After years of improvement, the number of Americans whose blood pressure (BP) is under control is declining, suggest two new analyses of data from the National Health and Nutrition Examination Survey (NHANES).
One analysis, presented at the American Heart Association's (AHA's) virtual Hypertension 2020 meeting, found that Americans with adequate BP control (defined as <140/90 mmHg) dropped by 11% between 2013–2014 and 2017–2018.
"We cannot assume improvement in blood pressure management will continue, even after 35 years of success," lead author Brent M. Egan, MD, professor, University of South Carolina School of Medicine, Greenville, South Carolina, said in a news release.
A similar pattern was observed in a separate report that was based on data from more than 18,000 NHANES participants with hypertension. That analysis showed a substantial decline in BP control from about 54% in 2013–2014 to roughly 44% in 2017–2018, despite encouraging increases in BP control from 1999–2000 to 2013–2014.
People who had visited a healthcare provider within the past year were six times as likely to have controlled BP compared to those who had not.
"What we found was startling and concerning," lead author Paul Muntner, PhD, professor of epidemiology and associate dean for research, School of Public Health, University of Alabama at Birmingham, told Medscape Medical News.
"We found that the strongest predictor of uncontrolled BP was not going to the doctor, which is especially relevant during this time of COVID-19, when so many people are not going to the doctor for their follow-up visits because they are afraid of being exposed to people who might be infected," he said.
This study was published online September 9 in JAMA.
Reversing Years of Progress
In 2014, the eighth Joint National Committee hypertension guideline (JNC8) raised the BP goal to <150/90 mmHg for adults aged ≥60 years who did not have diabetes; but in 2017, the American College of Cardiology and American Heart Association (AHA/ACC) released a guideline that lowered the BP target to <130/90 mmHg for all adults.
Egan and colleagues found that, prior to the JNC8 guideline, BP control among NHANES participants rose from 32.2% in 1999–2000, peaked at 54.5% in 2013–2014, then fell to 48.0% in 2015–2016. It declined further to 43.4% in 2017–2018.
"Despite the 2017 BP goal of <130/<90 in all adults, control of <140/<90 continued to fall in 2017–2018," the authors report. There was an 11.1% decline from 2013–2014 (P < .001).
The number of adults aged 40 to 59 years with successfully treated BP declined by almost 10% between 2009–2012 and 2015–2018 (56.3% vs 46.6%). Among adults aged ≥60 years, it declined by 6% (from 53.6% to 47.9%).
Systolic blood pressure (SBP) rose 3–4 mmHg in all age groups (P < .01).
The decline in BP control seen in adults aged ≥60 years reflected lower treatment efficiency, whereas the decline in BP control in adults aged 40–59 years reflected less awareness and treatment, the authors note.
"Thus, declining control was not fully explained by BP targets for adults ≥60 years and subsequent controversy," they state.
"Worrisome" Findings
In a separate report by Muntner and colleagues that was published in JAMA, researchers analyzed cross-sectional NHANES data beginning in 1999–2000 and ending in 2017–2018.
In particular, they analyzed data on 18,262 participants (aged ≥18 years) who had hypertension (defined as BP ≥140/90 mmHg or use of antihypertensive medication) from among the total number of participants included in the NHANES analysis (N = 51,761 participants; mean age, 48 years; 50.1% female).
Among participants, 43.2% were non-Hispanic White adults, 26.1% were Hispanic adults, 21.6% were non-Hispanic Black adults, and 5.3% were non-Hispanic Asian adults.
From among the 18,262 participants with hypertension, the age-adjusted estimated proportion of patients with controlled BP increased between 1999–2000 and 2007–2008 (P < .001), continuing to increase between 2007–2008 and 2013–2014 (P < .14), but then declined during the period 2017–2018 (P < .003).
| Period | Participants with BP control (%) |
|---|---|
| 1999 – 2000 | 31.8 |
| 2007 – 2008 | 48.5 |
| 2013 – 2014 | 53.8 |
| 2017 – 2018 | 43.6 |
Compared with adults aged 18 to 44 years, controlled BP was more likely among individuals aged 45 to 64 years (49.7% vs 36.7%) and less likely among those aged ≥75 years (37.3% vs 36.7%).
There was a dramatic difference in BP control between people who had a usual healthcare facility compared to those who did not (48.4% vs 26.5%) and between those who had vs those who had not visited a healthcare provider in the past year (49.1% vs 8.0%).
"This is a little worrisome, and our findings reinforce the message that it is important to go to the doctor and get BP checked, and if it is high, the patient can be started on medication or can have the dose adjusted," Muntner commented.
Racial Disparities
Non-Hispanic Black adults were less likely to have controlled BP compared to non-Hispanic White adults. Individuals without health insurance were also less likely to have successfully controlled BP.
Similar to the findings of Egan and colleagues, awareness of hypertension increased between 1999–2000 and 2013–2014 (from 69.9% to 84.7%), but then declined to 77.0% in 2017–2018.
In 2017–2018, awareness of having hypertension was greater among non-Hispanic Black participants compared to non-Hispanic White, Asian, and Hispanic participants, but rates of BP control were lower.
"There have been good public health campaigns to raise awareness of hypertension among African Americans, and they are equally likely to be treated, but rates of BP control are a little lower," Muntner observed.
"I think it comes down to making sure everyone has access [to care], reducing disparities, having pharmacies or mail order pharmacies where everyone can get the right medications that are effective in lowering BP," he added.
Addressing Disparities
Commenting on both studies for Medscape Medical News, Robert M. Carey, MD, professor of medicine, University of Virginia, Charlottesville, Virginia, said, "Unfortunately, the recent increase in adults with BP out of control likely reflects the 2014 recommendation to relax control. In 2017, however, the importance of tight blood pressure control was reaffirmed and the goal blood pressure reduced by the 2017 ACC/AHA clinical practice guideline."
Carey was co-chair of the writing committee for the 2017 ACC/AHA guideline and was not involved in either study. He noted that the findings do not "reflect changes in blood pressure control after the 2017 guideline was published and disseminated to the clinical practice community, and we can anticipate improvement in control as a result of the recommendations in this guideline."
Paul Whelton, MB, MD, Show Chwan Chair in Global Public Health, Department of Epidemiology Tulane University School of Public Health and Tropical Medicine Tulane University of Medicine, New Orleans, Louisiana, agreed. In recommending higher levels of BP control, he said, the JNC8 report perhaps "put some confusion out there that may have said to people, 'You can back off, you don't have to be so strict' " with BP control, he told Medscape Medical News.
Whelton was chair of the writing committee of the 2017 ACC/AHA guideline and was not involved in either study. He emphasized that lifestyle improvement "should always be the core management strategy for prevention and treatment of high blood pressure, to which drugs should be added in certain settings."
In an editorial that accompanied the report in JAMA, Gregory Curfman, MD, and colleagues suggest that it "will be crucial to repeat the analyses of Muntner et al in another 5 years to determine whether progress has been achieved, with direction provided by the 2017 US and 2018 European guidelines."
A second editorial in JAMA, written by Griffin Rodgers, MD, and Gary Gibbons, MD, of the National Institutes of Health, noted that non-Hispanic Black adults had poorer BP control than non-Hispanic White adults.
"If the US is committed to changing the trend line of health disparities in obesity and hypertension, it is critical to acknowledge the important contributions of systemic racism and the social determinants of health in the context of the current COVID-19 crisis," they write.
In a statement jointly issued by the American Medical Association (AMA) and the AHA, Susan R. Bailey, MD, president of the AMA, and Mitchell S. V. Elkind, MD, president of the AHA, said that the study by Muntner and colleagues "reinforces the need for all healthcare providers and their patients to prioritize blood pressure control, especially now, as cardiovascular disease places people at greater risk for adverse outcomes associated with COVID-19."
The AMA has developed a framework for improving BP control and provides online resources to make it easier for clinicians to access the latest evidence-based guidance for the management of patients with hypertension. It is part of the AMA's and the AHA's joint Target: BP initiative.
In addition, the AMA and AHA teamed up with a group of national healthcare organizations and ESSENCE on the Release the Pressure campaign to advocate for improved heart health among Black women.
The study authors have received support from the National Heart, Lung, and Blood Institute. Muntner has received grant funding and consulting fees from Amgen, Inc. The original article lists the other authors' relevant financial relationships. Carey, Whelton, Curfman and coauthors, Rogers, and Gibbons have disclosed no such financial relationships.
Hypertension Scientific Sessions 2020 Virtual Meeting: Presentation MP33, Session MP07.
JAMA. Published online September 9, 2020. Full text; Curfman et al, Editorial; Rogers et al, Editorial
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