Clinical Characteristic of Patients with Uncontrolled, Potentially Under-treated and
Apparent Treatment Resistant Hypertension: NHANES 19882008.
1Brent
1Yumin
1,2R.
1Walter
3Keith
M. Egan,
Zhao,
Neal Axon,
A. Brzezinski,
C. Ferdinand
1Medical University of South Carolina and 2Ralph H. Johnson VAMC, Charleston, SC; 3Emory University, Atlanta, GA
 Abstract.
Background. Defining the characteristics of uncontrolled hypertensive
patients may facilitate efforts to improve blood pressure (BP) control.
Methods: Subjects included 13,375 hypertensive adults from National Health and
Nutrition Examination Surveys (NHANES) 1988 – 2008. Uncontrolled hypertension
was defined as BP 140/90 mmHg and apparent treatment resistant (aTRH) if the
patient reported taking 3 antihypertensive medications. Framingham 10-year coronary
risk (FCR) was calculated. Multivariate regression was used to identify predictors of
untreated, treated uncontrolled, and aTRH.
Results: The majority of uncontrolled hypertensives were untreated across surveys.
Multivariate predictors of untreated hypertension in all three NHANES survey periods,
i.e., consistent, included male sex (odds ratio [OR} 2.262.73, 95% confidence
intervals [{CI}1.863.51]), infrequent healthcare (01 visits/yr) OR (4.664.95 , 95%
CI [3.116.94]), body mass index <25 kg/m2 and <Stage 3 chronic kidney disease
([CKD], (OR 1.672.28, 95% CI [1.103.66] and FCR <10% (OR 7.658.61 [4.78
12.26]).
Most treated, uncontrolled patients reported taking 12 BP medications. Predictors of
treated, uncontrolled hypertension among all controlled and uncontrolled subjects that
reported taking 1–2 BP medis included increasing age (OR 1.191.30, 95% CI
[1.061.42]/10 yrs), black race/ethnicity (OR 1.431.47, 95% CI [1.131.85]), and
FCR >20% (OR 1.812.93, 95% CI [1.273.86]).
The percentage of uncontrolled hypertensives with aTRH increased over time (15.9%
vs. 28.0%, p<0.01). Predictors of aTRH included obesity (OR 2.04, 95% CI
[1.173.53], CKD (OR 2.52, 95% CI [1.75 3.62]), and FCR >20% (OR 4.29, 95% CI
[1.95 9.42]) with age and black race/ethnicity significant in 2005 2008.
 RESULTS. The number of BP meds reportedly taken by hypertensives in 3
NHANES periods are shown in Figure 1. The majority of uncontrolled
hypertensives were untreated across surveys. Multivariate predictors of
untreated hypertension in all three NHANES survey periods (Figure 2), i.e.,
consistent, included male sex, infrequent (01) healthcare visits/yr, body
mass index <25 kg/m2, <Stage 3 chronic kidney disease (CKD), and FCR
<10%.
 Most treated, uncontrolled patients reported taking 12 BP meds.
Predictors of treated, uncontrolled hypertension across surveys are
depicted in Figure 3.
Consistent predictors of ‘under-treated’
hypertension included increasing age, black race, and FCR >20%.
Fig 1. # of BP Meds Reportedly Taken by
Hypertensive Patients in the 3 NHANES periods.
 RESULTS (continued) The percentage of uncontrolled hypertensives with
aTRH increased over time (15.9% vs. 28.0%, p<0.01). Consistent independent
clinical predictors of aTRH across surveys included obesity (Figure 4), CKD,
and FCR >20%. Increasing age and black race were independently predictive of
aTRH in 20052008.
Fig 3. Independent Clinical Predictors of Uncontrolled among
Treated Hypertension in 3 NHANES. Periods (multivariate logistic
regression analysis)
Fig 4. Independent Clinical Predictors of TRH among
Uncontrolled Hypertension in 3 NHANES. Periods
(multivariate logistic regression analysis)
Fig 2. Independent Clinical Predictors of Untreated Hypertension in 3
NHANES. Periods (multivariate logistic regression analysis)
Conclusions: Strategies to increase healthcare use by people that are
disproportionately male, lean and low 10-yr FCR could improve hypertension
treatment and control. Targeted strategies are needed to offset projected increases in
uncontrolled (under)treated (1–2 BP meds) and aTRH (≥3 BP meds) given population
health trends to older age, more ethnic minorities, a higher prevalence of obesity
complicated by CKD, and CHD risk equivalence.
 BACKGROUND. Defining characteristics of uncontrolled
hypertensive patients that are untreated, under-treated and
treatment resistant may facilitate efforts to improve blood
pressure (BP) control.
 OBJECTIVES.
Define clinical predictors of uncontrolled
hypertension that is (a) untreated (b) potentially under-treated
(1–2 BP meds) and apparent treatment resistant ([aTRH] ≥3
meds)
 METHODS. Subjects included 13,375 hypertensive adults from
NHANES 1988 to 2008. Uncontrolled hypertension was
defined as BP 140/90. Framingham 10-year coronary risk
(FCR) was calculated. Multivariate logistic regression analysis
was used to identify independent clinical predictors of
untreated (0 BP meds), ‘under-treated’ (1–2 BP meds), and
aTRH (≥3 BP meds).
 SUMMARY AND CONCLUSIONS. Untreated, ‘under-treated’, and aTRH
patients have consistent distinguishing clinical characteristics that could
inform strategies to decrease untreated hypertension, reduce therapeutic
inertia in under-treated patients, and enhance therapeutic efficiency in aTRH.
 Given an aging population with complicated, high-risk obesity, the prevalence
of ‘under-treated’ and aTRH is likely to increase in the absence of a dataguided response.
Published in Circulation. 2011; 124:1046–1058.