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.

Hypertensive patients with clinic blood pressure (BP) uncontrolled on ≥3 antihypertensive medications, i.e., apparent treatment resistant hypertension (aTRH) comprise ~28%–30% of all uncontrolled patients in the U.S. However, the proportion receiving these medications in optimal doses is unknown; aTRH is used, since treatment adherence, BP measurement artifacts, and optimal therapy were not available in electronic record data from our >200 community-based clinics Outpatient QUuality Improvement Network (OQUIN). This study sought to define the proportion of uncontrolled hypertensives with aTRH on optimal regimens and clinical factors associated with optimal therapy. During 2007–2010, 468,877 hypertensive patients met inclusion criteria. BP <140/<90 defined control. Multivariable logistic regression was used to assess variables independently associated with ‘optimal therapy’ (prescription of diuretic and ≥2 other BP medications at ≥50% of maximum recommended hypertension doses). Among 468,877 hypertensives, 147,635 (31.5%) were uncontrolled; among uncontrolled hypertensives, 44,684 were prescribed ≥3 BP medications (30.3%) of which 22,189 (15.0%) were prescribed ‘optimal’ therapy. Clinical factors independently associated with optimal BP therapy included black race (OR 1.40 [95% CI 1.32–1.49]), chronic kidney disease (1.31 [1.25–1.38]) diabetes (1.30 [1.24–1.37]), and coronary heart disease risk equivalent status (1.29 [1.14–1.46]). Clinicians more often prescribe optimal therapy for aTRH when cardiovascular risk is greater and treatment goals lower. Approximately one in seven of all uncontrolled hypertensives and one in two with uncontrolled aTRH are prescribed ≥3 BP medications in optimal regimens. Prescribing more optimal pharmacotherapy, for uncontrolled hypertensives including aTRH, confirmed with out-of-office BP, could improve hypertension control.