Objective We conducted the first systematic review and meta-analysis to estimate the specific prevalence of apparent treatment-resistant, pseudo-resistant and true-resistant hypertension among treated patients with hypertension globally.

Methods We conducted a search in PubMed, EMBASE, Web of Science and Global Index Medicus to identify articles published from inception to 30 September 2017, and searched the reference list of retrieved articles. We used a random-effects model to estimate the prevalence of resistant hypertension across studies and heterogeneity was assessed via the χ² test on Cochran’s Q statistic.

Results We included 91 studies published between 1991 and 2017 reporting data of a pooled sample of 3 207 911 patients with hypertension on antihypertensive drugs globally. Most of the studies (n=64, 70%) only used office blood pressure (BP) measurement. In the general, population of treated patients with hypertension, the prevalence of true-resistant, apparent treatment-resistant and pseudo-resistant hypertension were 10.3% (95% CI 7.6% to 13.2%), 14.7% (95% CI 13.1% to 16.3%) and 10.3% (95% CI 6.0% to 15.5%). The prevalence of true-resistant hypertension was 22.9% (95% CI 19.1% to 27.0%), 56.0% (95% CI 52.7% to 59.3%) and 12.3% (95% CI 1.7% to 30.5%) in chronic kidney disease, renal transplant and elderly patients, respectively.

Conclusions This study shows a high prevalence of true-resistant hypertension. This prevalence is lower than that of apparent treatment-resistant hypertension, demonstrating the importance to exclude causes of pseudo-resistant hypertension including white-coat hypertension with the use of ambulatory BP measurement. The burden of resistant hypertension is highest in patients with chronic kidney disease. New treatments for resistant hypertension are highly needed, considering the disastrous complications of the disease.