis, evaluation, and treatment. A scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research.
        Hypertension. 2008; 51: 1403-1419
        • Kumbhani D.J.
        • Steg P.G.
        • Cannon C.P.
        • et al.
        • REACH Registry Investigators
        Resistant hypertension: a frequent and ominous finding among hypertensive patients with atherothrombosis.
        Eur Heart J. 2013; 34: 1204-1214
        • Sarafidis P.A.
        • Georgianos P.
        • Bakris G.L.
        Resistant hypertension—its identification and epidemiology.
        Nat Rev Nephrol. 2013; 9 ([published correction appears in Nat Rev Nephrol. 2013;9(9):492]): 51-58
        • Muntner P.
        • Davis B.R.
        • Cushman W.C.
        • et al.
        • ALLHAT Collaborative Research Group
        Treatment-resistant hypertension and the incidence of cardiovascular disease and end-stage renal disease: results from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).
        Hypertension. 2014; 64: 1012-1021
        • Whelton P.K.
        • Carey R.M.
        • Aronow W.S.
        • et al.
        2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
        Hypertension. 2018; 71 ([published correction appears in Hypertension. 2018]): e13-e115
        • Centers for Disease Control and Prevention
        National Health and Nutrition Examination Survey (NHANES): Physician Examination Procedures Manual.
        (Accessed August 28, 2018)
        • Achelrod D.
        • Wenzel U.
        • Frey S.
        Systematic review and meta-analysis of the prevalence of resistant hypertension in treated hypertensive populations.
        Am J Hypertens. 2015; 28: 355-361
        • Tanner R.M.
        • Calhoun D.A.
        • Bell E.K.
        • et al.
        Incident ESRD and treatment-resistant hypertension: the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.
        Am J Kidney Dis. 2014; 63: 781-788
        • Brinker S.
        • Pandey A.
        • Ayers C.
        • et al.
        Therapeutic drug monitoring facilitates blood pressure control in resistant hypertension.
        J Am Coll Cardiol. 2014; 63: 834-835
        • Pandey A.
        • Raza F.
        • Velasco A.
        • et al.
        Comparison of Morisky Medication Adherence Scale with therapeutic drug monitoring in apparent treatment-resistant hypertension.
        J Am Soc Hypertens. 2015; 9: 420-426.e422
        • Carey R.M.
        • Calhoun D.A.
        • Bakris G.L.
        • et al.
        • American Heart Association Professional/Public Education and Publications Committee of the Council on Hypertension
        • Council on Cardiovascular and Stroke Nursing
        • Council on Clinical Cardiology
        • Council on Genomic and Precision Medicine
        • Council on Peripheral Vascular Disease
        • Council on Quality of Care and Outcomes Research; and Stroke Council
        Resistant hypertension: detection, evaluation, and management. A scientific statement from the American Heart Association.
        Hypertension. 2018; 72: e53-e90
        • Bundy J.D.
        • Mills K.T.
        • Chen J.
        • Li C.
        • Greenland P.
        • He J.
        Estimating the association of the 2017 and 2014 hypertension guidelines with cardiovascular events and deaths in US adults: an analysis of national data.
        JAMA Cardiol. 2018; 3: 572-581