Headline option: What if BP stays high despite medicines? India lacks data on true ‘resistant’ hypertension
New Delhi: More than 22 crore people in India are living with hypertension, with only 12 percent of them having their blood pressure under control. Among those with high BP despite medication, doctors say, it is important to identify patients with resistant hypertension, a condition which is on the rise in people with high BP.
Resistant hypertension is when BP remains above the recommended treatment target despite treatment with three or more BP-lowering medicines, including a diuretic, at maximum or highest tolerated doses, or is controlled only with four or more medicines.
Unlike uncontrolled hypertension, which refers to blood pressure that remains above the treatment target, and may happen when a patient is untreated, misses medication doses, takes inadequate doses, resistant hypertension is a more specific category of uncontrolled hypertension.
It can be associated with underlying conditions such as excess aldosterone (leading to the body retaining more sodium and water, potentially raising BP), kidney disease or obstructive sleep apnoea.
Before confirming the condition, doctors must rule out factors such as poor medication adherence and the “white coat” effect, in which BP rises in a clinical setting.
Cardiologists and researchers across cities like Bengaluru, Chennai, Mumbai and Delhi told ThePrint they are seeing an upsurge in patients who continue to have high BP despite taking over three medicines.
“Over the last few years, we have been seeing an increase in the number of patients with resistant hypertension. Earlier, around 15 percent of hypertension patients used to be resistant. Now, it is around 30 percent where the patients are resistant to drugs,” said Dr Ameya Udyavar, consultant cardiologist and cardiac electrophysiologist at P.D. Hinduja Hospital and Medical Research Centre in Mumbai.
Dr Gopi A, a senior cardiologist at Fortis Hospital in Bengaluru, estimated that up to 15 percent of the hypertensive patients he sees have resistant hypertension. Dr. Balamurugan, Consultant- Interventional Cardiologist, SRM Prime Hospital in Chennai, also gave a similar estimate from his practice.
However, India has no official national or state-level estimates of how many people have true resistant hypertension, making it difficult to establish the scale of the problem, and mount a response.
Globally, a 2019 meta-analysis published in Heart, which pooled data from more than 3.2 million treated patients across 91 studies, estimated that 10.3 percent had true resistant hypertension, while 14.7 percent had apparent treatment-resistant hypertension.
In true resistant hypertension, BP remains above target despite appropriate treatment with at least three medicines, including a diuretic, after excluding factors such as incorrect measurement, patients missing medicines, and the white-coat effect.
‘Over last few years, we’ve been seeing an increase in number of patients with resistant hypertension. Earlier, around 15% of hypertension patients used to be resistant. Now, it is around 30%,’ Dr Ameya Udyavar, consultant cardiologist, P.D. Hinduja Hospital, Mumbai.
In apparent treatment-resistant hypertension, BP appears resistant to treatment, but there is insufficient information to confirm that it is genuinely resistant, or there are other factors such as missed medication, data gap etc.
Evidence suggests resistant hypertension is a substantial clinical burden, with studies across different populations linking it to higher mortality in some groups.
In an interview with ThePrint, Dr P Ganeshkumar, scientist and head of the Division of Non-Communicable Diseases at the ICMR-National Institute of Epidemiology, Chennai, said some meta-analyses have estimated the prevalence of resistant hypertension at between 1 percent and 5 percent, depending on the population studied.
But he cautioned that this range cannot be used as an estimate for India, as different populations can produce different figures.
“More reliable estimates could be generated through chronic-care data, where patients taking three BP-lowering medicines are followed over time and their treatment and BP records analysed,” he said.
Such analysis, he added, could provide more precise information on the burden of resistant hypertension.
The data gap on resistant hypertension comes amid a much larger effort to identify and treat people with high BP.
In April this year, Union Health Minister JP Nadda told an event in Delhi that 41.5 crore people had been screened for hypertension since 2017, of whom 7.1 crore had been diagnosed and 5.7 crore notified. Notified patients are those who have been officially registered in the government’s health portal to receive standard care, follow-ups, and regular treatment.
The Union Health Ministry, the Indian Council of Medical Research (ICMR), and World Health Organisation (WHO), India, joined hands to launch the India Hypertension Control Initiative in 2017 with an aim to improve the treatment and control of high blood pressure through standardised treatment protocols, reliable supplies of medicines and regular patient follow-ups.
It started with five states and 26 districts in 2017. By 2017, it had expanded to 141 districts across 25 states, covering 303 million people and 21,579 health facilities.
However, the gaps in hypertension care make it difficult to identify people with true resistant hypertension.
Resistant hypertension & why it’s difficult to track
Unlike diabetes, which can be assessed using an HbA1c test that measures average blood sugar over about three months, resistant hypertension cannot be confirmed by a single test.
Doctors instead look at repeated BP readings, the medicines and doses being taken, treatment changes and whether the patient is taking them regularly. A single high BP reading is not enough.
The American Heart Association also recommends checking for factors that can make hypertension appear resistant, including poor adherence, inaccurate BP measurement and the white-coat effect.
About 37.5 percent of apparent resistant hypertension cases may be explained by the white-coat effect, while non-adherence also accounts for a substantial proportion of apparent resistance.
Dr Gopi said measurement errors and the white-coat effect can make BP appear resistant when it may not remain high outside the hospital.
A 24-hour ambulatory BP monitor, which records BP at regular intervals during the day and night, can help doctors establish whether BP remains high outside the clinic.
He identified non-adherence to medication, lifestyle factors, including high sodium intake from processed foods, obesity, physical inactivity and excess alcohol consumption, as contributing factors.
“Obstructive sleep apnoea, a condition in which breathing repeatedly stops and starts during sleep, is another important contributor,” he said. It can occur even in slim and young people without other obvious health conditions.
Dr Balamurugan said that apart from obesity and undiagnosed obstructive sleep apnoea, kidney problems such as chronic kidney disease and secondary hypertension are also possible contributors.
Medical experts also pointed to underlying conditions such as excess production of the aldosterone hormone and narrowing of the arteries supplying the kidneys. Some medicines, including common painkillers, nasal decongestants and steroids, can also make blood pressure harder to control.Dr Saptarshi Bhattacharya, an endocrinologist at Apollo Hospitals, explained that when BP remains high despite medication, the underlying problem may not be that the drugs have stopped working, but that another condition in the body is continuing to drive up blood pressure.
“It is not drug-resistance. It is an internal resistance. There is something happening inside the body which is causing the blood pressure to remain high despite the drugs,” he said.
The prevalence
There is some evidence showing how large the problem of uncontrolled BP is among people already on treatment.
An analysis of the National Family Health Survey-5 data, published in January 2025, found that 49.5 percent of men and 36.8 percent of women taking BP medicines still had uncontrolled hypertension.
But these figures do not show how many had resistant hypertension. The study did not assess whether patients were taking their medicines regularly, whether treatment had been intensified when needed, or whether other causes of uncontrolled BP had been ruled out.
India has screened crores for hypertension, but control remains a challenge
According to Dr Ganeshkumar, the national hypertension detection gap was around 70 percent, meaning that about seven in 10 people who had high blood pressure had not yet been diagnosed with hypertension.
The treatment gap was about 14 percent, meaning some people who had been diagnosed were still not receiving treatment.
In Tamil Nadu, for instance, he said, about half of people with hypertension had been diagnosed, and around 30 percent of those diagnosed were not receiving treatment. Of those receiving treatment, only about half had their BP under control.
‘If you don’t have data, you don’t know whether it is because of treatment gap, whether it is because of therapeutic inertia, or whether it is actually resistant hypertension,’ Dr P Ganeshkumar, head of NCD Division, the ICMR-NIE, Chennai.
Therapeutic ‘inertia’
Dr Ganeshkumar said hypertension care can broadly be divided into three stages: detecting the condition, treating it with medicines and bringing BP under control. But even after starting treatment, some patients continue to have high BP because their medicines are not increased or another drug is not added when needed. This is known as therapeutic inertia.
Data from the India Hypertension Control Initiative (IHCI), he said, suggest that this happens in about 80-90 percent of patients whose BP remains uncontrolled and who need a change in treatment.
“If you don’t have the data, you don’t know whether it is because of the treatment gap, whether it is because of the therapeutic inertia, or whether it is actually resistant hypertension,” he said.
He said resistant hypertension can therefore only be identified after doctors establish that a patient is receiving appropriate treatment and is being followed up.
“Without those records, a person with uncontrolled BP could be counted as resistant when the underlying issue is missed diagnosis, poor adherence or failure to intensify treatment,” he said.
Once resistant hypertension is confirmed, doctors can intensify existing treatment, often adding medicines such as spironolactone. For patients whose BP remains uncontrolled despite appropriate medicines, newer options include renal denervation, a minimally invasive procedure that reduces nerve activity around the kidney arteries.
These treatment options are being explored alongside newer medicines aimed at some of the hormonal pathways involved in difficult-to-control hypertension.
For instance, in May this year, the US Food and Drug Administration approved baxdrostat, an aldosterone synthase inhibitor, for adults whose hypertension is not adequately controlled with other medicines. The drug lowers aldosterone, a hormone that increases sodium retention and can raise BP. But it has not yet been approved in India.
Missed target?
In 2019, then ICMR director general Dr Balram Bhargava said the government had set a target of reducing high BP by 25 percent by 2025 under India’s national NCD (Non-communicable Diseases) action plan. The IHCI was intended to help achieve that target.
Asked whether India had achieved the target, Dr Ganeshkumar said there was no national data to answer the question.
India’s last nationally representative National Noncommunicable Disease Monitoring Survey was conducted in 2017–18. It found that 28.5 percent of adults aged 18–69 had hypertension, while only 12.6 percent had controlled BP.
Dr Ganeshkumar said a new national survey is being planned.
“Until comparable national data are available, India cannot reliably say whether the 25% reduction target was achieved or how far it is from the target,” he said.
At the district level, however, IHCI studies have shown improvements in BP control, he said, including in Bathinda, Punjab, and Thrissur, Kerala.
He identified the gaps: detection, treatment and control, along with patients not taking medicines regularly and doctors not intensifying treatment when required. The same gaps also make it harder to identify resistant hypertension. He described the condition as “important and neglected” and “a growing concern”.
“Are we treating it seriously? No, we are not. We are still neglecting this particular disease by and large,” he said.
(Edited by Ajeet Tiwari)
Also read: 31% Indians live with hypertension, only 37% diagnosed in time & fewer treated, says WHO