Incidence, prevalence, and predictors of treatment-resistant hypertension with intensive blood pressure lowering

J Clin Hypertens (Greenwich). 2019 Jun;21(6):825-834. doi: 10.1111/jch.13550. Epub 2019 May 7.


Recent guidelines call for more intensive blood pressure (BP)-lowering and a less-stringent treatment-resistant hypertension (TRH) definition, both of which may increase the occurrence of this high-risk phenotype. We performed a post hoc analysis of 11 784 SPRINT and ACCORD-BP participants without baseline TRH, who were randomized to an intensive (<120 mm Hg) or standard (<140 mm Hg) systolic BP target. Incidence, prevalence, and predictors of TRH were compared using the updated definition (requiring ≥4 drugs to achieve BP < 130/80 mm Hg) during intensive treatment, vs the former definition (requiring ≥4 drugs to achieve BP < 140/90 mm Hg) during standard treatment. Incidence/prevalence of apparent refractory hypertension (RFH; uncontrolled BP despite ≥5 drugs) was similarly compared. Overall, 5702 and 6082 patients were included in the intensive and standard treatment cohorts, respectively. Crude TRH incidence using the updated definition under intensive treatment was 30.3 (95% CI, 29.3-31.4) per 100 patient-years, compared with 9.7 (95% CI, 9.2-10.2) using the prior definition under standard treatment. Point prevalence using the prior TRH definition at 1-year was 7.5% in SPRINT and 14% in ACCORD vs 22% and 36%, respectively, with the updated TRH definition. Significant predictors of incident TRH included number of baseline antihypertensive drugs, having diabetes, baseline systolic BP, and Black race. Incidence of apparent RFH was also significantly greater using the updated vs prior definition (4.5 vs 1.0 per 100 person-years). Implementation of the 2017 hypertension guideline, including lower BP goals for most individuals, is expected to substantially increase treatment burden and incident TRH among the hypertensive population.

Trial registration: NCT01206062 NCT00000620.

Keywords: ACCORD; SPRINT; epidemiology; hypertension; resistant hypertension.

Publication types

  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Aged
  • Antihypertensive Agents / pharmacology*
  • Antihypertensive Agents / therapeutic use
  • Blood Pressure / physiology*
  • Case-Control Studies
  • Coronary Vasospasm / epidemiology*
  • Coronary Vasospasm / ethnology
  • Diabetes Mellitus / drug therapy
  • Female
  • Guidelines as Topic
  • Humans
  • Hypertension / epidemiology*
  • Hypertension / ethnology
  • Incidence
  • Male
  • Middle Aged
  • Predictive Value of Tests
  • Prevalence
  • Prospective Studies
  • Systole / drug effects*


  • Antihypertensive Agents

Supplementary concepts

  • Hypertension Resistant to Conventional Therapy

Associated data