Hypertension Control in the US Still Has a Long Way to Go

More than half of US adults with uncontrolled hypertension are not aware that they have high blood pressure, according to an analysis of National Health and Nutrition Examination Survey (NHANES) data.

What’s more, even among those who were aware they had hypertension and were treated for it, there was a high rate of uncontrolled BP (70.8%) based on thresholds set in the latest US guidelines, researchers led by LaTonia Richardson, PhD (Centers for Disease Control and Prevention, Atlanta, GA), report in a study published online this week in JAMA Network Open.

“What we believe,” senior author Fátima Coronado, MD (Centers for Disease Control and Prevention), told TCTMD, “is that [the findings] have massive implications for the overall health in the country given the links . . . between hypertension, high blood pressure, and increased CVD in the US.”

There are implications beyond health, too. The researchers note that uncontrolled hypertension takes a heavy economic toll, costing the US $131 to $198 billion each year.

Updated NHANES Data

Coronado said that hypertension control has declined in recent years, “so there’s a big need for the community to understand” what’s happening across the different aspects of the control cascade. “We're talking about hypertension awareness, the actual diagnosis and treatment, and the management and control,” she explained.

For the study, the investigators examined NHANES data spanning January 2017 to March 2020. The analysis included 3,129 adults with uncontrolled hypertension, defined as a systolic BP of at least 130 mm Hg or a diastolic BP of at least 80 mm Hg, regardless of medication use. Those patients represented an estimated 100.4 million adults with uncontrolled hypertension living in the US, or 83.7% of all individuals with hypertension.

Overall, 52.3% were men and 29.4%, 41.4%, and 29.2% were ages 18 to 44, 45 to 64, and 65 or older, respectively.

More than half of the patients with uncontrolled hypertension (57.6%) were unaware they had high BP, but even among those who had been told they had hypertension and were eligible for antihypertensive drug therapy, most remained uncontrolled.

There are opportunities to address and make changes at every level of the cascade. Fátima Coronado

These findings were relatively consistent across demographic groups, although the problem was worse in younger adults and those who had engaged with the healthcare system in the past year. For example, of the estimated 30.1 million adults ages 18 to 44 with hypertension, 91.8% of women and 94.3% of men did not have their BP under control. Roughly two-thirds of younger women and men with uncontrolled hypertension weren’t aware of it.

“When we talk about 18 to 44, that's young,” Coronado said. “We're talking about the workforce. We're talking about people that could potentially develop CVD and . . . the consequences of morbidity and mortality.”

The researchers underscore, too, the concerning situation around hypertension control in women of reproductive age, noting that having uncontrolled BP during pregnancy increases risks of pregnancy-related death and complications, as well as lifetime risk of CVD.

“There are implications, there are pressing issues, on implementing evidence-based strategies to improve hypertension awareness [and] management among adults with uncontrolled hypertension in the US,” Coronado said.

The Implementation Gap

Daniel Lackland, DrPH (Medical University of South Carolina, Charleston), picks up on the implementation theme in an accompanying commentary.

“At this point, it seems the knowledge of specific strategies to prevent and manage high blood pressure is sufficient for success,” he writes. “The remaining gaps are the effective implementation of the strategies in all aspects of the population. Because studies like [this one] describe the disparities and poor overall rates of hypertension control, implementation strategies must be developed and reported in complement.”

Social determinants of health present challenges to implementation of various strategies, he says. “Nonetheless, it is imperative for all to join the challenge for the development and employment of implementation for the multiple aspects of high blood pressure detection, prevention, management, and control. Such commitment can facilitate success in population hypertension control and will be demonstrated in future studies of high blood pressure.”

Tackling the shortfalls identified in this study will take multiple approaches, Coronado said.

“First, we have to have blood pressure checked regularly, even if a person feels healthy. We need to remember that hypertension often, most of the time, is asymptomatic,” Coronado said. “So every time that there's an opportunity to have a healthcare provider screen for blood pressure measurements, we need to do that.”

The healthcare community also has to continue to encourage the adoption of a healthy lifestyle—which includes eating a balanced diet, exercising, avoiding smoking, and limiting alcohol—and increase awareness of hypertension risk factors like family history, obesity, and sedentary behavior.

“Once the patient is diagnosed, I think the main recommendation is adherence to treatment plans and lifestyle recommendations from the healthcare professionals,” Coronado said.

On the clinician side, Coronado stressed the importance of care delivered by multidisciplinary teams, of accurate BP measurements, and of adherence to the latest US hypertension guidance. In addition, she said, “we need to ensure that the appropriate medication dosage [is being used] for our patients, encourage medication adherence, [and] assist our patients with support like self-monitoring blood pressure and frequent follow-ups.”

Overall, Coronado said, “there are opportunities to address and make changes at every level of the cascade.”