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Resistant hypertension: bad and getting worse.

See related article, pp 1076–1080

Resistant hypertension (RHTN) is most simply defined as high blood pressure (BP) requiring ≥4 antihypertensive medications, whether controlled or uncontrolled.1 The true prevalence of RHNT is unknown and is likely to remain so, because determining an accurate estimation of prevalence would require a large prospective study of a diverse hypertensive cohort in which subjects' medications are force titrated if the BP remains above goal, adherence is closely monitored, and ambulatory BP monitoring is done to exclude white-coat RHTN. Given the cost and logistical challenges, such a study has not been done and is not likely to ever be done.

In the absence of a definitive study, clinical trials have been largely relied on to serve as surrogate opportunities to estimate the prevalence of RHTN. In that regard, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) is probably the most relevant in that it included a large and diverse cohort, and, per protocol, subjects were to have continued escalation of their treatment regimen as long as the BP remained elevated.2 At the end of the 5-year treatment period, uncontrolled hypertension was common in ALLHAT, with 34% of subjects never having achieved BP control and with 27% of subjects receiving ≥3 antihypertensive medications.3 These data, as well as control rates from other clinical trials, have been interpreted to suggest a prevalence of RHTN of 20% to 30% of general hypertensive cohorts.1

The problem, of course, is that ALLHAT and other clinical trials …