Blood pressure was controlled in an estimated 50.1% of all patients with hypertension in NHANES 2007-2008, with most of the improvement since 1988 occurring after 1999-2000. Hypertension control was significantly lower among younger than middle-aged individuals and older adults, and Hispanic vs white individuals.

Resistant hypertension (RH) is defined as above-goal elevated blood pressure (BP) in a patient despite the concurrent use of 3 antihypertensive drug classes, commonly including a long-acting calcium channel blocker, a blocker of the renin-angiotensin system (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker), and a diuretic. The antihypertensive drugs should be administered at maximum or maximally tolerated daily doses. RH also includes patients whose BP achieves target values on ≥4 antihypertensive medications. The diagnosis of RH requires assurance of antihypertensive medication adherence and exclusion of the “white-coat effect” (office BP above goal but out-of-office BP at or below target). The importance of RH is underscored by the associated risk of adverse outcomes compared with non-RH. This article is an updated American Heart Association scientific statement on the detection, evaluation, and management of RH. Once antihypertensive medication adherence is confirmed and out-of-office BP recordings exclude a white-coat effect, evaluation includes identification of contributing lifestyle issues, detection of drugs interfering with antihypertensive medication effectiveness, screening for secondary hypertension, and assessment of target organ damage. Management of RH includes maximization of lifestyle interventions, use of long-acting thiazide-like diuretics (chlorthalidone or indapamide), addition of a mineralocorticoid receptor antagonist (spironolactone or eplerenone), and, if BP remains elevated, stepwise addition of antihypertensive drugs with complementary mechanisms of action to lower BP. If BP remains uncontrolled, referral to a hypertension specialist is advised.

Over a period of four years, stage 1 hypertension developed in nearly two thirds of patients with untreated prehypertension (the placebo group). Treatment of prehypertension with candesartan appeared to be well tolerated and reduced the risk of incident hypertension during the study period. Thus, treatment of prehypertension appears to be feasible. (ClinicalTrials.gov number, NCT00227318.).

Background Despite progress, many hypertensive patients remain uncontrolled. Defining characteristics of uncontrolled hypertensives may facilitate efforts to improve blood pressure (BP) control. Methods and Results Subjects included 13,375 hypertensive adults from National Health and Nutrition Examination Surveys (NHANES) subdivided into 1988–1994, 1999–2004, 2005–2008. Uncontrolled hypertension was defined as BP ≥140/≥90 mmHg and apparent treatment resistant (aTRH) when subjects reported taking ≥3 antihypertensive medications. Framingham 10-year coronary risk (FCR) was calculated. Multivariable logistic regression was used to identify clinical characteristics associated with untreated, treated uncontrolled on 1–2 BP medications, and aTRH across all three survey periods. More than half of uncontrolled hypertensives were untreated across surveys including 52.5% in 2005–2008. Clinical factors linked with untreated hypertension included male sex, infrequent healthcare visits (0–1/yr), body mass index <25 kg/m2, absence of chronic kidney disease (CKD), and FCR <10% (p<0.01). Most treated, uncontrolled patients reported taking 1–2 BP medications, a proxy for therapeutic inertia. This group was older, had higher FCR than patients controlled on 1–2 medications (p<0.01), and comprised 34.4% of all uncontrolled and 72.0% of treated uncontrolled patients in 2005–2008. Apparent TRH 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/yr, obesity, CKD and FCR >20% (p<0.01). Conclusions Untreated, under-treated, and aTRH patients have consistent characteristics that could inform strategies to improve BP control by decreasing untreated hypertension, reducing therapeutic inertia in under-treated patients, and enhancing therapeutic efficiency in aTRH.