Prevalence, regional variations and factors associated with resistant hypertension in India: A systematic review and meta-analysis

Background Resistant hypertension (RH) raises the risk of adverse cardiovascular and renal outcomes. Data on RH burden across India remain fragmented. This systematic review and meta-analysis estimated pooled prevalence, regional variations, and factors associated with RH among hypertensive adults in India. Methods We searched PubMed, Scopus, and EBSCOhost: Academic Search Complete for studies reporting RH prevalence among Indian hypertensive adults published until November 2025. Pooled prevalence and odds ratios were estimated using a random-effects model. Heterogeneity was assessed using I 2 statistic and 95% confidence and prediction intervals. Quality was assessed using the NHLBI tool, and publication bias using the Doi plot and LFK index. The protocol was registered with OSF, and reporting followed PRISMA 2020 guidelines. Results Thirteen studies comprising 14,311 hypertensive patients were included. The pooled prevalence of RH was 19% (95% CI, 11–30%), with substantial heterogeneity (I 2 = 98.2%) and a wide prediction interval (2–70%). Regional pooled estimates ranged from 14% in the East to 22% in the West; however, the between-region difference was not statistically significant (p=0.86). Diabetes (OR 2.95), obesity (OR 3.81), and dyslipidaemia (OR 1.83) showed positive but nonsignificant associations. The Doi plot symmetry and LFK index (0.15) indicated a low likelihood of publication bias. Conclusion RH appears common among hypertensive adults in India. However, substantial heterogeneity and a wide prediction interval limit the generalizability of the pooled estimate. Regional differences were not statistically significant, and cardiometabolic associations were inconclusive. Standardised diagnostic criteria and region-specific research are needed to clarify the burden and guide management.