Hypertension Awareness, Treatment, and Control in US Adults: Trends in the Hypertension Control Cascade by Population Subgroup (National Health and Nutrition Examination Survey, 1999-2016)

High blood pressure in the emergency department as an opportunistic screening tool for detection of hypertension

Hypertension is the most preventable cause of morbidity and mortality, but many individuals are underdiagnosed and lack treatment control. High blood pressure (BP) in the emergency department (ED) is commonly observed, but mostly used for short-term evaluation. We aimed to study the usefulness of high BP in the ED as a screening tool for undiagnosed hypertension. We used the electronic medical record system to identify all patients that had attended the ED at a university hospital from 2018-01-01 to 2018-03-31 and from 2018-07-01 to 2018-09-30 with an obtained systolic BP ≥ 160 and/or diastolic BP ≥ 100 mmHg measured at the ED. We excluded patients with previously diagnosed hypertension and patients on BP-lowering medication. All patients identified where contacted two years after attending the ED, with a letter of consent and a questionnaire regarding diagnosis of hypertension and current medication. 5424 patients attended the ED during the 6-months-period. 271 patients met the inclusion criteria and were asked to participate. 167 individuals (62%) agreed to participate and responded to the questionnaire. Mean age of participants were 63.1 years and 51% were women. 134 patients (80%) had measured their BP after the ED-visit, and 48 (36%) of those had been diagnosed with hypertension. 96% of patients diagnosed with hypertension were on BP-lowering medication. To follow-up BP ≥ 160/100 mmHg after an ED visit can reveal undiagnosed hypertension in one third of the patients. Given the amount of undiagnosed hypertension, an ED-measured BP might provide an important tool to detect and start treatment of hypertension.

Sex disparities in hypertension prevalence, blood pressure trajectories and the effects of anti-hypertensive treatment

INTRODUCTION

Sex differences in blood pressure (BP), hypertension and hypertension mediated cardiovascular complications have become an increasingly important focus of attention. This narrative review gives an overview of current studies on this topic, with the aim to provide a deeper understanding of the sex-based disparities in hypertension with essential insights for refining prevention and management strategies for both men and women.

METHODS AND RESULTS

We searched Medline, Embase and the Cochrane libray on sex differences in BP-trajectories and hypertension prevalence. In the past decade various population-based studies have revealed substantial sex-disparities in BP-trajectories throughout life with women having a larger increase in hypertension prevalence after 30 years of age and a stronger association between BP and cardiovascular disease (CVD). In general, the effects of antihypertensive treatment appear to be consistent across sexes in different populations, although there remains uncertainty about differences in the efficacy of BP lowering drugs below 55 years of age.

CONCLUSION

The current uniform approach to the diagnosis and management of hypertension in both sexes neglects the distinctions in hypertension, while the differences underscore the need for sex-specific recommendations, particularly for younger individuals. A major limitation hampering insights into sex differences in BP-related outcomes is the lack of sex-stratified analyses or an adequate representation of women. Additional large-scale, longitudinal studies are imperative.

Variations in antihypertensive medication treatment and blood pressure control among Veterans with HIV and existing hypertension

BACKGROUND

Hypertension is a leading risk factor for cardiovascular disease among patients living with HIV (PLWH). Understanding the predictors and patterns of antihypertensive medication prescription and blood pressure (BP) control among PLWH with hypertension (HTN) is important to improve the primary prevention efforts for this high-risk population. We sought to assess important patient-level correlates (eg, race) and inter-facility variations in antihypertension medication prescriptions and BP control among Veterans living with HIV (VLWH) and HTN.

METHODS

We studied VLWH with a diagnosis of HTN who received care in the Veterans Health Administration (VHA) from January 2018 to December 2019. We evaluated HTN treatment and blood pressure control across demographic variables, including race, and by medical comorbidities. Data were also compared among VHA facilities. Predictors of HTN treatment and control were assessed in 2-level hierarchical multivariate logistic regression models to estimate odds ratios (ORs). The VHA facility random-effects parameters from the hierarchical models were used to calculate the median odds ratios to characterize the variation across the different VHA facilities.

RESULTS

A total of 17,468 VLWH with HTN (mean age 61 years, 97% male, 54% Black, 40% White) who received care within the VHA facilities in 2018-2019 were included. 73% were prescribed antihypertension medications with higher prescription rates among Black vs White patients (75% vs 71%) and higher prescription rates among patients with a history of cardiovascular disease, diabetes, and kidney disease (>80%), and those receiving antiretroviral therapy and with controlled HIV viral load (∼75%). Only 27% of VLWH with HTN had optimal BP control of systolic BP <130 mmHg and diastolic BP <80 mmHg, with a lower rate of control among Black vs White patients (24% v. 31%). In multivariate regression, Black patients had a higher likelihood of HTN medication prescription (OR 1.32, 95% CI: 1.22-1.42) but were less likely to have optimal BP control (OR 0.82; 0.76-0.88). Important positive correlates of antihypertensive prescription and optimal BP control included: number of outpatient visits in prior year, and histories of diabetes, coronary artery disease, and heart failure. There was about 10% variability in both antihypertensive prescription and BP control patterns between VHA facilities for patients with similar characteristics. There was increased inter-facility variation in antihypertensive prescription among those with a history of heart failure and those not receiving antiretroviral therapy.

CONCLUSION

In a retrospective analysis of large VHA data, we found that VLWH with HTN have suboptimal antihypertensive medication prescription and BP control. Black VLWH had higher HTN medication prescription rates but lower optimal BP control.

Pediatric Blood Pressure and Cardiovascular Health in Adulthood

PURPOSE OF REVIEW

This review summarizes current knowledge on blood pressure in children and adolescents (youth), with a focus on primary hypertension-the most common form of elevated blood pressure in this demographic. We examine its etiology, progression, and long-term cardiovascular implications. The review covers definitions and recommendations of blood pressure classifications, recent developments in measurement, epidemiological trends, findings from observational and clinical studies, and prevention and treatment, while identifying gaps in understanding and suggesting future research directions.

RECENT FINDINGS

Youth hypertension is an escalating global issue, with regional and national variations in prevalence. While the principles of blood pressure measurement have remained largely consistent, challenges in this age group include a scarcity of automated devices that have passed independent validation for accuracy and a generally limited tolerance for ambulatory blood pressure monitoring. A multifaceted interplay of factors contributes to youth hypertension, impacting long-term cardiovascular health. Recent studies, including meta-analysis and sophisticated life-course modelling, reveal an adverse link between youth and life-course blood pressure and subclinical cardiovascular outcomes later in life. New evidence now provides the strongest evidence yet linking youth blood pressure with clinical cardiovascular events in adulthood. Some clinical trials have expanded our understanding of the safety and efficacy of antihypertensive medications in youth, but this remains an area that requires additional attention, particularly regarding varied screening approaches. This review outlines the potential role of preventing and managing blood pressure in youth to reduce future cardiovascular risk. A global perspective is necessary in formulating blood pressure definitions and strategies, considering the specific needs and circumstances in low- and middle-income countries compared to high-income countries.

Prevalence and risk factors associated with undiagnosed hypertension among adults aged 15-49 years in India: insights from the National Family Health Survey (NFHS-5)

OBJECTIVES

To estimate the prevalence and identify the factors associated with undiagnosed hypertension in India.

STUDY DESIGN

A secondary data analysis using the National Family Health Survey (NFHS-5) covering the period 2019-2021.

METHODS

Information on hypertension among individuals aged 15-49 years was extracted from the survey dataset. We estimated the prevalence of undiagnosed hypertension using physical measurements along with self-reported data from the survey. A log-binomial model with survey-adjusted Poisson regression was used to estimate the prevalence ratio between undiagnosed and diagnosed hypertension. Multinomial logistic regression analysis examined the factors associated with diagnosed hypertension (vs healthy) and undiagnosed hypertension (vs healthy). All the analyses were survey-weight adjusted and stratified by gender.

RESULTS

The survey-adjusted prevalence of undiagnosed hypertension was 8.75% (8.62%-8.87%) and was higher among males [13.56% (13.03%-14.12%)] than in females [8.14% (8.03%-8.25%)]. The proportion of individuals with undiagnosed hypertension among total hypertension was 44.99% (44.44%-45.55%) and was higher in males [65.94% (64.25%-67.60%)] than in females [42.18% (41.66%-42.71%)].

CONCLUSIONS

Our findings revealed that age, higher body mass index, no access to health care, and having no comorbidities were risk factors for undiagnosed hypertension. One in twelve people had undiagnosed hypertension, and of those with hypertension, one in two were undiagnosed, with males being disproportionately affected. Targeted public health interventions are crucial to improve hypertension screening, particularly among middle-aged and obese individuals without comorbidities.

The Construction and Meaning of Race Within Hypertension Guidelines: A Systematic Scoping Review

BACKGROUND

Professional society guidelines are evidence-based recommendations intended to promote standardized care and improve health outcomes. Amid increased recognition of the role racism plays in shaping inequitable healthcare delivery, many researchers and practitioners have critiqued existing guidelines, particularly those that include race-based recommendations. Critiques highlight how racism influences the evidence that guidelines are based on and its interpretation. However, few have used a systematic methodology to examine race-based recommendations. This review examines hypertension guidelines, a condition affecting nearly half of all adults in the United States (US), to understand how guidelines reference and develop recommendations related to race.

METHODS

A systematic scoping review of all professional guidelines on the management of essential hypertension published between 1977 and 2022 to examine the use and meaning of race categories.

RESULTS

Of the 37 guidelines that met the inclusion criteria, we identified a total of 990 mentions of race categories. Black and African/African American were the predominant race categories referred to in guidelines (n = 409). Guideline authors used race in five key domains: describing the prevalence or etiology of hypertension; characterizing prior hypertension studies; describing hypertension interventions; social risk and social determinants of health; the complexity of race. Guideline authors largely used race categories as biological rather than social constructions. None of the guidelines discussed racism and the role it plays in perpetuating hypertension inequities.

DISCUSSION

Hypertension guidelines largely refer to race as a distinct and natural category rather than confront the longstanding history of racism within and beyond the medical system. Normalizing race as a biological rather than social construct fails to address racism as a key determinant driving inequities in cardiovascular health. These changes are necessary to produce meaningful structural solutions that advance equity in hypertension education, research, and care delivery.

Examining the Hypertension Control Cascade in Adults With Uncontrolled Hypertension in the US

Importance

Uncontrolled hypertension is a major contributor to cardiovascular disease (CVD) in the US.

Objective

To determine the prevalence of hypertension control cascade outcomes (hypertension awareness, treatment recommendations, and medication use) among individuals with uncontrolled hypertension to inform action across cascade levels.

Design, Setting, and Participants

This weighted cross-sectional study used January 2017 to March 2020 National Health and Nutrition Examination Survey (NHANES) data from noninstitutionalized adults aged 18 years or older in the US with uncontrolled hypertension. Data analysis occurred from January to February 2024.

Exposure

Calendar year of response to the NHANES survey.

Main Outcomes and Measures

Mean blood pressure (BP) was computed using up to 3 measurements. Uncontrolled hypertension was defined as systolic BP of 130 mm Hg or greater or diastolic BP of 80 mm Hg or greater, regardless of medication use. Outcomes included patient awareness of hypertension, treatment recommendations, and medication use. To estimate population totals by subgroup, the age-standardized proportion of each outcome was multiplied by the estimated number of adults with uncontrolled hypertension.

Results

The study included 3129 US adults with uncontrolled hypertension (1675 male [weighted percentage, 52.3%]; 775 aged 18 to 44 years [weighted percentage, 29.4%]; 1306 aged 45 to 64 years [weighted percentage, 41.4%]; 1048 aged 65 years or older [weighted percentage, 29.2%]), resulting in a population estimate of 100.4 million adults (weighted percentage, 83.7%) with uncontrolled hypertension. More than one-half of study participants (57.8 million adults [weighted percentage, 57.6%]) were unaware that they had hypertension, and of the 35.0 million who were aware and met criteria for antihypertensive medication, 24.8 million (weighted percentage, 70.8%) took the medication but had hypertension that remained uncontrolled. These negative outcomes in the hypertension control cascade occurred across demographic groups, with notably high prevalence among younger adults and individuals engaged in health care. Among an estimated 30.1 million adults aged 18 to 44 years with hypertension, 10.4 of 11.3 million females (weighted percentage, 91.8%) and 17.7 million of 18.8 million males (weighted percentage, 94.3%) had uncontrolled hypertension. Of the 10.4 million females, 7.2 million (weighted percentage, 68.8%) were unaware of their hypertension status, and of the 17.7 million males, 12.0 million (weighted percentage, 68.1%) were unaware. Additionally, 9.9 of 13.0 million adults with uncontrolled hypertension (weighted percentage, 75.7%) reported no health care visits in the past year and were unaware. Conversely, among 70.6 million adults with uncontrolled hypertension reporting 2 or more health care visits, approximately one-half (36.6 million [weighted percentage, 51.8%]) were unaware.

Conclusions and Relevance

In this cross-sectional study, more than 50% of adults with uncontrolled hypertension in the US were unaware of their hypertension and were untreated, and 70.8% of those who were treated had hypertension that remained uncontrolled. These findings have serious implications for the nation's overall health given the association of hypertension with increased risk for CVD.

Awareness, treatment, and control of hypertension among women at risk or living with HIV in the US South

OBJECTIVES

Timely control of hypertension is vital to prevent comorbidities. We evaluated the association of race/ethnicity and HIV infection with incident hypertension outcomes, including awareness, treatment, and control.

DESIGN

We evaluated cisgender women living with HIV and sociodemographically matched women living without HIV recruited into four Southern sites of the Women's Interagency HIV Study (WIHS) (2013-2019).

METHODS

We calculated measurements of the time to four events or censoring: incident hypertension, hypertension awareness, hypertension treatment, and hypertension control. Hazard ratios for race/ethnicity and HIV status were calculated for each outcome using Cox proportional-hazards models adjusted for sociodemographic, behavioral, and clinical risk factors.

RESULTS

Among 712 women, 56% were hypertensive at baseline. Forty-five percentage of the remaining women who were normotensive at baseline developed incident hypertension during follow-up. Non-Hispanic white and Hispanic women had faster time to hypertension control compared with non-Hispanic black women ( P  = 0.01). In fully adjusted models, women living with HIV who were normotensive at baseline had faster time to treatment compared with normotensive women living without HIV ( P  = 0.04).

CONCLUSION

In our study of women in the US South, non-Hispanic black women became aware of their hypertension diagnosis more quickly than non-Hispanic white and Hispanic women but were slower to control their hypertension. Additionally, women living with HIV more quickly treated and controlled their hypertension compared with women living without HIV.

Multiple forms of perceived job discrimination and hypertension risk among employed women: Findings from the Sister Study

BACKGROUND

Hypertension has been linked to socially patterned stressors, including discrimination. Few studies have quantified the risk of hypertension associated with exposure to perceived job discrimination.

METHODS

We used prospective cohort data from the Sister Study (enrollment from 2003-2009) to estimate self-reported incident hypertension associated with perceived job discrimination based on race, gender, age, sexual orientation, or health status. Job discrimination in the prior 5 years was assessed in 2008-2012, and incident doctor-diagnosed hypertension was ascertained in previously hypertension-free participants.

RESULTS

Among the 16,770 eligible participants aged 37-78 years at the start of follow-up, 10.5% reported job discrimination in the past 5 years, and 19.2% (n = 3226) reported incident hypertension during a median follow-up of 9.7 years (interquartile range 8.2-11.0 years). Self-reported poor health or inclusion in minoritized groups based on race/ethnicity or sexual orientation were more frequent among those reporting job discrimination. In a Cox proportional hazards model adjusting for covariates, report of at least one type of job discrimination (compared to none) was associated with a 14% (hazard ratio = 1.14 [95% confidence: 1.02-1.27]) higher hypertension risk. Results from sensitivity analyses reinforced the findings.

CONCLUSIONS

Results suggest that interventions addressing job discrimination could have workplace equity and health benefits.

The impact of health insurance on hypertension care: a household fixed effects study in India

INTRODUCTION

Hypertension is highly prevalent in India, but the proportion of patients achieving blood pressure control remains low. Efforts have been made to expand health insurance coverage nationwide with the aim of improving overall healthcare access. It is critical to understand the role of health insurance coverage in improving hypertension care.

METHODS

We used secondary data from the nationally representative sample of adults aged 15-49 years from the 2015-2016 National Family Health Survey (NFHS) in India. We defined the hypertension care cascade as four successive steps of (1) screened, (2) diagnosed, (3) treated, and (4) controlled, and operationalized these variables using blood pressure measurements and self-reports. We employed household fixed effect models that conceptually matched people with and without insurance within the household, to estimate the impact of insurance coverage on the likelihood of reaching each care cascade step, while controlling for a wide range of additional individual-level variables.

RESULTS

In all 130,151 included individuals with hypertension, 20.4% reported having health insurance. For the insured hypertensive population, 79.8% (95% Confidence Interval: 79.3%-80.3%) were screened, 49.6% (49.0%-50.2%) diagnosed, 14.3% (13.9%-14.7%) treated, and 7.9% (7.6%-8.2%) controlled, marginally higher than the percentages for the uninsured 79.8% (79.5%-80.0%), 48.2% (47.9%-48.6%), 13.3% (13.1%-13.5%), and 7.5% (7.4%-7.7%) for each cascade step, respectively. From the household fixed effects model, health insurance did not show significant impact on the hypertension care cascade, with the estimated relative risks of health insurance 0.97 (0.93-1.02), 0.97 (0.91-1.03), 0.95 (0.77-1.30), and 0.97 (0.65-1.10) for each cascade step, respectively. We further performed stratified analyses by sociodemographic and behavioral risk factors and a sensitivity analysis with district fixed effects, all of which yielded results that confirmed the robustness of our main findings.

CONCLUSIONS

Health insurance did not show significant impact on improving hypertension care cascade among young and middle-aged adults with hypertension in India. Innovative strategies for overcoming practical barriers to healthcare services in addition to improving financial access are needed to address the large unmet need for hypertension care.

Trends of hypertensive heart disease prevalence and mortality in the United States between the period 1990-2019, Global burden of disease database

Hypertension presents a substantial cardiovascular risk, with poorly managed cases increasing the likelihood of hypertensive heart disease (HHD). This study examines individual-level trends and burdens of HHD in the US from 1990 to 2019, using the Global Burden of Disease (GBD) 2019 database. In 2019, HHD prevalence in the US reached 1,487,975 cases, with stable changes observed since 1990. Sex stratification reveals a notable increase in prevalence among females (AAPC 0.3, 95 % CI: 0.2 to 0.4), while males showed relative constancy (AAPC 0.0, 95 % CI: -0.1 to 0.1). Mortality rates totaled 51,253 cases in 2019, significantly higher than in 1990, particularly among males (AAPC 1.0, 95 % CI: 0.8 to 1.3). Younger adults experienced a surge in HHD-related mortality compared to older adults (AAPC 2.6 versus 2.0). These findings highlight the need for tailored healthcare strategies to address sex and age-specific disparities in managing HHD.

Hypertension treatment cascade among men and women of reproductive age group in India: analysis of National Family Health Survey-5 (2019-2021)

Background

Only a proportion of adults with hypertension are diagnosed and receive recommended prescriptions despite the availability of inexpensive and efficacious treatment. We aimed to estimate the prevalence of different stages of hypertension treatment cascade among the reproductive age groups in India at the national and state levels. We also identified the predictors of different stages of the hypertension treatment cascade.

Methods

We used the nationally representative data from National Family Health Survey (NFHS)-5. We included all the males (15-54 years) and females aged 15-49. Socio-demographic factors, anthropometric measurements, habits, comorbid conditions, and healthcare access stratified the stages of the hypertension treatment cascade among hypertensives. We used multinomial logistic regression to identify the determinants of the treatment cascade levels.

Findings

We had data from 1,267,786 individuals. The national prevalence of hypertension was 18.3% (95% CI: 18.1%-18.4%). Men (21.6%, 95% CI: 21.5%-21.7%) were found to have a higher prevalence as compared to women (14.8%, 95% CI: 14.7%-14.9%). Among hypertensive individuals, 70.5% (95% CI: 70.3%-70.7%) had ever received a BP measurement ("screened"), 34.3% (95% CI: 34.1%-34.5%) had been diagnosed prior to the survey ("aware"), 13.7% (95% CI: 13.5%-13.8%) reported taking a prescribed anti-hypertensive drug ("under treatment"), and 7.8% (95% CI: 7.7%-7.9%) had their BP under control ("controlled"). Males, illiterates, poor, never married, residents of rural areas, smokers/tobacco users, and alcoholic users were less likely to be in any of the treatment cascades.

Interpretation

The prevalence of hypertension in India is high. The "Rule of half" of hypertension does not apply to India as the proportion of people screened, aware of their hypertension status, treated, and controlled are lower than 50% at each stage. Program managers must improve access to hypertension diagnosis and treatment, especially among men in rural areas and populations with lower household wealth.

Funding

None.

National Trends of Vascular Risk Factor Control Among Stroke Survivors: From the National Health and Nutrition Examination Survey 2009 to 2020

BACKGROUND

Contemporary data describing the national trends on vascular risk factor control among stroke survivors are limited.

METHODS AND RESULTS

This is a cross-sectional analysis of the National Health and Nutrition Examination Survey cycles 2009 to 2010 to 2017 to March 2020. Adults (≥18 years of age) with a self-reported diagnosis of stroke were identified. Age-adjusted trends in hypertension, diabetes, and hyperlipidemia control were examined. Sex and racial differences in vascular risk factor control were also investigated. Among 32 497 adult individuals who participated in the National Health and Nutrition Examination Survey, 1354 participants (4.2%) self-reported a prior diagnosis of stroke (55% were women). The rates of age-adjusted blood pressure control worsened when using the cutoff <140/90 mm Hg (79.1% in 2009-2010 versus 61.5% in 2017-March 2020, Ptrend<0.001) and using the cutoff <130/80 mm Hg (53.3% in 2009-2010 versus 38.6% in 2017-March 2020, Ptrend=0.006). Age-adjusted diabetes control (hemoglobin A1c <7 mg/dL) did not significantly change during the study period (88.8% in 2009-2010 versus 85.9% in 2017-March 2020, Ptrend=0.41). Achieving a total cholesterol level <200 mg/dL did not change during the study period (67.3% in 2009-2010 versus 73.3% in 2017-March 2020, Ptrend=0.16). These findings were mostly consistent in men and women and across the different racial and ethnic groups.

CONCLUSIONS

In the United States, secondary prevention was suboptimal for stroke survivors, and there has not been any major significant improvement in the rates of achieving the recommended targets for vascular risk factors during the past decade. These findings highlight the need for targeted interventions to improve these modifiable risk factors.

Satisfaction with local healthcare services and medical need among hypertensive patients: a nationwide study

BACKGROUND

Investigating the factors associated with unmet medical needs is important since it can reflect access to healthcare. This study examined the relationship between the unmet medical needs of patients with hypertension and their satisfaction with the healthcare services available in their neighborhoods.

METHODS

Data were from the 2021 Korean Community Health Survey. The sample included individuals aged 19 years who were diagnosed with hypertension. The main outcome measure was unmet medical need. The relationship between the outcome measure and independent variables were analyzed using multivariate logistic regressions, along with a subgroup analysis based on whether patients were currently receiving treatment for hypertension.

RESULTS

Unmet medical needs were found in 4.3% of the study participants. A higher likelihood of unmet medical needs was found in individuals not satisfied with the healthcare services at proximity (adjusted OR = 1.69, 95% CI: 1.49-1.92) compared to those satisfied with services nearby. Similar tendencies were found regardless of whether individuals were currently receiving treatment for hypertension, although larger differences were found between groups in participants who were currently not receiving treatment.

CONCLUSIONS

The findings infer the need to consider patient satisfaction with nearby healthcare services in implementing public health policies that address unmet medical need in patients with hypertension.

Age and sex disparities in blood pressure control and therapeutic inertia: Impact of a quality improvement program

Objective

Hypertension quality improvement programs reduce uncontrolled blood pressure (BP) but impact may differ by sex and age.

Methods

This study examined uncontrolled BP, defined as a BP ≥ 140/90 mmHg, and therapeutic inertia, defined as absence of medication initiation or escalation during visits with uncontrolled BP, by sex and by age group (19-40, 41-65, 66-75, and 76+ years) during a 12 month follow-up period among 21, 861 patients with hypertension and ≥ two visits in primary care clinics enrolled in the American Medical Association (AMA) Measure Accurately, Act Rapidly, and Partner with Patients (MAP) BP hypertension quality improvement program.

Results

The mean age was 64.8 years (standard deviation [SD 12.8]) and ranged from 19 to 87 years; 53.6% were female. In age groups 19-40, 41-65, 66-75, 76-87 years, uncontrolled BP at the first clinic visit was present in 51.5%, 42.5%, 37.5% and 36.6% of males, respectively, and in 40.0%, 38.0%, 36.0% and 39.6% of females, respectively. Based on vital signs at the first vs. last clinic visit, the proportion of patients with uncontrolled BP in age groups 19-40, 41-65, 66-75 years declined by 19.4%, 13.5%, 10.1% and 8.7% in males, respectively, and 14.4%, 12.5%, 9.3%, and 8.4%, among females, respectively. Therapeutic inertia ranged from 66.5% and 75.9% of clinic visits among males and females age 19-40 years, to 85.6% and 84.9% of clinic visits among males and females age 76-87 years, respectively. The proportion of clinic visits with therapeutic inertia was lower among males vs. females across all age groups until age 76-87 years.

Conclusion

A quality improvement program improves BP control but declines in uncontrolled BP are larger and therapeutic inertia is lower for younger vs. older age groups and for males vs. females. More interventions are needed to reduce sex and age disparities in hypertension management.

Understanding Gaps in the Hypertension and Diabetes Care Cascade: Systematic Scoping Review

BACKGROUND

Hypertension and diabetes are global health challenges requiring effective management to mitigate their considerable burden. The successful management of hypertension and diabetes requires the completion of a sequence of stages, which are collectively termed the care cascade.

OBJECTIVE

This scoping review aimed to describe the characteristics of studies on the hypertension and diabetes care cascade and identify potential interventions as well as factors that impact each stage of the care cascade.

METHODS

The method of this scoping review has been guided by the framework by Arksey and O'Malley. We systematically searched MEDLINE, Embase, and Web of Science using terms pertinent to hypertension, diabetes, and specific stages of the care cascade. Articles published after 2011 were considered, and we included all studies that described the completion of at least one stage of the care cascade of hypertension and diabetes. Study selection was independently performed by 2 paired authors. Descriptive statistics were used to elucidate key patterns and trends. Inductive content analysis was performed to generate themes regarding the barriers and facilitators for improving the care cascade in hypertension and diabetes management.

RESULTS

A total of 128 studies were included, with 42.2% (54/128) conducted in high-income countries. Of them, 47 (36.7%) focused on hypertension care, 63 (49.2%) focused on diabetes care, and only 18 (14.1%) reported on the care of both diseases. The majority (96/128, 75.0%) were observational in design. Cascade stages documented in the literature were awareness, screening, diagnosis, linkage to care, treatment, adherence to medication, and control. Most studies focused on the stages of treatment and control, while a relative paucity of studies examined the stages before treatment initiation (76/128, 59.4% vs 52/128, 40.6%). There was a wide spectrum of interventions aimed at enhancing the hypertension and diabetes care cascade. The analysis unveiled a multitude of individual-level and system-level factors influencing the successful completion of cascade sequences in both high-income and low- and middle-income settings.

CONCLUSIONS

This review offers a comprehensive understanding of hypertension and diabetes management, emphasizing the pivotal factors that impact each stage of care. Future research should focus on upstream cascade stages and context-specific interventions to optimize patient retention and care outcomes.

Digital Health Interventions for Hypertension Management in US Populations Experiencing Health Disparities: A Systematic Review and Meta-Analysis

Importance

Hypertension remains a leading factor associated with cardiovascular disease, and demographic and socioeconomic disparities in blood pressure (BP) control persist. While advances in digital health technologies have increased individuals' access to care for hypertension, few studies have analyzed the use of digital health interventions in vulnerable populations.

Objective

To assess the association between digital health interventions and changes in BP and to characterize tailored strategies for populations experiencing health disparities.

Data Sources

In this systematic review and meta-analysis, a systematic search identified studies evaluating digital health interventions for BP management in the Cochrane Library, Ovid Embase, Google Scholar, Ovid MEDLINE, PubMed, Scopus, and Web of Science databases from inception until October 30, 2023.

Study Selection

Included studies were randomized clinical trials or cohort studies that investigated digital health interventions for managing hypertension in adults; presented change in systolic BP (SBP) or baseline and follow-up SBP levels; and emphasized social determinants of health and/or health disparities, including a focus on marginalized populations that have historically been underserved or digital health interventions that were culturally or linguistically tailored to a population with health disparities. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline.

Data Extraction and Synthesis

Two reviewers extracted and verified data. Mean differences in BP between treatment and control groups were analyzed using a random-effects model.

Main Outcomes and Measures

Primary outcomes included mean differences (95% CIs) in SBP and diastolic BP (DBP) from baseline to 6 and 12 months of follow-up between digital health intervention and control groups. Shorter- and longer-term follow-up durations were also assessed, and sensitivity analyses accounted for baseline BP levels.

Results

A total of 28 studies (representing 8257 participants) were included (overall mean participant age, 57.4 years [range, 46-71 years]; 4962 [60.1%], female). Most studies examined multicomponent digital health interventions incorporating remote BP monitoring (18 [64.3%]), community health workers or skilled nurses (13 [46.4%]), and/or cultural tailoring (21 [75.0%]). Sociodemographic characteristics were similar between intervention and control groups. Between the intervention and control groups, there were statistically significant mean differences in SBP at 6 months (-4.24 mm Hg; 95% CI, -7.33 to -1.14 mm Hg; P = .01) and SBP changes at 12 months (-4.30 mm Hg; 95% CI, -8.38 to -0.23 mm Hg; P = .04). Few studies (4 [14.3%]) reported BP changes and hypertension control beyond 1 year.

Conclusions and Relevance

In this systematic review and meta-analysis of digital health interventions for hypertension management in populations experiencing health disparities, BP reductions were greater in the intervention groups compared with the standard care groups. The findings suggest that tailored initiatives that leverage digital health may have the potential to advance equity in hypertension outcomes.

Lost in Translation: Why Are Rates of Hypertension Control Getting Worse Over Time?

Treatment of hypertension to decrease rates of cardiovascular disease is the most well studied and most broadly applicable treatment in cardiovascular prevention. Blood pressure can be measured anywhere, not just in a physician's office; medications are readily available, inexpensive, and have highly favorable benefit/harm ratios with relatively minimal side effects; and stepped medication regimens can be prescribed in algorithmic fashion by a variety of practitioners. Yet overall hypertension control rates in the United States have never exceeded 60%, and the last 5-10 years have seen decreased, rather than increased, rates of control. Here, I describe the scale of this massive failure to deliver on the promise of preventive hypertension care; outline the populations most affected and the contemporaneous events that have impacted hypertension control; discuss the disparate paths of hypertension science and health care delivery; and highlight novel interventions, approaches, and future opportunities to bend the curve back toward improvements in hypertension control.

Prevalence of Statin Use for Primary Prevention of Atherosclerotic Cardiovascular Disease by Race, Ethnicity, and 10-Year Disease Risk in the US: National Health and Nutrition Examination Surveys, 2013 to March 2020

Importance

The burden of atherosclerotic cardiovascular disease (ASCVD) in the US is higher among Black and Hispanic vs White adults. Inclusion of race in guidance for statin indication may lead to decreased disparities in statin use.

Objective

To evaluate prevalence of primary prevention statin use by race and ethnicity according to 10-year ASCVD risk.

Design, Setting, and Participants

This serial, cross-sectional analysis performed in May 2022 used data from the National Health and Nutrition Examination Survey, a nationally representative sample of health status in the US, from 2013 to March 2020 (limited cycle due to the COVID-19 pandemic), to evaluate statin use for primary prevention of ASCVD and to estimate 10-year ASCVD risk. Participants aged 40 to 75 years without ASCVD, diabetes, low-density lipoprotein cholesterol levels 190 mg/dL or greater, and with data on medication use were included.

Exposures

Self-identified race and ethnicity (Asian, Black, Hispanic, and White) and 10-year ASCVD risk category (5%-<7.5%, 7.5%-<20%, ≥20%).

Main Outcomes and Measures

Prevalence of statin use, defined as identification of statin use on pill bottle review.

Results

A total of 3417 participants representing 39.4 million US adults after applying sampling weights (mean [SD] age, 61.8 [8.0] years; 1289 women [weighted percentage, 37.8%] and 2128 men [weighted percentage, 62.2%]; 329 Asian [weighted percentage, 4.2%], 1032 Black [weighted percentage, 12.7%], 786 Hispanic [weighted percentage, 10.1%], and 1270 White [weighted percentage, 73.0%]) were included. Compared with White participants, statin use was lower in Black and Hispanic participants and comparable among Asian participants in the overall cohort (Asian, 25.5%; Black, 20.0%; Hispanic, 15.4%; White, 27.9%) and within ASCVD risk strata. Within each race and ethnicity group, a graded increase in statin use was observed across increasing ASCVD risk strata. Statin use was low in the highest risk stratum overall with significantly lower rates of use among Black (23.8%; prevalence ratio [PR], 0.90; 95% CI, 0.82-0.98 vs White) and Hispanic participants (23.9%; PR, 0.90; 95% CI, 0.81-0.99 vs White). Among other factors, routine health care access and health insurance were significantly associated with higher statin use in Black, Hispanic, and White adults. Prevalence of statin use did not meaningfully change over time by race and ethnicity or by ASCVD risk stratum.

Conclusions and Relevance

In this study, statin use for primary prevention of ASCVD was low among all race and ethnicity groups regardless of ASCVD risk, with the lowest use occurring among Black and Hispanic adults. Improvements in access to care may promote equitable use of primary prevention statins in Black and Hispanic adults.

Long-term Outcomes of a 1-year Hypertension Quality Improvement Initiative in a Large Health System

BACKGROUND

Understanding whether practices retain outcomes attained during a quality improvement (QI) initiative can inform resource allocation.

OBJECTIVE

We report blood pressure (BP) control and medication intensification in the 3 years after a 2016 QI initiative ended.

RESEARCH DESIGN

Retrospective cohort.

SUBJECTS

Adults with a diagnosis of hypertension who had a primary care visit in a large-integrated health system between 2015 and 2019.

MEASURES

We report BP control (<140/90 mm Hg) at the last reading of each year. We used a multilevel regression to identify the adjusted propensity to receive medication intensification among patients with an elevated BP in the first half of the year. To examine variation, we identified the average predicted probability of control for each practice. Finally, we grouped practices by the proportion of their patients whose BP was controlled in 2016: lowest performing (<75%), middle (≥75%-<85%), and highest performing (≥85%).

RESULTS

The dataset contained 184,981 patients. From 2015 to 2019, the percentage of patients in control increased from 74% to 82%. In 2015, 38% of patients with elevated BP received medication intensification. This increased to 44% in 2016 and 50% in 2019. Practices varied in average BP control (from 62% to 91% in 2016 and 68% to 90% in 2019). All but one practice had a substantial increase from 2015 to 2016. Most maintained the gains through 2019. Higher-performing practices were more likely to intensify medications than lower-performing practices.

CONCLUSIONS

Most practices maintained gains 3 years after the QI program ended. Low-performing practices should be the focus of QI programs.

Impact of free hypertension pharmacy program and social distancing policy on stroke: A longitudinal study

Background

The estimated lifetime risk of stroke was the highest in East Asia worldwide, especially in China. Antihypertensive therapy can significantly reduce stroke mortality. However, blood pressure control is poor. Medication adherence is a barrier as patients' out-of-pocket costs have risen. We aimed to take advantage of a free hypertension pharmacy intervention and quantified the impact on stroke mortality.

Methods

A free pharmaceutical intervention program was implemented in Deqing, Zhejiang province in April 2018. Another non-pharmaceutical intervention, social distancing due to the pandemic of Coronavirus disease 2019 (COVID-19), was also key to affecting stroke mortality. We retrospectively collected the routine surveillance data of stroke deaths from Huzhou Municipal Center for Disease Prevention and Control in 2013-2020 and obtained within-city mobility data from Baidu Migration in 2019-2020, then we quantified the effects of both pharmaceutical intervention and social distancing using Serfling regression model.

Results

Compared to the predicted number, the actual number of stroke deaths was significantly lower by 10% (95% CI, 6-15%; p < 0.001) from April 2018 to December 2020 in Deqing. Specifically, there was a reduction of 19% (95% CI, 10-28%; p < 0.001) in 2018. Moreover, we observed a 5% (95% CI, -4 - 14%; p = 0.28) increase in stroke mortality due to the adverse effect of COVID-19 but it wasn't statistically significant.

Conclusion

Free hypertension pharmacy program has great potential to prevent considerable stroke deaths. In the future, the free supply of low-cost, essential medications that target patients with hypertension at increased risk of stroke could be taken into account in formulating public health policies and guiding allocations of health care resources.

Hypertension Across a Woman's Life Cycle

PURPOSE OF REVIEW

We reviewed the effects of hypertension and the means to prevent and treat it across the spectrum of a woman's lifespan and identified gaps in sex-specific mechanisms contributing to hypertension in women that need to be addressed.

RECENT FINDINGS

Hypertension continues to be an important public health problem for women across all life stages from adolescence through pregnancy, menopause, and older age. There remain racial, ethnic, and socioeconomic differences in hypertension rates not only overall but also between the sexes. Blood pressure cutoffs during pregnancy have not been updated to reflect the 2017 ACC/AHA changes due to a lack of data. Additionally, the mechanisms behind hypertension development in menopause, including sex hormones and genetic factors, are not well understood. In the setting of increasing inactivity and obesity, along with an aging population, hypertension rates are increasing in women. Screening and management of hypertension throughout a women's lifespan are necessary to reduce the burden of cardiovascular disease, and further research to understand sex-specific hypertension mechanisms is needed.

Self-reported arterial hypertension, use of health services and guidelines for care in Brazilian population: National Health Survey, 2019

OBJECTIVE

To describe the prevalence of arterial hypertension according to sociodemographic characteristics in Brazil and to analyze the indicators related to access to health services and guidelines for controlling the disease in the country.

METHODS

Cross-sectional descriptive study using the National Health Survey (PNS) conducted in 2019. The prevalence of hypertension was estimated with a 95% confidence interval, in addition to the proportions of hypertension indicators.

RESULTS

There were 88,531 respondents, of which 23.9% self-reported hypertension, more prevalent among females (26.4%) and the elderly (55.0%). Among those who self-reported hypertension, 57.8% reported medical attention in the last six months; most received guidance on self-care; 66.1% were seen in public health services; and 45.8%, in primary health care units.

CONCLUSION

The prevalence of hypertension in the Brazilian population was high, with most people who self-reported the condition being seen in services of the Brazilian National Health System (SUS), where they received guidance on health promotion.

Cardiovascular Disease Projections in the United States Based on the 2020 Census Estimates

BACKGROUND

Understanding trends in cardiovascular (CV) risk factors and CV disease according to age, sex, race, and ethnicity is important for policy planning and public health interventions.

OBJECTIVES

The goal of this study was to project the number of people with CV risk factors and disease and further explore sex, race, and ethnical disparities.

METHODS

The prevalence of CV risk factors (diabetes mellitus, hypertension, dyslipidemia, and obesity) and CV disease (ischemic heart disease, heart failure, myocardial infarction, and stroke) according to age, sex, race, and ethnicity was estimated by using logistic regression models based on 2013-2018 National Health and Nutrition Examination Survey data and further combining them with 2020 U.S. Census projection counts for years 2025-2060.

RESULTS

By the year 2060, compared with the year 2025, the number of people with diabetes mellitus will increase by 39.3% (39.2 million [M] to 54.6M), hypertension by 27.2% (127.8M to 162.5M), dyslipidemia by 27.5% (98.6M to 125.7M), and obesity by 18.3% (106.3M to 125.7M). Concurrently, projected prevalence will similarly increase compared with 2025 for ischemic heart disease by 31.1% (21.9M to 28.7M), heart failure by 33.0% (9.7M to 12.9M), myocardial infarction by 30.1% (12.3M to 16.0M), and stroke by 34.3% (10.8M to 14.5M). Among White individuals, the prevalence of CV risk factors and disease is projected to decrease, whereas significant increases are projected in racial and ethnic minorities.

CONCLUSIONS

Large future increases in CV risk factors and CV disease prevalence are projected, disproportionately affecting racial and ethnic minorities. Future health policies and public health efforts should take these results into account to provide quality, affordable, and accessible health care.

An analytical model of population level uncontrolled hypertension management: a care cascade approach

Effective control of hypertension at the population level is a global public health challenge. This study shows how improving population coverages at different hypertension care cascade levels could impact population-level hypertension management. We developed an analytical framework and a companion Excel model of multi-level hypertension care cascade entailing awareness, treatment, and control. The model estimates the prevalence of uncontrolled hypertension for different level of population coverages at certain cascade levels. We applied the model to data from Bangladesh and reported prevalence estimates associated with coverage interventions at different cascade levels. The model estimated that if 50% of the unaware hypertensive patients became aware of their hypertensive condition, the prevalence of uncontrolled hypertension would decrease by 1.8 and 1.3 percentage points (8.2% and 5.8% relative reduction), respectively, for constant and variable rates in the status quo setting. When 50% of the aware, but untreated individuals received treatment, the prevalence would decrease by around 0.7 percentage points (3.3% relative reduction). A 50% decrease in the share of treated individuals who did not have hypertension under control, would result in decreasing the prevalence by 2.8 percentage points (12.7% relative reduction). By providing an analytical tool that demonstrates the probable impact of population coverage interventions at certain hypertension care cascade levels, our study endows public health practitioners with vital information to identify gaps and design effective policies for hypertension management.

Association between genetic risk of high SBP and hypertension control: the CoLaus|PsyColaus study

OBJECTIVE

To assess whether a genetic risk score (GRS) for high SBP is associated with poor control of hypertension.

METHODS

Data from the four waves of a population-based, prospective study conducted in Lausanne, Switzerland. Control of hypertension was defined based on SBP less than 140 mmHg and DBP less than 90 mmHg. A weighted GRS was computed from 362 SNPs.

RESULTS

Overall, 1097 (51% men, mean age 61 years), 1126 (53% men, age 65 years), 1020 (52% men, age 69 years) and 809 (50% men, age 71 years) participants treated for hypertension were selected from the baseline (2003-2006), first (2009-2012), second (2014-2017) and third (2018-2021) surveys. Hypertension control rates were 50, 58, 52 and 59% for the baseline, first, second and third surveys, respectively. No association was found between GRS and hypertension control: multivariate-adjusted mean ± standard error for controlled vs. uncontrolled participants: 9.30 ± 0.09 vs. 9.50 ± 0.09 ( P  = 0.12); 9.32 ± 0.08 vs. 9.53 ± 0.10 ( P  = 0.10); 9.17 ± 0.08 vs. 9.34 ± 0.11 ( P  = 0.22), and 9.18 ± 0.09 vs. 9.46 ± 0.11 ( P  = 0.07) for the baseline, first, second and third surveys, respectively. Power analysis showed that a minimum of 3410 people treated for hypertension would be necessary to detect an association between the GRS and hypertension control rates. Notably, positive associations between the GRS and SBP levels were found among participants not treated for hypertension, with Spearman correlations ranging between 0.05 and 0.09 (all P  < 0.05).

CONCLUSION

Using a GRS associated with SBP levels is not predictive of hypertension control. The use of GRS for hypertension management is not warranted in clinical practice.

http://links.lww.com/HJH/C26.

Establishing a National Cardiovascular Disease Surveillance System in the United States Using Electronic Health Record Data: Key Strengths and Limitations

Cardiovascular disease surveillance involves quantifying the evolving population-level burden of cardiovascular outcomes and risk factors as a data-driven initial step followed by the implementation of interventional strategies designed to alleviate this burden in the target population. Despite widespread acknowledgement of its potential value, a national surveillance system dedicated specifically to cardiovascular disease does not currently exist in the United States. Routinely collected health care data such as from electronic health records (EHRs) are a possible means of achieving national surveillance. Accordingly, this article elaborates on some key strengths and limitations of using EHR data for establishing a national cardiovascular disease surveillance system. Key strengths discussed include the: (1) ubiquity of EHRs and consequent ability to create a more "national" surveillance system, (2) existence of a common data infrastructure underlying the health care enterprise with respect to data domains and the nomenclature by which these data are expressed, (3) longitudinal length and detail that define EHR data when individuals repeatedly patronize a health care organization, and (4) breadth of outcomes capable of being surveilled with EHRs. Key limitations discussed include the: (1) incomplete ascertainment of health information related to health care-seeking behavior and the disconnect of health care data generated at separate health care organizations, (2) suspect data quality resulting from the default information-gathering processes within the clinical enterprise, (3) questionable ability to surveil patients through EHRs in the absence of documented interactions, and (4) the challenge in interpreting temporal trends in health metrics, which can be obscured by changing clinical and administrative processes.

Blood Pressure Control Among Non-Hispanic Black Adults Is Lower Than Non-Hispanic White Adults Despite Similar Treatment With Antihypertensive Medication: NHANES 2013-2018

BACKGROUND

Controlled blood pressure can prevent or reduce adverse health outcomes. Social and structural determinants may contribute to the disparity that despite equivalent proportions on antihypertensive medication, non-Hispanic Black (Black) adults have lower blood pressure control and more cardiovascular events than non-Hispanic White (White) adults.

METHODS

Data from 2013 to 2018 National Health and Nutrition Examination Survey were pooled to assess control among Black and White adults by antihypertensive medication use and selected characteristics using the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Blood Pressure Guideline definition (systolic blood pressure <130 mm Hg and diastolic blood pressure <80 mm Hg) among 4,739 adults.

RESULTS

Among those treated with antihypertensive medication, an estimated 34.9% of Black and 45.0% of White adults had controlled blood pressure. Control was lower for Black and White adults among most subgroups of age, sex, education, insurance status, usual source of care, and poverty-income ratio. Black adults had higher use of diuretics (28.5%-Black adults vs. 23.5%-White adults) and calcium channel blockers (24.2%-Black adults vs. 14.7%-White adults) compared with White adults. Control among Black adults was lower than White adults across all medication classes including diuretics (36.1%-Black adults vs. 47.3%-White adults), calcium channel blockers (30.2%-Black adults vs. 40.1%-White adults), and number of medication classes used.

CONCLUSIONS

Suboptimal blood pressure control rates and disparities warrant increased efforts to improve control, which could include addressing social and structural determinants along with emphasizing implementation of the 2017 ACC/AHA Blood Pressure Guideline into clinical practice.

Age, Sex, Race/Ethnicity, and Income Patterns in Ideal Cardiovascular Health Among Adolescents and Adults in the U.S

INTRODUCTION

Ideal cardiovascular health is present in <50% of children and <1% of adults, yet its prevalence from adolescence through adulthood has not been fully evaluated. This study characterizes the association of age with ideal cardiovascular health and compares these associations across sex, race/ethnicity, and SES subgroups.

METHODS

This study, conducted in 2020, analyzed adolescents and adults aged 12-79 years from the cross-sectional National Health and Nutrition Examination Survey 2005-2016 (N=38,706). Polynomial models were used to model the association of age with ideal cardiovascular health, defined using the American Heart Association's Life's Simple 7 criteria (scales 0-14, with higher values indicating better cardiovascular health).

RESULTS

Mean cardiovascular health was lower with increasing age, starting in early adolescence and dropping to a nadir by age 60 years before stabilizing. At age 20 years, only 45% of adults had ideal cardiovascular health (≥5 ideal cardiovascular health metrics), and >50% of adults had poor cardiovascular health (≤2 ideal cardiovascular health metrics) at age 53 years. Women had higher mean cardiovascular health than men in early life but lower mean cardiovascular health from age 60 years onward. Mean cardiovascular health scores were highest for non-Hispanic White and higher-income adults and lowest for non-Hispanic Black and low-income adults across all ages. Mean cardiovascular health scores fell from intermediate to poor levels approximately 30 years earlier for non-Hispanic Black than for non-Hispanic White adults and approximately 35 years earlier for low-income adults than in higher-income adults.

CONCLUSIONS

Cardiovascular health scores are lower with increasing age from early adolescence through adulthood. Race/ethnicity and income disparities in cardiovascular health are observed at young ages and are more profound at older ages.

Proceedings From a National Heart, Lung, and Blood Institute and the Centers for Disease Control and Prevention Workshop to Control Hypertension

Hypertension treatment and control prevent more cardiovascular events than management of other modifiable risk factors. Although the age-adjusted proportion of US adults with controlled blood pressure (BP) defined as <140/90 mm Hg, improved from 31.8% in 1999-2000 to 48.5% in 2007-2008, it remained stable through 2013-2014 and declined to 43.7% in 2017-2018. To address the rapid decline in hypertension control, the National Heart, Lung, and Blood Institute and the Division for Heart Disease and Stroke Prevention of the Centers for Disease Control and Prevention convened a virtual workshop with multidisciplinary national experts. Also, the group sought to identify opportunities to reverse the adverse trend and further improve hypertension control. The workshop immediately preceded the Surgeon General's Call to Action to Control Hypertension, which recognized a stagnation in progress with hypertension control. The presentations and discussions included potential reasons for the decline and challenges in hypertension control, possible "big ideas," and multisector approaches that could reverse the current trend while addressing knowledge gaps and research priorities. The broad set of "big ideas" was comprised of various activities that may improve hypertension control, including: interventions to engage patients, promotion of self-measured BP monitoring with clinical support, supporting team-based care, implementing telehealth, enhancing community-clinical linkages, advancing precision population health, developing tailored public health messaging, simplifying hypertension treatment, using process and outcomes quality metrics to foster accountability and efficiency, improving access to high-quality health care, addressing social determinants of health, supporting cardiovascular public health and research, and lowering financial barriers to hypertension control.

Moving the Paradigm Forward for Prediction and Risk-Based Primary Prevention of Heart Failure in Special Populations

PURPOSE OF REVIEW

Heart failure (HF) treatment paradigms increasingly recognize the importance of primary prevention. This review explores factors that enhance HF risk, summarizes evidence supporting the pharmacologic primary prevention of HF, and notes barriers to the implementation of primary prevention of HF with a focus on female and sexual and gender minority patients.

RECENT FINDINGS

HF has pathophysiologic sex-specific distinctions, suggesting that sex-specific preventive strategies may be beneficial. Pharmacologic agents that have shown benefit in reducing the risk of HF address the pathobiology underpinning these sex-specific risk factors. The implementation of pharmacologic therapies for primary prevention of HF needs to consider a risk-based model. Current pharmacotherapies hold mechanistic promise for the primary prevention of HF in females and gender and sexual minorities, although research is needed to understand the specific populations most likely to benefit. There are significant systemic barriers to the equitable provision of HF primary prevention.

Health care fragmentation and blood pressure control among adults taking antihypertensive medication

OBJECTIVES

To determine the association of fragmented ambulatory health care with uncontrolled blood pressure (BP) and apparent treatment-resistant hypertension (aTRH) among older adults taking antihypertensive medication, overall and by race and gender.

STUDY DESIGN

Cross-sectional study using data from 2868 REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants 66 years and older who completed a study examination in 2013-2016, had Medicare fee-for-service coverage, and were taking antihypertensive medication.

METHODS

We used logistic regression to analyze the association of fragmented health care with uncontrolled BP and aTRH. Fragmented health care was operationalized as a reversed Bice-Boxerman Index score in the 75th percentile or higher, calculated using the number of ambulatory providers and health care visits in the year preceding the study examination. Uncontrolled BP was defined by systolic BP of at least 140 mm Hg or diastolic BP of at least 90 mm Hg. aTRH was defined by taking 3 or more classes of antihypertensive medication with uncontrolled BP or 4 or more classes with controlled BP.

RESULTS

The overall adjusted odds ratios (95% CIs) for uncontrolled BP, aTRH with controlled BP, and aTRH with uncontrolled BP associated with fragmented health care were 1.10 (0.89-1.37), 1.08 (0.80-1.47), and 1.32 (0.96-1.81), respectively. Fragmented health care was not associated with uncontrolled BP or aTRH among White participants, women, or men. Among Black participants, the odds ratio (95% CI) associated with fragmented health care was 1.21 (0.81-1.82) for uncontrolled BP, 1.22 (0.72-2.07) for aTRH with controlled BP, and 1.82 (1.07-3.11) for aTRH with uncontrolled BP.

CONCLUSIONS

Fragmented health care may increase the likelihood of aTRH with uncontrolled BP among older Black adults taking antihypertensive medication.

Sex-Specific Temporal Trends in Hypertensive Crisis Hospitalizations in the United States

Background Despite recent improvements in hypertension control overall, the extent to which these trends apply to the most extreme forms of elevated blood pressure-hypertensive crises requiring hospitalization-in both women and men at risk remains unknown. Methods and Results Using data from the National Inpatient Sample, we estimated sex-pooled and sex-specific temporal trends in hypertensive crisis hospitalization and case fatality rates over serial time periods: years 2002 to 2006, 2007 to 2011, and 2012 to 2014. Over the entire study period (years 2002-2014), there were an estimated 918 392±9331 hypertensive crisis hospitalizations and 4377±157 in-hospital deaths. Hypertensive crisis represented 0.23%±0.002% of all hospitalizations during the entire study period: 0.24%±0.002% for men and 0.22%±0.002% for women. In multivariable analyses adjusting for age, race or ethnicity, and cardiovascular conditions, the odds of experiencing a hospitalization primarily for hypertensive crisis increased annually for both men (odds ratio [OR], 1.083 per year; 95% CI, 1.08-1.09) and women (OR, 1.07 per year, 95% CI, 1.07-1.08) with a higher rate of increase observed in men compared with women (P<0.001). The multivariable-adjusted odds of death during hypertensive crisis hospitalization decreased annually and similarly for men (OR, 0.89 per year; 95% CI, 0.86-0.92) and for women (0.92 per year; 95% CI, 0.90-0.94). Conclusions Hypertensive crisis hospitalizations have steadily increased, slightly more among men than women, along with an observed increase in the burden of cardiovascular conditions. These trends, observed despite contemporaneous improvements in hypertension prevention and control nationwide, warrant further investigations to identify contributing factors that could be amenable to targeted interventions.

Awareness, perceptions, and attitudes toward community pharmacist clinical services: An analysis of data from 2004 and 2018

OBJECTIVE

This study aimed to describe and compare the public's change in awareness and perceptions of, willingness to use, willingness to pay, and interest in insurance coverage for community pharmacist prescriptive authority services and point of care testing over a time span of 14 years.

METHODS

This was a retrospective review of anonymous questionnaires administered by student pharmacists in 2004 and in 2018. Questionnaires were administered to individuals who presented to University of New Mexico College of Pharmacy sponsored health fair screenings and at various community pharmacies throughout the state of New Mexico (NM).

RESULTS

In total, 545 (2004) and 659 (2017-2018) participants completed the questionnaire. Awareness of community pharmacist clinical services increased from 2004 to 2018. In 2018, awareness of newer prescriptive authority services provided by pharmacists in NM was low relative to the services assessed in previous years. Most respondents indicated a willingness to use and pay for pharmacist-provided clinical services and felt that pharmacists should receive compensation by their insurance for these services. Trust in pharmacist advice grew from 2004 to 2018.

CONCLUSION

Overall rates of awareness of community pharmacist clinical services were low with the exception of immunizations; however, most participants indicated interest in and willingness to use these services. Most participants believed pharmacists should receive reimbursement from insurance companies for clinical services and were also willing to pay a copay or out-of-pocket cost for these services.

How Hypertension Guidelines Address Social Determinants of Health: A Systematic Scoping Review

BACKGROUND

Patient-level and community-level social and economic conditions impact hypertension risk and control. We examined adult hypertension management guidelines to explore whether and how existing guidelines refer to social care activities.

OBJECTIVE

The objective of this study was to explore how hypertension guidelines reference social care activities.

RESEARCH DESIGN

A systematic scoping review of clinical guidelines for adult hypertension management. We employed a PubMed search strategy to identify all hypertension guidelines published in the United States between 1977 and 2019. We reviewed all titles to identify the most updated versions focused on nonpregnant adults with hypertension. We extracted instances where guidelines referred to social determinants of health (SDH) or social care activities. The primary outcome was how guidelines covered social care activities, defined using a framework adapted from the National Academies of Sciences, Engineering, and Medicine (NASEM).

RESULTS

Search terms yielded 126 guidelines. Thirty-six guidelines met the inclusion criteria. Of those, 72% (26/36) recommended social care activities as part of hypertension management; 58% recommended clinicians change clinical practice based on social risk information. These recommendations often lacked specific guidance around how to directly address social risk factors or reduce the impact of these risks on hypertension management. When guidelines referred to specific social factors, patient financial security was the most common. Over time, hypertension guidelines have included more references to SDH.

CONCLUSION

Information about SDH is included in many hypertension guidelines, but few guidelines provide clear guidance for clinicians or health systems on how to identify and address social risk factors in the context of care delivery.

Socioeconomic status affects achievement of blood pressure target in hypertension: contemporary results from the Swedish primary care cardiovascular database

OBJECTIVE

To assess the relation between socioeconomic status and achievement of target blood pressure in hypertension.

DESIGN

Retrospective longitudinal cohort study between 2001 and 2014.

SETTING

Primary health care in Skaraborg, Sweden.

SUBJECTS

48,254 patients all older than 30 years, and 53.3% women, with diagnosed hypertension.

MAIN OUTCOME MEASURES

Proportion of patients who achieved a blood pressure target <140/90 mmHg in relation to the country of birth, personal disposable income, and educational level.

RESULTS

Patients had a lower likelihood of achieving the blood pressure target if they were born in a Nordic country outside Sweden [risk ratio 0.92; 95% confidence interval (CI) 0.88-0.97], or born in Europe outside the Nordic countries (risk ratio 0.87; 95% CI 0.82-0.92), compared to those born in Sweden. Patients in the lowest income quantile had a lower likelihood to achieve blood pressure target, as compared to the highest quantile (risk ratio 0.93; 95% CI 0.90-0.96). Educational level was not associated with outcome. Women but not men in the lowest income quantile were less likely to achieve the blood pressure target. There was no sex difference in achieved blood pressure target with respect to the country of birth or educational level.

CONCLUSION

In this real-world population of primary care patients with hypertension in Sweden, being born in a foreign European country and having a lower income were factors associated with poorer blood pressure control.KEY POINTSThe association between socioeconomic status and achieving blood pressure targets in hypertension has been ambiguous.•In this study of 48,254 patients with hypertension, lower income was associated with a reduced likelihood to achieve blood pressure control.•Being born in a foreign European country is associated with a lower likelihood to achieve blood pressure control.•We found no association between educational level and achieved blood pressure control.

Gender heterogeneity in self-reported hypertension

We investigate the gender gap in hypertension misreporting using the French Constances cohort. We show that false negative reporting of hypertension is more frequent among men than among women, even after conditioning on a series of individual characteristics. As a second step, we investigate the causes of the gender gap in hypertension misreporting. We show that women go to the doctor more often than men do and that they have better knowledge of their family medical history. Once these differences are taken into account, the gender gap in false negative reporting of hypertension is reversed. This suggests that information acquisition and healthcare utilisation are crucial ingredients in fighting undiagnosed male hypertension.

National Trends in Racial and Ethnic Disparities in Antihypertensive Medication Use and Blood Pressure Control Among Adults With Hypertension, 2011-2018

Poor hypertension awareness and underuse of guideline-recommended medications are critical factors contributing to poor hypertension control. Using data from 8095 hypertensive people aged ≥18 years from the National Health and Nutrition Examination Survey (2011-2018), we examined recent trends in racial and ethnic differences in awareness and antihypertensive medication use, and their association with racial and ethnic differences in hypertension control. Between 2011 and 2018, age-adjusted hypertension awareness declined for Black, Hispanic, and White individuals, but the 3 outcomes increased or did not change for Asian individuals. Compared with White individuals, Black individuals had a similar awareness (odds ratio, 1.20 [0.96-1.45]) and overall treatment rates (1.04 [0.84-1.25]), and received more intensive antihypertensive medication if treated (1.41 [1.27-1.56]), but had a lower control rate (0.72 [0.61-0.83]). Asian and Hispanic individuals had significantly lower awareness rates (0.69 [0.52-0.85] and 0.74 [0.59-0.89]), overall treatment rates (0.72 [0.57-0.88] and 0.69 [0.55-0.82]), received less intensive medication if treated (0.60 [0.50-0.72] and 0.86 [0.75-0.96]), and had lower control rates (0.66 [0.54-0.79] and 0.69 [0.57-0.81]). The racial and ethnic differences in awareness, treatment, and control persisted over the study period and were consistent across age, sex, and income strata. Lower awareness and treatment were significantly associated with lower control in Asian and Hispanic individuals (P<0.01 for all) but not in Black individuals. These findings highlight the need for interventions to improve awareness and treatment among Asian and Hispanic individuals, and more investigation into the downstream factors that may contribute to the poor hypertension control among Black individuals.

Motivation to move fast, motivation to wait and see: The association of prevention and promotion focus with clinicians' implementation of the JNC-7 hypertension treatment guidelines

Roughly half of the adults in the United States are diagnosed with hypertension (HTN). Unfortunately, less than one-third have their condition under control. Clinicians generally have positive regard for the use of HTN guidelines to achieve HTN treatment goals; however, actual uptake remains low. Factors underpinning clinician variation in practice are poorly understood. To understand the relationship between clinicians' personal motivation to complete goals and their uptake of the Joint National Commission's HTN guidelines. The authors used Regulatory Focus Theory (RFT, ie, prevention and promotion focus), an empirically supported motivational theory, as a guiding framework to examine the relationship. The authors hypothesized that clinicians with high prevention focus would report following guidelines more often and have shorter follow-up visit intervals for patients with uncontrolled blood pressure. Clinicians (n  = 27) caring for adult patients diagnosed with HTN (n = 8605) in Federally Qualified Health Centers (n = 8). Clinicians' prevention and promotion focus scores and the number of days between visits for their patients with uncontrolled systolic blood pressure (SBP) (≥ 140 mm Hg). Consistent with RFT, 60% of prevention focused clinicians reported they always followed the monthly visit guideline for the patients with uncontrolled blood pressure, compared with 38% of promotion focused clinicians (p = .254). The unadjusted probability of returning for a follow-up visit within 30 days was greater among patients whose clinician was higher in prevention focus (p = .009), but there was no evidence at the 0.05 significance level in our adjusted model. These findings provide some limited evidence that RFT is a useful framework to understand clinician adherence to HTN treatment guidelines.

Selective Inhibition of the C-Domain of ACE (Angiotensin-Converting Enzyme) Combined With Inhibition of NEP (Neprilysin): A Potential New Therapy for Hypertension

[Figure: see text].

Projecting the long-term benefits of single pill combination therapy for patients with hypertension in five countries

OBJECTIVE

To project the 10-year clinical outcomes associated with single pill combination (SPC) therapies compared with multi-pill regimens for the management of hypertension in five countries (Italy, Russia, China, South Korea and Mexico).

METHODS

A microsimulation model was designed to project health outcomes between 2020 and 2030 for populations with hypertension managed according to four different treatment pathways: current treatment practices (CTP), single drug with dosage titration then sequential addition of other agents (start low and go slow, SLGS), free choice combination with multiple pills (FCC) and combination therapy in the form of a single pill (SPC). Model inputs were derived from the Global Burden of Disease 2017 dataset. Simulated outcomes of mortality, chronic kidney disease (CKD), stroke, ischemic heart disease (IHD), and disability-adjusted life years (DALYs) were estimated for 1,000,000 patients on each treatment pathway.

RESULTS

SPC therapy was projected to improve clinical outcomes over SLGS, FCC and CTP in all countries. SPC reduced mortality by 5.4% in Italy, 4.9% in Russia, 4.5% in China, 2.3% in South Korea and 3.6% in Mexico versus CTP and showed greater reductions in mortality than SLGS and FCC. The projected incidence of clinical events was reduced by 11.5% in Italy, 9.2% in Russia, 8.4% in China, 4.9% in South Korea and 6.7% in Mexico for SPC versus CTP.

CONCLUSIONS

Ten-year projections indicated that combination therapies (FCC and SPC) are likely to reduce the burden of hypertension compared with conventional management approaches, with SPC showing the greatest overall benefits due to improved adherence.

Age and sex disparities in hypertension control: The multi-ethnic study of atherosclerosis (MESA)

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Improving hypertension control will reduce heart disease and mortality.

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After age 65 years, women are less likely than men to have controlled hypertension.

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Sex differences in hypertension control widen with advancing age.

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Sex differences in hypertension control appear independent of obesity and diabetes.

Objective

Determine sex differences in hypertension control by age group in a diverse cohort of adults age 45–84 years at baseline followed for an average of 12 years.

Methods

The Multi-Ethnic Study of Atherosclerosis enrolled 3213 men and 3601 women from six communities in the U.S. during years 2000–2002 with follow-up exams completed approximately every two years. At each exam, resting blood pressure (BP) was measured in triplicate, and the last two values were averaged. Hypertension was defined as a BP ≥ 140/90 mmHg and/or use of antihypertensive medications. Hypertension control was defined as a BP < 140/90 mmHg and in separate analyses as < 130/90 mmHg. Generalized linear mixed effects models with a binomial function were used to calculate the odds of hypertension control by age group (45–64,75–74, 75+) at a given exam and by sex, while accounting for the intra-individual correlation, and adjustment for demographics, co-morbidities, smoking, alcohol use, education and site among participants with hypertension at any of the first five exams.

Results

At baseline, mean age was 64.1 (9.1 [SD]) years, 48.0% were men, and race/ethnicity was Non-Hispanic white in 34.1%, 10.1% Chinese, 35.1% Non-Hispanic Black and 20.7% Hispanic. Average SBP was lower while average DBP was higher among men vs. women at each exam. Adjusted odds ratios of hypertension control defined as BP < 140/90 mmHg among men vs. women was 0.89 (95% CI 0.67, 1.19) for age 45–64 years, 1.37 (95% CI 1.04, 1.81) for age 65–74 years and 2.08 (95% CI 1.43, 3.02) for age 75+ years. When defined as < 130/80 mmHg, adjusted odds of hypertension control among men vs. women was 0.60 (OR 0.60; 95% CI 0.46, 0.79) at age 45–64 years, 1.01 (OR 1.01; 95% CI 0.77, 1.31) at age 65–74 years and 1.71 (95% CI 1.19, 2.45) at age 75+ years.

Conclusion

Sex disparities in hypertension control increase with advancing age and are greatest among adults age 75+ years.

Cost-Effectiveness of Hypertension Treatment by Pharmacists in Black Barbershops

BACKGROUND

In LABBPS (Los Angeles Barbershop Blood Pressure Study), pharmacist-led hypertension care in Los Angeles County Black-owned barbershops significantly improved blood pressure control in non-Hispanic Black men with uncontrolled hypertension at baseline. In this analysis, 10-year health outcomes and health care costs of 1 year of the LABBPS intervention versus control are projected.

METHODS

A discrete event simulation of hypertension care processes projected blood pressure, medication-related adverse events, fatal and nonfatal cardiovascular disease events, and noncardiovascular disease death in LABBPS participants. Program costs, total direct health care costs (2019 US dollars), and quality-adjusted life-years (QALYs) were estimated for the LABBPS intervention and control arms from a health care sector perspective over a 10-year horizon. Future costs and QALYs were discounted 3% annually. High and intermediate cost-effectiveness thresholds were defined as <$50 000 and <$150 000 per QALY gained, respectively.

RESULTS

At 10 years, the intervention was projected to cost an average of $2356 (95% uncertainty interval, -$264 to $4611) more per participant than the control arm and gain 0.06 (95% uncertainty interval, 0.01-0.10) QALYs. The LABBPS intervention was highly cost-effective, with a mean cost of $42 717 per QALY gained (58% probability of being highly and 96% of being at least intermediately cost-effective). Exclusive use of generic drugs improved the cost-effectiveness to $17 162 per QALY gained. The LABBPS intervention would be only intermediately cost-effective if pharmacists were less likely to intensify antihypertensive medications when systolic blood pressure was ≥150 mm Hg or if pharmacist weekly time driving to barbershops increased.

CONCLUSIONS

Hypertension care delivered by clinical pharmacists in Black barbershops is a highly cost-effective way to improve blood pressure control in Black men.

Sex differences in health status, healthcare utilization, and costs among individuals with elevated blood pressure: the LARK study from Western Kenya

BACKGROUND

Elevated blood pressure is the leading risk factor for global mortality. While it is known that there exist differences between men and women with respect to socioeconomic status, self-reported health, and healthcare utilization, there are few published studies from Africa. This study therefore aims to characterize differences in self-reported health status, healthcare utilization, and costs between men and women with elevated blood pressure in Kenya.

METHODS

Data from 1447 participants enrolled in the LARK Hypertension study in western Kenya were analyzed. Latent class analysis based on five dependent variables was performed to describe patterns of healthcare utilization and costs in the study population. Regression analysis was then performed to describe the relationship between different demographics and each outcome.

RESULTS

Women in our study had higher rates of unemployment (28% vs 12%), were more likely to report lower monthly earnings (72% vs 51%), and had more outpatient visits (39% vs 28%) and pharmacy prescriptions (42% vs 30%). Women were also more likely to report lower quality-of-life and functional health status, including pain, mobility, self-care, and ability to perform usual activities. Three patterns of healthcare utilization were described: (1) individuals with low healthcare utilization, (2) individuals who utilized care and paid high out-of-pocket costs, and (3) individuals who utilized care but had lower out-of-pocket costs. Women and those with health insurance were more likely to be in the high-cost utilizer group.

CONCLUSIONS

Men and women with elevated blood pressure in Kenya have different health care utilization behaviors, cost and economic burdens, and self-perceived health status. Awareness of these sex differences can help inform targeted interventions in these populations.

Guideline-Driven Management of Hypertension: An Evidence-Based Update

Several important findings bearing on the prevention, detection, and management of hypertension have been reported since publication of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline. This review summarizes and places in context the results of relevant observational studies, randomized clinical trials, and meta-analyses published between January 2018 and March 2021. Topics covered include blood pressure measurement, patient evaluation for secondary hypertension, cardiovascular disease risk assessment and blood pressure threshold for drug therapy, lifestyle and pharmacological management, treatment target blood pressure goal, management of hypertension in older adults, diabetes, chronic kidney disease, resistant hypertension, and optimization of care using patient, provider, and health system approaches. Presenting new information in each of these areas has the potential to increase hypertension awareness, treatment, and control which remain essential for the prevention of cardiovascular disease and mortality in the future.

Social Ecology of Hypertension Management Among Latinos Living in the U.S.-Mexico Border Region

INTRODUCTION

While a growing body of research examines individual factors affecting the prevalence and management of hypertension among Latinos, less is known about how socioecological factors operate to determine health and affect implementation of interventions in rural communities.

METHOD

We conducted eight focus groups to assess perceived risks and protective factors associated with managing hypertension among Latino adults and their family members living in two rural/frontier counties in the U.S.-Mexico border region. This analysis is part of a larger study, Corazon por la Vida (Heart for Life), which involved multiple data collection strategies to evaluate the effectiveness of a primary care and a promotora de salud intervention to manage hypertension.

RESULTS

Of the 49 focus group participants, 70% were female and 30% were male, 39% were Spanish-only speakers, and 84% had hypertension. Participants' ages ranged between 18 and 75 years, and 63% reported annual incomes below $30,000. Drawing from a social-ecological framework to analyze focus group data, four major themes and subthemes emerged as factors facilitating or inhibiting disease management: (1) individual (emotional burdens, coping mechanisms), (2) social relationships (family as a source of support, family as a source of stress), (3) health system (trust/mistrust, patient-provider communication), and (4) environment (lack of access to safe exercise environment, lack of affordable food).

CONCLUSION

Our findings are relevant to public health practitioners, researchers, and policymakers seeking to shift from individual level or single interventions aimed at improving treatment-modality adherence to multilevel or multiple interventions for rural Latino communities.

Interleukin 17A: Key Player in the Pathogenesis of Hypertension and a Potential Therapeutic Target

PURPOSE OF REVIEW

To summarize key advances in our understanding of the role of interleukin 17A (IL-17A) in the pathogenesis of hypertension and highlight important areas for future research and clinical translation.

RECENT FINDINGS

While T helper 17 (Th17) cells are major producers of IL-17A, there are several additional innate and adaptive immune cell sources including gamma-delta T cells, innate lymphoid cells, and natural killer cells. IL-17A promotes an increase in blood pressure through multiple mechanisms including inhibiting endothelial nitric oxide production, increasing reactive oxygen species formation, promoting vascular fibrosis, and enhancing renal sodium retention and glomerular injury. IL-17A production from Th17 cells is increased by high salt conditions in vitro and in vivo. There is also emerging data linking salt, the gut microbiome, and intestinal T cell IL-17A production. Novel therapeutics targeting IL-17A signaling are approved for the treatment of autoimmune diseases and show promise in both animal models of hypertension and human studies. Hypertensive stimuli enhance IL-17A production. IL-17A is a key mediator of renal and vascular dysfunction in hypertensive mouse models and correlates with hypertension in humans. Large randomized clinical trials are needed to determine whether targeting IL-17A might be an effective adjunct treatment for hypertension and its associated end-organ dysfunction.