Blood Pressure Control Among US Adults, 2009 to 2012 Through 2017 to 2020

Gender and Sex-Based Differences in Hypertension Risk Factors Among Non-Hispanic Asian Adults in the United States

INTRODUCTION

The prevalence of hypertension (HTN) is rising at an accelerated rate, and it remains the primary factor contributing to cardiovascular illnesses. Sex can serve as an influencing factor, leading to variations in the factors affecting HTN.

OBJECTIVE

This study aimed to investigate gender and sex differences in the prevalence of HTN and explore the associations between HTN and 4 categories of risk factors: demographics, habits or lifestyle, body measurement, and laboratory blood results among non-Hispanic Asians in the United States.

METHODS

This secondary analysis included non-Hispanic Asian adults aged 18 years or older from the 2017 to 2018 National Health and Nutrition Examination Surveys.

RESULTS

Among the 815 participants, 35% of men (140 of 399) and 37% (154 of 416) of women had HTN ( P = .610). The mean age for men is 46.03 ± 16.9 years, whereas the mean age for women is 49.24 ± 16.8 years. After regression analysis, advancing age, increased body mass index, and increased serum uric acid were significant predictors of HTN in both sexes. However, men developed HTN earlier compared with women. Marital status and increased fasting glucose were only significant in men. Compared with their never-married counterparts, men who were currently married or living with a partner had lower odds of having HTN (odds ratio, 0.28; P = .034).

CONCLUSIONS

There was no significant difference in the prevalence of HTN between the sexes. Age, body mass index, and serum uric acid were significant risk factors in both men and women. Meanwhile, marital status and fasting glucose were only significant in men.

Cuffless Blood Pressure Measurement Devices-International Perspectives on Accuracy and Clinical Use: A Narrative Review

Importance

Hypertension is a primary modifiable risk factor for cardiovascular death and disability. Accurate blood pressure (BP) measurement is essential for the diagnosis and treatment of hypertension. Conventional BP measurement with cuff devices is recommended but difficult for patients to perform due to inconvenience, discomfort, and challenges with appropriate cuff sizing and measurement protocols. The emergence of cuffless BP devices provides an opportunity to address many of these problems, including inconvenience, patient comfort, positional requirements, and continuous measurement.

Observations

Cuffless BP measurement devices are appealing to patients and clinicians, but validation of these technologies is essential before they can be deployed for clinical use. Key issues that remain include accuracy with risk of undertreatment or overtreatment, equitable access for low- and middle-income countries and minoritized populations, data privacy concerns, and how the devices will be deployed in clinical practice.

Conclusions

Clinicians and patients should only use validated BP cuff devices until cuffless BP measurement devices are appropriately tested and validated.

Prevalence and Mortality Trends of Hypertension Subtypes Among US Adults: An Analysis of the National Health and Nutrition Examination Survey

BACKGROUND

Hypertension (HTN) has been demonstrated as one of the leading risk factors for development of cardiovascular disease (CVD) and CVD mortality.

METHODS

This study examines the prevalence and distribution of HTN subtypes (isolated diastolic hypertension [IDH], isolated systolic hypertension [ISH], and systolic-diastolic hypertension [SDH]) across age, sex, and race/ethnicity per the nationally representative National Health and Nutrition Examination Survey (NHANES) from 1999 to 2020 based on the updated 2017 ACC/AHA HTN definition. We further examined for associations of each subtype with CVD and all-cause mortality using Cox regression analysis.

RESULTS

Among US adults, the overall prevalence of HTN is 47.4%. Across increasing age, the prevalence of IDH decreased, ISH increased, and SDH increased and peaked in the 6th decade of life after which SDH prevalence decreased. By age 80, over 80% of persons with HTN demonstrated ISH. A subcohort from NHANES 1999-2008 with follow-up until 2018 showed that ISH and SDH were most strongly associated with increased risk for CVD (HR = 1.18, 95% CI, 1.01-1.38; HR = 1.31, 95% CI, 1.07-1.60, respectively) and all-cause mortality (HR = 1.17, 95% CI, 1.06-1.28; HR = 1.21, 95% CI, 1.08-1.37, respectively).

CONCLUSIONS

Our data demonstrate the continuing importance of HTN subtype transitions across age and their differences in predicting future CVD and total mortality.

Modifiable factors to achieve target blood pressure in hypertensive participants

The management of hypertension is one of the most important public health issues. Many patients with untreated hypertension in Japan require urgent treatment. This retrospective cohort study in Hiratsuka city aimed to evaluate the proportion of participants achieving target blood pressure and identify modifiable factors affecting the achievement. We retrospectively analyzed data from a merged database of claims, specific health checkup (SHC), and national health insurance data in Hiratsuka City, Japan, from June 2016 to March 2023. The study participants were adults aged 40-74 years without a history of hypertension treatment and with blood pressure ≥140/90 mmHg at SHC. The primary outcome was the achievement of target blood pressure <140/90 mmHg at the next SHC. Furthermore, multivariable logistic regression was performed to explore factors influencing the achievement. Of 5428 participants, 43.6% were female. The median age was 69 years, and 58.4% (95% confidence interval 57.1-59.7) achieved target blood pressure <140/90 mmHg. Multivariable logistic regression results showed that achievement of target blood pressure was associated with younger age (50-69 years), mild hypertension (grade I), no hypertension at the previous SHC, no record of SHC in the previous year, and willingness to improve lifestyle. One-third of people reported that their hypertension at SHCs failed to achieve target blood pressure. For community-level hypertension management, people who have the influencing factors must be educated by public health nurses, which might be effective for lifestyle improvement. Additionally, the elderly and people with persistent hypertension or severe hypertension should seek medical advice.

Home Blood Pressure Monitoring

The diagnosis and management of hypertension have been based primarily on blood pressure (BP) measurement in the office setting. Higher out-of-office BP is associated with an increased risk of cardiovascular disease, independent of office BP. Home BP monitoring (HBPM) consists of the measurement of BP by a person outside of the office at home and is a validated approach for out-of-office BP measurement. HBPM provides valuable data for diagnosing and managing hypertension. Another validated approach, ambulatory BP monitoring (ABPM), has been considered to be the reference standard of out-of-office BP measurement. However, HBPM offers potential advantages over ABPM including being a better measure of basal BP, wide availability to patients and clinicians, evidence supporting its use for better office BP control, and demonstrated efficacy when using telemonitoring along with HBPM. This state-of-the-art review examines the current state of HBPM and includes discussion of recent hypertension guidelines on HBPM, advantages of using telemonitoring with HBPM, use of self-titration of antihypertensive medication with HBPM, validation of HBPM devices, best practices for conducting HBPM in the clinical setting, how HBPM can be used as an implementation strategy approach to improve BP control in the United States, health equity in HBPM use, and HBPM use among specific populations. Finally, research gaps and future directions of HBPM are reviewed.

Temporal Patterns in Blood Pressure Management Before and After Recent Clinical Trials and Guideline Recommendations

We aimed to study trends in achieving blood pressure (BP) goals, antihypertensive prescribing, and whether clinician behavior changed in temporal relationship to the JNC-8 (October 1, 2014), SPRINT results (November 9, 2015), and the 2017 hypertension guideline (November 13, 2017). We used the National Cardiovascular Data Registry (NCDR) Practice INNovation and CLinical Excellence (PINNACLE) registry and studied patients with hypertension aged >65 years (n = 3 678 774). We found a statistically significant, albeit small and minimally relevant, increase from 2013 to 2018 in achieving office-based SBP.

Insulin resistance and periodontitis: Mediation by blood pressure

AIM

This study investigated the association between the triglyceride-glucose (TyG) index, a surrogate marker of insulin resistance, and moderate/severe periodontitis and the role of blood pressure as a mediator in this association. A second aim was to assess the role of cardiometabolic conditions such as obesity, hypertension, and dyslipidemia as potential effect modifiers.

METHODS

Data from 5733 US adults aged 30-64 years and with complete periodontal examination were analyzed (NHANES 2011-2014). Participants were classified as having moderate/severe periodontitis or mild/no periodontitis according to the CDC/AAP criteria as the outcome. The exposure was the TyG index, while both systolic (SBP), and diastolic (DBP) blood pressure were tested as mediators using parametric g-formula. Analyses were adjusted for relevant confounders, namely, age, sex, ethnicity, poverty-income ratio, and smoking, using inverse probability treatment weighting. Obesity status (based on a body mass index ≥30 kg/m2), self-report of hypertension and dyslipidemia (calculated based on the thresholds provided by National Cholesterol Education Program-Adult Treatment Panel-III) were tested as effect modifiers.

RESULTS

The findings showed the TyG index to be associated with increased odds of moderate/severe periodontitis [odds ratio (OR), 95% confidence interval (CI) = 1.17 (1.11-1.23)], with 50% of the total effect mediated by SBP. Stratified analysis showed a stronger association in individuals with obesity, hypertension, and dyslipidemia compared to those without these conditions. However, in those taking anti-hypertensive medications, the association was partially mitigated. Sensitivity analysis using imputed data showed consistent results.

CONCLUSION

The TyG index was associated with increased odds of moderate/severe periodontitis, especially in individuals with obesity, hypertension, and dyslipidemia. SBP levels partially mediated this association.

Blood pressure control among Veterans with high cardiovascular disease risk

Objective

Blood pressure (BP) control reduces risk of cardiovascular disease (CVD), the major cause of disability and mortality among the nine million U.S. Veterans receiving care in Veterans Affairs (VA) medical centers. This study examined BP control, defined as a systolic BP < 130 mmHg and diastolic BP < 80 mmHg, among U.S. Veterans with hypertension at high risk for primary or secondary CVD events.

Methods

We utilized data from the VA Informatics and Computing Infrastructure Corporate Data Warehouse on primary care visits within the eight Great Lakes VA medical centers for Veterans with at least one visit between January 1, 2019, and February 28, 2020 and a documented visit within the 12 months prior to study initiation date. Analyses focused on Veterans with diagnosed hypertension and one or more of the following: age ≥65 years, and/or diagnosis of CVD, diabetes mellitus (DM) or chronic kidney disease (CKD). BP control was based on the last recorded BP measurement during the study period.

Results

The mean age of 83,633 Veterans with hypertension was 71.6 years (10.4) years, 96.4 % were male and race/ethnicity was reported as non-Hispanic White in 74.8 %, non-Hispanic Black or African American in 18.4 %, non-Hispanic Asian in 0.3 %, Alaskan Indian or Pacific Islander in 2.6 % and Hispanic in 2.5 %. Mean SBP and DBP based on vital signs at the last clinic visit were 130.8 mmHg (standard deviation [SD] 11.6) and 73.7 mmHg (SD 8.8), respectively. Overall, BP was controlled to < 130/80 mmHg in 38.7 % (95 % Confidence Interval [CI] 38.4, 39.1) and <140/90 mmHg in 76.9 % (95 % CI 76.7, 77.2). Among subgroups, BP was controlled to < 130/80 mmHg in 39.8 % (95 % CI 39.4, 40.2) of the Veterans aged ≥65 years, 45.3 % (95 % CI 44.7, 45.9) with CVD, 39.8 % (95 % CI 39.2, 40.3) with DM, 42.8 % (95 % CI 41.9, 43.6) with CKD and 47.1 % (95 % CI 45.5, 48.6) with CVD +DM +CKD. In contrast, BP control <140/90 mmHg was noted in over 75 % of Veterans within all subgroups.

Conclusion

In this group of Veterans with hypertension and high risk for CVD events, less than half had BP controlled to < 130/80 mmHg. Future studies should investigate strategies to improve BP control such as team-based care with home BP monitoring, education of clinicians on hypertension management, and increased utilization of automated office BP.

Intensive Home Blood Pressure Lowering in Patients With Advanced CKD

RATIONALE & OBJECTIVE

Optimal blood pressure (BP) targets in advanced chronic kidney disease (CKD) are controversial. More intensive BP lowering in the setting of advanced CKD is thought to be associated with risk of acute kidney injury, hyperkalemia, and end-stage kidney disease. We conducted a pilot trial of intensive BP control to determine if lower home systolic BP (SBP) targets can be safely achieved for patients with CKD through titration of BP medications using in-home measured BP.

STUDY DESIGN

Nonblinded randomized controlled trial.

SETTING & PARTICIPANTS

108 patients with advanced CKD (estimated glomerular filtration rate≤30mL/min/1.73m2) and hypertension.

INTERVENTIONS

Participants were randomized either to a target SBP goal of<120mm Hg (N=66) or a less intensive SBP goal (N=42). Antihypertensive medications were titrated to achieve the target home SBP range in the first 4 months of the study and maintained until the end of the study. Home BP was measured using a wireless Bluetooth-enabled monitor that transmitted readings to providers in real-time.

OUTCOME

The primary efficacy outcome was the difference in achieved clinic SBP between the 2 study arms from months 4-12. Safety outcomes included hyperkalemia, a composite outcome of falls or syncope, and onset of need for dialysis or kidney transplantation.

RESULTS

The mean clinic SBP at month 12 was 124.7mm Hg in the intensive SBP group versus 138.2mm Hg in the less intensive SBP group. Averaged over months 4-12, the achieved mean clinic SBP in the intensive SBP arm was 11.7mm Hg ([95% CI, 7.5-16], P<0.001), lower than the mean SBP achieved in the less intensive SBP arm. Primary safety outcomes were not statistically significantly different between the 2 arms (all P>0.05).

LIMITATIONS

Small sample size, which may have limited our ability to detect clinically significant differences in rates of adverse outcomes, and single-center design.

CONCLUSIONS

A clinic SBP goal of<120mm Hg is feasible to achieve with the help of real-time home BP monitoring and appears to be safe in this study population with advanced CKD. Larger trials to determine optimal BP targets in advanced CKD and the risks and benefits associated with more intensive BP control are warranted.

FUNDING

Grant from an educational institution (UCSF Research Allocation Program award).

TRIAL REGISTRATION

Registered at ClinicalTrials.gov with study number NCT02975505.

PLAIN-LANGUAGE SUMMARY

We conducted a pilot trial to test the feasibility of lowering blood pressure (BP) intensively through the use of home BP monitoring in patients with low kidney function. We found that home BP monitoring used to guide antihypertensive medication dosing permitted better BP control for patients with chronic kidney disease and did not appear to be associated with major adverse events.

Hypertension Prevention and Healthy Life Expectancy in Black Adults: The Jackson Heart Study

BACKGROUND

The impact of preventing hypertension and maintaining normal blood pressure (BP) on life expectancy and healthy life expectancy (HLE) among Black adults, who are disproportionately affected by hypertension, has not been quantified.

METHODS

We used a discrete event simulation to estimate life expectancy and HLE among a cohort of Black adults from the Jackson Heart Study (n=4933) from age 20 to 100 years or until death. We modeled preventing hypertension as having BP <130/80 mm Hg and maintaining normal BP as having BP <120/80 mm Hg across the lifespan. In the primary analysis, we assumed that lowering BP decreased the risk of cardiovascular disease events, resulting in life expectancy and HLE gains. In a secondary analysis, we assumed that preventing hypertension and maintaining normal BP directly reduced both cardiovascular disease and mortality risk.

RESULTS

At age 20 years, the projected average life expectancy was age 80.8 (95% uncertainty interval [UI], 80.6-81.1) years, and HLE was 70.5 (95% UI, 70.3-70.7) healthy life years. In the primary analysis, preventing hypertension and maintaining normal BP added 0.9 (95% UI, 0.8-1.1) and 1.1 (95% UI, 0.9-1.3) years to life expectancy, respectively, and 2.7 (95% UI, 2.6-2.9) and 2.9 (95% UI, 2.7-3.1) healthy life years to HLE, respectively. In the secondary analysis, preventing hypertension and maintaining normal BP added 4.5 (95% UI, 4.3-4.6) and 4.6 (95% UI, 4.4-4.8) years to life expectancy, respectively, and 5.7 (95% UI, 5.6-5.8) and 5.9 (95% UI, 5.7-6.0) healthy life years to HLE, respectively.

CONCLUSIONS

Preventing hypertension and maintaining normal BP were projected to increase life expectancy and HLE among Black adults.

Individualized Net Benefit of Intensive Blood Pressure Lowering Among Community-Dwelling Older Adults in SPRINT

BACKGROUND

The optimal blood pressure (BP) target for older adults with hypertension remains controversial, particularly among those with advanced age, frailty, or polypharmacy. This study estimated the individualized net benefit of intensive BP lowering among community-dwelling older adults in the Systolic Blood Pressure Intervention Trial (SPRINT).

METHODS

Among 5143 SPRINT participants age ≥ 65 years, Cox models were internally validated to predict an absolute difference in risk between treating to a systolic BP target of < 120 versus < 140 mm Hg for all-cause death, cardiovascular outcomes, cognitive outcomes, and serious adverse events. Treatment effects were combined using simulated preference weights into individualized net benefits, representing the weighted sum of risk differences across outcomes. Net benefits were compared across categories of age (65-74 vs. ≥ 75 years), SPRINT-derived frailty status (fit, less fit, and frail), and polypharmacy (≥ 5 medications).

RESULTS

When simulating preferences for participants who view the benefits of BP lowering (reduction in death, cardiovascular events, and cognitive impairment) as much more important than treatment-related harms (e.g., acute kidney injury and syncope), the median net benefit from intensive BP lowering was 4 percentage points (IQR: 3-6), and 100% had a positive net benefit favoring intensive BP lowering. When simulating benefits and harms to have similar, intermediate importance, the median net benefit was 1 percentage point (IQR: 0-2), and 85% had a positive net benefit. Participants with advanced age and frailty had greater net benefits from intensive BP lowering despite experiencing more harm in both simulations, and those with polypharmacy had greater net benefits when benefits were viewed as much more important than harms (p < 0.001 for all comparisons).

CONCLUSIONS

Among community-dwelling older adults with hypertension in SPRINT, almost all participants had a net benefit that favored a systolic BP target of < 120 mm Hg, but the magnitude of net benefit varied according to estimated risks and simulated preferences.

Long-Term Effect of Intensive vs Standard Blood Pressure Control on Mild Cognitive Impairment and Probable Dementia in SPRINT

BACKGROUND AND OBJECTIVES

The Systolic Blood Pressure Intervention Trial suggested that intensive lowering of systolic blood pressure (SBP) decreases the risk of developing dementia. However, an insufficient number of probable dementia cases stemming from the trial's early termination made results inconclusive. The goal of this study was to estimate the effect of intensive vs standard SBP lowering on the longer term incidence of cognitive impairment leveraging extended follow-up for cognitive status.

METHODS

This is a prespecified secondary analysis of a randomized clinical trial. Between 2010 and 2013, patients aged 50 years and older with hypertension and increased cardiovascular risk excluding those with diabetes mellitus or history of stroke were recruited from 102 clinics in the United States and Puerto Rico. Participants were randomized to a SBP goal of <120 mm Hg (intensive treatment) or <140 mm Hg (standard treatment) and received treatment for 3.3 years. In-person cognitive assessment follow-up occurred through July 2018. Continued ascertainment of cognitive status by telephone began in December 2019 for participants who had not withdrawn consent or been previously adjudicated with probable dementia, but provided consent for future research. Data were analyzed using survival analyses.

RESULTS

Of 9,361 randomized participants, 7,221 (77%) were eligible to be re-contacted. Cognitive status of 4,232 (59%) was ascertained (mean age 67 years, 36% female). We accrued a total of 216 new cases of probable dementia, less than our target of 326. Over a median follow-up of 7 years, 248 participants of the intensive treatment group (8.5 per 1,000 person-years) were adjudicated with probable dementia, compared with 293 participants (10.2 per 1,000 person-years) in the standard treatment group (hazard ratio [HR], 0.86; 95% CI, 0.72-1.02). Consistent with earlier results from the trial, the rate of both mild cognitive impairment (MCI; HR, 0.87 95% CI, 0.76-1.00) and a composite of MCI or probable dementia was lower with intensive treatment (HR, 0.89; 95% CI, 0.79, 0.99).

DISCUSSION

Among ambulatory adults with hypertension and high cardiovascular risk, intensive treatment vs standard treatment of SBP for 3.3 years resulted in a lower risk of MCI and cognitive impairment including MCI or probable dementia, but not for probable dementia alone.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that intensively reducing SBP (target <120 mm Hg) decreases the risk of cognitive impairment in individuals aged 50 years and older with hypertension.

CLINICAL TRIAL INFORMATION

Clinical trial number NCT01206062.

Cumulative Incidence of Mortality Associated with Cardiovascular-Kidney-Metabolic (CKM) Syndrome

Key Points

Background

It is imperative to critically evaluate the prognostic implications of cardiovascular–kidney–metabolic (CKM) syndrome staging to inform clinical practice. The primary aims of this study were to define the risk of mortality associated with each CKM syndrome stage and to determine the corresponding restricted mean survival time over a 15-year period.

Methods

This was a longitudinal study of 50,678 community-dwelling US adults aged 20 years and older with baseline data for CKM stage determination participating in the 1999–2018 National Health and Nutrition Examination Survey. CKM stages were defined according to the American Heart Association presidential advisory. Fifteen-year adjusted cumulative incidences of cardiovascular mortality were calculated for each stage from confounder-adjusted survival curves using the G-formula.

Results

Over a median 9.5-year follow-up, 2564 participants experienced cardiovascular death. The 15-year adjusted cumulative incidences of cardiovascular mortality were stage 0, 5.5% (95% confidence interval [CI], 1.8 to 9.3); stage 1, 5.7% (95% CI, 3.2 to 8.2); stage 2, 7.9% (95% CI, 6.8 to 9.1); stage 3, 8.7% (95% CI, 6.7 to 10.8); and stage 4, 15.2% (95% CI, 13.6 to 16.8). The absolute risk difference between CKM stage 4 and stage 0 at 15 years was 9.6% (95% CI, 5.6 to 13.6). The survival difference between CKM stage 0 and stage 4 at 15 years was 8.1 (95% CI, 8.0 to 8.2) months.

Conclusions

Our findings reveal a graded risk of cardiovascular mortality associated with higher CKM syndrome stage.

Caregiving and Hypertension in Younger Black Women: The Jackson Heart Study

BACKGROUND

Caregiving has been associated with high blood pressure in middle-aged and older women, but this relationship is understudied among younger Black women, a population at high risk for hypertension. We examined the associations of caregiving stress and caregiving for high-needs dependents with incident hypertension among reproductive-age women in the JHS (Jackson Heart Study), a cohort of community-dwelling Black adults.

METHODS

We included 453 participants, aged 21 to 44 years, with blood pressure <140/90 mm Hg, and not taking antihypertensive medication at baseline (2000-2004). Caregiving stress over the past 12 months was assessed via a single item in the global perceived stress scale. Caregiving for a high-needs dependent status was assessed via a question on hours per week spent caregiving for children (≤5 years or disabled) or older adults. Incident hypertension was defined as systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or self-report of taking antihypertensive medication at follow-up exams in 2005 to 2008 and 2009 to 2013.

RESULTS

Over a median follow-up of 7.4 years, 43.5% of participants developed hypertension. Participants with moderate/high versus no/low caregiving stress had a higher incidence of hypertension (51.7% versus 40.6%). Higher caregiving stress was associated with incident hypertension after adjustment for sociodemographic and clinical factors, health behaviors, and depressive symptoms (hazard ratio, 1.39 [95% CI, 1.01-1.94]). Being a caregiver for a high-needs dependent was not associated with incident hypertension (adjusted hazard ratio, 0.88 [95% CI, 0.64-1.21]).

CONCLUSIONS

Higher caregiving stress among reproductive-age Black women was associated with incident hypertension. Hypertension prevention approaches for this high-risk population may include caregiving stress management strategies.

Variation in Hypertension Control by Race and Ethnicity, and Geography in US Veterans

BACKGROUND

Hypertension control and related cardiovascular outcomes among Americans remain suboptimal, and differ by race, ethnicity, and geography. Healthcare access is one of multiple critical factors in hypertension control. Understanding the degree to which healthcare access, versus other factors, produce these outcomes can inform policies and interventions to improve cardiovascular outcomes and reduce disparities. Department of Veterans Affairs Healthcare System data provide a unique opportunity to understand residual racial and ethnic differences in hypertension control after accounting for healthcare access. Our objective was to describe pre-pandemic post-Affordable Care Act implementation hypertension control by geographic sector and race and ethnicity, and assess spatial clustering of hypertension control.

METHODS AND RESULTS

A secondary data analysis of hypertension control among US veterans (n=1 619 414) nationwide and in 4 US territories was conducted using electronic health record data. Age- and sex-adjusted regression models estimated overall and race- and ethnicity-specific rates by geographic sector. We created choropleth maps of hypertension control rates and assessed spatial autocorrelation. Hypertension control rates varied across sectors by race and ethnicity (range, 44.1%-97.5%); Black veterans, followed by American Indian or Alaska Native veterans, had the lowest mean control rates (72.5% and 75.4%, respectively). There was clustering of low hypertension control rates for Black veterans in the Pacific Northwest, Southwest, Missouri, Kansas, and Arkansas, and for American Indian or Alaska Native veterans in the West and Southwest.

CONCLUSIONS

Hypertension control rates varied geographically for veteran groups experiencing racial and ethnic disparities. Geographic areas with concentrations of low rates of hypertension control should be a focus for interventions to address racial and ethnic disparities.

Association of Questionnaire-Assessed Fall Risk With Uncontrolled Blood Pressure and Therapeutic Inertia Among Older Adults

Therapeutic inertia (TI), or failure to escalate or initiate BP lowering medications when BP is uncontrolled, increases with advancing age and may in part be due to perceived fall risk. This study examined the association of a fall risk assessment, based on patient response to three questions administered by trained staff, with uncontrolled BP (≥140/90 mmHg) during a clinic visit and with TI during clinic visits with uncontrolled BP among 13 893 patients age ≥ 65 years corresponding to 41 122 primary care visits. Separate generalized linear mixed effects models were used to examine the association of fall risk (low, moderate, and high) with uncontrolled BP and with TI at a clinic visit after adjustment for demographics, comorbidities, and total number of visits. Baseline mean age was 73.0 years (standard deviation [SD] 5.6), 43.3% were men and questionnaire-assessed fall risk severity was low in 73.6%, moderate in 14.3%, and high in 12.2%. Compared to low fall risk, the adjusted odds of uncontrolled BP during a clinic visit were 0.97 (95% CI: 0.89, 1.06) and 0.90 (95% CI: 0.82, 0.98) with moderate and high fall risk, respectively. In contrast, adjusted odds of TI during a clinic visit with BP ≥ 140/90 mmHg was 1.16 (95% CI: 1.01, 1.34) and 1.30 (95% CI: 1.11, 1.52) with moderate and high fall risk, respectively, compared to low fall risk. These findings suggest that perceived fall risk severity may be one of several factors that influence hypertension management in older adults.

Agreement between self-reported and objectively measured hypertension diagnosis and control: evidence from a nationally representative sample of community-dwelling middle-aged and older adults in China

BACKGROUND

As the population ages, hypertension has become the leading risk factor for cardiovascular diseases (CVDs) and premature deaths worldwide. Accurate monitoring of CVD risks and planning community-based public health interventions require reliable estimates of hypertension prevalence and management. While the validity of self-reporting in assessing hypertension prevalence has been debated, the concordance between self-reports and clinical measurements of hypertension control remains underexplored, particularly in large, community-based older populations. This study aims to examine the agreement between self-reported and objectively measured data on both hypertension diagnosis and control, as well as the associated factors, among community-dwelling middle-aged and older Chinese adults.

METHODS

Data from the China Health and Retirement Longitudinal Study were utilized, with household survey responses combined with biomedical data. Sensitivity, specificity, and kappa coefficients were used to assess the agreement between self-reported and objectively measured hypertension diagnosis in the general sample, and the agreement on hypertension control among individuals who reported having hypertension. Binary and multinomial logistic regression analyses were conducted to identify individual, household, and community-level factors associated with the agreement.

RESULTS

Self-reports exhibited substantial sensitivity, excellent specificity, and moderate agreement with objective measurements for hypertension diagnosis, while demonstrating fair sensitivity, excellent specificity, but low agreement for hypertension control. The odds of agreement on hypertension diagnosis were negatively associated with older age and heavy drinking, but positively related to marital status, higher education, chronic kidney disease, recent healthcare service utilization, and higher household economic levels. Meanwhile, the likelihood of agreement on hypertension control was negatively associated with older age, comorbid diabetes or cardiovascular disease, heavy drinking, BMI over 25, and antihypertensive medication adherence, but positively associated with recently healthcare service utilization.

CONCLUSIONS

Self-reporting underestimated hypertension prevalence but significantly overestimated the hypertension control rates. For middle-aged and older Chinese adults, individual-level factors including age, multimorbidity, behavioural risks, and healthcare-seeking behaviours were identified as significant predictors of agreement between self-reported and objectively measured hypertension data. Recognizing these factors is essential for improving the accuracy of chronic condition estimates and facilitating targeted chronic disease management programs for China's aging population and other developing countries with similar demographic and health challenges.

The burden of diseases, injuries, and risk factors by state in the USA, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides a comprehensive assessment of health and risk factor trends at global, regional, national, and subnational levels. This study aims to examine the burden of diseases, injuries, and risk factors in the USA and highlight the disparities in health outcomes across different states.

METHODS

GBD 2021 analysed trends in mortality, morbidity, and disability for 371 diseases and injuries and 88 risk factors in the USA between 1990 and 2021. We used several metrics to report sources of health and health loss related to specific diseases, injuries, and risk factors. GBD 2021 methods accounted for differences in data sources and biases. The analysis of levels and trends for causes and risk factors within the same computational framework enabled comparisons across states, years, age groups, and sex. GBD 2021 estimated years lived with disability (YLDs) and disability-adjusted life-years (DALYs; the sum of years of life lost to premature mortality and YLDs) for 371 diseases and injuries, years of life lost (YLLs) and mortality for 288 causes of death, and life expectancy and healthy life expectancy (HALE). We provided estimates for 88 risk factors in relation to 155 health outcomes for 631 risk-outcome pairs and produced risk-specific estimates of summary exposure value, relative health risk, population attributable fraction, and risk-attributable burden measured in DALYs and deaths. Estimates were produced by sex (male and female), age (25 age groups from birth to ≥95 years), and year (annually between 1990 and 2021). 95% uncertainty intervals (UIs) were generated for all final estimates as the 2·5th and 97·5th percentiles values of 500 draws (ie, 500 random samples from the estimate's distribution). Uncertainty was propagated at each step of the estimation process.

FINDINGS

We found disparities in health outcomes and risk factors across US states. Our analysis of GBD 2021 highlighted the relative decline in life expectancy and HALE compared with other countries, as well as the impact of COVID-19 during the first 2 years of the pandemic. We found a decline in the USA's ranking of life expectancy from 1990 to 2021: in 1990, the USA ranked 35th of 204 countries and territories for males and 19th for females, but dropped to 46th for males and 47th for females in 2021. When comparing life expectancy in the best-performing and worst-performing US states against all 203 other countries and territories (excluding the USA as a whole), Hawaii (the best-ranked state in 1990 and 2021) dropped from sixth-highest life expectancy in the world for males and fourth for females in 1990 to 28th for males and 22nd for females in 2021. The worst-ranked state in 2021 ranked 107th for males (Mississippi) and 99th for females (West Virginia). 14 US states lost life expectancy over the study period, with West Virginia experiencing the greatest loss (2·7 years between 1990 and 2021). HALE ranking declines were even greater; in 1990, the USA was ranked 42nd for males and 32nd for females but dropped to 69th for males and 76th for females in 2021. When comparing HALE in the best-performing and worst-performing US states against all 203 other countries and territories, Hawaii ranked 14th highest HALE for males and fifth for females in 1990, dropping to 39th for males and 34th for females in 2021. In 2021, West Virginia-the lowest-ranked state that year-ranked 141st for males and 137th for females. Nationally, age-standardised mortality rates declined between 1990 and 2021 for many leading causes of death, most notably for ischaemic heart disease (56·1% [95% UI 55·1-57·2] decline), lung cancer (41·9% [39·7-44·6]), and breast cancer (40·9% [38·7-43·7]). Over the same period, age-standardised mortality rates increased for other causes, particularly drug use disorders (878·0% [770·1-1015·5]), chronic kidney disease (158·3% [149·6-167·9]), and falls (89·7% [79·8-95·8]). We found substantial variation in mortality rates between states, with Hawaii having the lowest age-standardised mortality rate (433·2 per 100 000 [380·6-493·4]) in 2021 and Mississippi having the highest (867·5 per 100 000 [772·6-975·7]). Hawaii had the lowest age-standardised mortality rates throughout the study period, whereas Washington, DC, experienced the most improvement (a 40·7% decline [33·2-47·3]). Only six countries had age-standardised rates of YLDs higher than the USA in 2021: Afghanistan, Lesotho, Liberia, Mozambique, South Africa, and the Central African Republic, largely because the impact of musculoskeletal disorders, mental disorders, and substance use disorders on age-standardised disability rates in the USA is so large. At the state level, eight US states had higher age-standardised YLD rates than any country in the world: West Virginia, Kentucky, Oklahoma, Pennsylvania, New Mexico, Ohio, Tennessee, and Arizona. Low back pain was the leading cause of YLDs in the USA in 1990 and 2021, although the age-standardised rate declined by 7·9% (1·8-13·0) from 1990. Depressive disorders (56·0% increase [48·2-64·3]) and drug use disorders (287·6% [247·9-329·8]) were the second-leading and third-leading causes of age-standardised YLDs in 2021. For females, mental health disorders had the highest age-standardised YLD rate, with an increase of 59·8% (50·6-68·5) between 1990 and 2021. Hawaii had the lowest age-standardised rates of YLDs for all sexes combined (12 085·3 per 100 000 [9090·8-15 557·1]), whereas West Virginia had the highest (14 832·9 per 100 000 [11 226·9-18 882·5]). At the national level, the leading GBD Level 2 risk factors for death for all sexes combined in 2021 were high systolic blood pressure, high fasting plasma glucose, and tobacco use. From 1990 to 2021, the age-standardised mortality rates attributable to high systolic blood pressure decreased by 47·8% (43·4-52·5) and for tobacco use by 5·1% (48·3%-54·1%), but rates increased for high fasting plasma glucose by 9·3% (0·4-18·7). The burden attributable to risk factors varied by age and sex. For example, for ages 15-49 years, the leading risk factors for death were drug use, high alcohol use, and dietary risks. By comparison, for ages 50-69 years, tobacco was the leading risk factor for death, followed by dietary risks and high BMI.

INTERPRETATION

GBD 2021 provides valuable information for policy makers, health-care professionals, and researchers in the USA at the national and state levels to prioritise interventions, allocate resources effectively, and assess the effects of health policies and programmes. By addressing socioeconomic determinants, risk behaviours, environmental influences, and health disparities among minority populations, the USA can work towards improving health outcomes so that people can live longer and healthier lives.

FUNDING

Bill & Melinda Gates Foundation.

Long-term Monitoring of Blood Pressure in Older Adults: A Focus on Self-Measured Blood Pressure Monitoring

Hypertension is among the most common chronic conditions in older adults. Effective treatment exists, yet many older adults do not achieve recommended control of their blood pressure (BP). Self-measured blood pressure (SMBP) monitoring, in which patients check their BP at home, is one underutilized tool for improving hypertension control. Older adults may face unique challenges in using SMBP monitoring and therefore require unique solutions. An individualized approach to guiding older adults to use SMBP monitoring is preferred.

Use and Cost Patterns of Antihypertensive Medications in the United States From 1996 to 2021

BACKGROUND

Antihypertensive medication use patterns have likely been influenced by changing costs and accessibility over the past 3 decades. This study examines the relationships between patent exclusivity loss, medication costs, and national health policies on antihypertensive medication use.

METHODS

Using 1996 to 2021 Medical Expenditure Panel Survey data of US adults with hypertension taking at least 1 antihypertensive medication, we conducted a cross-sectional analysis. We explored the associations between patent exclusivity loss, per-pill costs, and Medicare Part D enactment on medication use over time, focusing on the most commonly used medications (lisinopril, amlodipine, losartan, hydrochlorothiazide, and metoprolol).

RESULTS

The unweighted sample comprised 50 095 US adults (mean age, 62 years; 53% female). The survey-weighted number of adults taking antihypertensive medications increased from 22 million (95% CIs, 20-23 million) to 55 million (95% CI, 51-60 million) between 1996 and 2021. Loss of patent exclusivity led to increased medication fills, notably for lisinopril, amlodipine, and losartan, which all exhibited within-class dominance. However, per-pill cost decreases coinciding with Medicare Part D did not increase the number of individuals treated or the use of specific antihypertensive medications or classes.

CONCLUSIONS

The increase in antihypertensive medication use over the past decades highlights the significant impact of loss of patent exclusivity on the uptake in the use of specific medications. These findings underscore the complexity of factors influencing medication use, beyond cost reductions alone, and suggest that policies need to consider multiple facets to effectively improve antihypertensive medication accessibility and utilization.

Optimal Antihypertensive Systolic Blood Pressure: A Systematic Review and Meta-Analysis

BACKGROUND

Systolic blood pressure (SBP) lowering reduces major cardiovascular disease (CVD) and all-cause mortality. However, the optimal target for SBP lowering remains controversial.

METHODS

We included trials with random allocation to an SBP <130 mm Hg treatment target and CVD as the primary outcome. Data were extracted from each study independently and in duplicate using a standardized protocol. Random-effects meta-analysis was used to obtain pooled hazard ratios (HRs) and 95% CIs for CVD and all-cause mortality comparing SBP <130 and ≥130 mm Hg treatment targets. A secondary analysis compared the same outcomes for randomization to an SBP target of <120 or <140 mm Hg.

RESULTS

Seven trials, including 72 138 participants, met the eligibility criteria. Compared with an SBP target of ≥130 mm Hg, an SBP target of <130 mm Hg significantly reduced major CVD (HR, 0.78 [95% CI, 0.70-0.87]) and all-cause mortality (HR, 0.89 [95% CI, 0.79-0.99]). Compared with an SBP target of <140 mm Hg, an intensive SBP target of <120 mm Hg significantly reduced major CVD (HR, 0.82 [95% CI, 0.74-0.91]), but all-cause mortality was marginally insignificant (HR, 0.85 [95% CI, 0.71-1.01]). Adverse events were significantly more likely in the intensive SBP target groups, but the absolute risks were low.

CONCLUSIONS

This study suggests targeting an SBP <130 mm Hg significantly reduces the risks of major CVD and all-cause mortality. The findings also support an SBP target of <120 mm Hg, based on a smaller number of trials.

REGISTRATION

URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42023490693.

Epidemiology of Hypertension in Older Adults

The exact definition of hypertension in older adults has changed over the decades, but the benefits of strict blood pressure control across the life span are being increasingly recognized by professional societies and guideline committees. This article discusses the prevalence of hypertension in older adults and describes the associations between hypertension and both clinical and nonclinical morbidity in that population.

Achieving Equity in Hypertension: A Review of Current Efforts by the American Heart Association

The purpose of this article is to summarize disparities in blood pressure (BP) by race in the United States, discuss evidence-based strategies to increase equity in BP, review recent American Heart Association BP equity initiatives, and highlight missed opportunities for achieving equity in hypertension. Over 122 million American adults have hypertension, with the highest prevalence among Black Americans. Racial disparities in hypertension and BP control in the United States are estimated to be the single largest contributor to the excess risk for cardiovascular disease among Black versus White adults. Worsening disparities in cardiovascular disease and life expectancy during the COVID-19 pandemic warrant an evaluation of the strategies and opportunities to increase equity in BP in the United States. Racial disparities in hypertension are largely driven by systemic inequities that limit access to quality education, economic opportunities, neighborhoods, and health care. To address these root causes, recent studies have evaluated evidence-based strategies, including community health workers, digital health interventions, team-based care, and mobile health care to enhance access to health education, screenings, and BP care in Black communities. In 2021, the American Heart Association made a $100 million pledge and 10 commitments to support health equity. This commitment included implementing multifaceted interventions with a focus on hypertension as a seminal risk factor contributing to disparities in cardiovascular disease mortality and morbidity. The American Heart Association is one organizational example of advocacy for equity in BP. Achieving equity nationwide will require sustained collaboration among individual stakeholders and public, private, and community organizations to address barriers across multiple socioecological levels.

Illness perceptions and blood pressure control among hypertensive Filipino Americans: A cross-sectional study

BACKGROUND

Among Asian Americans, Filipino Americans (FAs)-who constitute the fourth largest US immigrant group and who fill in health care workforce shortages-experience high prevalence but low control rates of high blood pressure (HBP). Research reveals that patients' illness perceptions, their common-sense model (CSM) of the illness, influence treatment behaviors, and management outcomes. However, scarce information exists about FAs' perceptions about HBP.

PURPOSE

To address this gap, we conducted a cross-sectional study to (a) identify the illness perceptions of hypertensive FAs, (b) classify these perceptions into clusters, and (c) determine the association between illness perceptions and BP control.

METHODOLOGY

The responses of 248 FAs with HBP to the Brief Illness Perception Questionnaire were analyzed using JMP Pro version 17 to discover their CSMs or illness perceptions. We used iterative K means cluster analysis to classify variations in CSMs and analysis of means chart to determine the association of illness perceptions and BP control.

RESULTS

Hypertensive FAs expressed threatening (negative) views of HBP through their emotional perceptions of the illness and its chronic time line, whereas their positive views centered on their cognitive beliefs about understanding HBP and its controllability. Based on the biomedical model of HBP, the overall illness perceptions or CSMs encompassed three clusters. Generally, threatening illness perceptions were associated with stage 2 HBP.

CONCLUSIONS/IMPLICATIONS

The findings underscore the need for nurse practitioners to elicit, listen, discern, and understand the illness perceptions or CSMs of hypertensive FAs to improve BP treatment and control with scientifically and culturally tailored interventions.

Effects of Sedentary Behavior Reduction on Blood Pressure in Desk Workers: Results From the RESET-BP Randomized Clinical Trial

BACKGROUND

Sedentary behavior (SB) is observationally associated with cardiovascular disease risk. However, randomized clinical trials testing causation are limited. We hypothesized that reducing SB would decrease blood pressure (BP) and pulse wave velocity (PWV) in sedentary adults.

METHODS

This parallel-arm, 3-month randomized clinical trial recruited desk workers, age 18 to 65 years, with systolic BP 120 to 159 or diastolic BP (DBP) 80 to 99 mm Hg, off antihypertensive medications, and reporting <150 min/wk of moderate to vigorous intensity physical activity. Participants were randomized to a SB reduction intervention or a no-contact control group. The intervention sought to replace 2 to 4 h/d of SB with standing and stepping through coaching, a wrist-worn activity prompter, and a sit-stand desk. SB and physical activity were measured with a thigh-worn accelerometer and quantified during all waking hours and separately during work and nonwork times. Clinic-based resting systolic BP (primary outcome) and DBP, 24-hour ambulatory BP, and PWV were assessed by blinded technicians at baseline and 3 months.

RESULTS

Participants (n=271) had a mean age of 45 years and systolic BP/DBP 129/83 mm Hg. Compared with controls, intervention participants reduced SB (-1.15±0.17 h/d), increased standing (0.94±0.14 h/d), and increased stepping (5.4±2.4 min/d; all P<0.05). SB and activity changes mainly occurred during work time and were below the goal. The intervention did not reduce BP or PWV in the intervention group compared with controls. Between-group differences in resting systolic BP and DBP changes were -0.22±0.90 (P=0.808) and 0.13±0.61 mm Hg (P=0.827), respectively. The findings were similarly null for ambulatory BP and PWV. Decreases in work-time SB were associated with favorable reductions in resting DBP (r=0.15, P=0.017). Contrary to our hypotheses, reductions in work-time SB (r=-0.19, P=0.006) and increases in work-time standing (r=0.17, P=0.011) were associated with unfavorable increases in carotid-femoral PWV. As expected, increases in nonwork-time standing were favorably associated with carotid-femoral PWV (r=-0.14, P=0.038).

CONCLUSIONS

A 3-month intervention that decreased SB and increased standing by ≈1 hour during the work day was not effective for reducing BP. Future directions include examining effects of interventions reducing SB through activity other than work-time standing and clarifying association between standing and PWV in opposite directions for work and nonwork time.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03307343.

Predictive Models for Sustained, Uncontrolled Hypertension and Hypertensive Crisis Based on Electronic Health Record Data: Algorithm Development and Validation

Background

Assessing disease progression among patients with uncontrolled hypertension is important for identifying opportunities for intervention.

Objective

We aim to develop and validate 2 models, one to predict sustained, uncontrolled hypertension (≥2 blood pressure [BP] readings ≥140/90 mm Hg or ≥1 BP reading ≥180/120 mm Hg) and one to predict hypertensive crisis (≥1 BP reading ≥180/120 mm Hg) within 1 year of an index visit (outpatient or ambulatory encounter in which an uncontrolled BP reading was recorded).

Methods

Data from 142,897 patients with uncontrolled hypertension within Atrium Health Greater Charlotte in 2018 were used. Electronic health record-based predictors were based on the 1-year period before a patient's index visit. The dataset was randomly split (80:20) into a training set and a validation set. In total, 4 machine learning frameworks were considered: L2-regularized logistic regression, multilayer perceptron, gradient boosting machines, and random forest. Model selection was performed with 10-fold cross-validation. The final models were assessed on discrimination (C-statistic), calibration (eg, integrated calibration index), and net benefit (with decision curve analysis). Additionally, internal-external cross-validation was performed at the county level to assess performance with new populations and summarized using random-effect meta-analyses.

Results

In internal validation, the C-statistic and integrated calibration index were 0.72 (95% CI 0.71-0.72) and 0.015 (95% CI 0.012-0.020) for the sustained, uncontrolled hypertension model, and 0.81 (95% CI 0.79-0.82) and 0.009 (95% CI 0.007-0.011) for the hypertensive crisis model. The models had higher net benefit than the default policies (ie, treat-all and treat-none) across different decision thresholds. In internal-external cross-validation, the pooled performance was consistent with internal validation results; in particular, the pooled C-statistics were 0.70 (95% CI 0.69-0.71) and 0.79 (95% CI 0.78-0.81) for the sustained, uncontrolled hypertension model and hypertensive crisis model, respectively.

Conclusions

An electronic health record-based model predicted hypertensive crisis reasonably well in internal and internal-external validations. The model can potentially be used to support population health surveillance and hypertension management. Further studies are needed to improve the ability to predict sustained, uncontrolled hypertension.

Use of Impedance Cardiography to Guide Blood Pressure Lowering Medication Selection: Systematic Review of Randomized Controlled Trials

BACKGROUND

Blood pressure (BP) control can be difficult to attain due to multiple factors, including choosing and titrating antihypertensive medications. Measurement of hemodynamic parameters using impedance cardiography (ICG) at the point of care may allow better alignment of medication with the mechanism(s) underlying an individual's hypertension. We conducted a systematic review of randomized controlled trials of ICG compared to usual care for attainment of BP control.

METHODS

We searched Medline inclusive of the year 1946 to January 31, 2024, using a combination of MeSH terms and keywords. English-language articles were eligible for inclusion if they described results of a randomized controlled trial designed to compare ICG-guided BP-medication selection to usual care (i.e., clinician judgment/guidelines-based alone) among a sample of hypertensive patients.

RESULTS

Of 1,952 titles screened, 6 trials met inclusion criteria. The first was published in 2002 from a specialty clinic in the United States, and the most recent in 2021 from a specialty clinic in China. One trial was conducted in a primary care setting. Sample sizes ranged from 102 to 164. Participants randomized to ICG-guided antihypertensive medication had reduced BP in the short-term to a greater extent than those randomized to usual care, with odds ratios for BP control (<140/90 mm Hg) at 3 months ranging from 1.87 to 2.92. This effect was seen in both specialty clinics and in a primary care setting.

CONCLUSIONS

Incorporation of ICG in the clinical setting may facilitate medication selection that leads to a greater proportion of patients obtaining BP control in the short term.

A retrospective cohort study of a community-based primary care program's effects on pharmacotherapy quality in low-income Peruvians with type 2 diabetes and hypertension

Little is known about the effects of the Chronic Care Model (CCM) and community health workers (CHWs) on pharmacotherapy of type 2 diabetes and hypertension in resource-poor settings. This retrospective cohort implementation study evaluated the effects of a community-based program consisting of CCM, CHWs, guidelines-based treatment protocols, and inexpensive freely accessible medications on type 2 diabetes and hypertension pharmacotherapy quality. A door-to-door household survey identified 856 adults 35 years of age and older living in a low-income Peruvian community, of whom 83% participated in screening for diabetes and hypertension. Patients with confirmed type 2 diabetes and/or hypertension participated in the program's weekly to monthly visits for < = 27 months. The program was implemented as two care periods employed sequentially. During home care, CHWs made weekly home visits and a physician made treatment decisions remotely. During subsequent clinic care, a physician attended patients in a centralized clinic. The study compared the effects of program (pre- versus post-) (N = 262 observations), and home versus clinic care periods (N = 211 observations) on standards of treatment with hypoglycemic and antihypertensive agents, angiotensin converting enzyme inhibitors, and low-dose aspirin. During the program, 80% and 50% achieved hypoglycemic and antihypertensive standards, respectively, compared to 35% and 8% prior to the program, RRs 2.29 (1.72-3.04, p <0.001) and 6.64 (3.17-13.9, p<0.001). Achievement of treatment standards was not improved by clinic compared to home care (RRs 1.0 +/- 0.08). In both care periods, longer retention in care (>50% of allowable time) was associated with achievement of all treatment standards. 85% compared to 56% achieved the hypoglycemic treatment standard with longer and shorter retention, respectively, RR 1.52 (1.13-2.06, p<0.001); 56% compared to 27% achieved the antihypertensive standard, RR 2.11 (1.29-3.45, p<0.001). In a dose-dependent manner, the community-based program was associated with improved guidelines-based pharmacotherapy of type 2 diabetes and hypertension.

Randomized Trials of Renal Denervation for Uncontrolled Hypertension: An Updated Meta-Analysis

BACKGROUND

Despite optimal medical therapy, a significant proportion of patients' blood pressure remains uncontrolled. Catheter-based renal denervation (RDN) has been proposed as a potential intervention for uncontrolled hypertension. We conducted an updated meta-analysis to assess the efficacy and safety of RDN in patients with uncontrolled hypertension, with emphasis on the differential effect of RDN in patients on and off antihypertensive medications.

METHODS AND RESULTS

Online databases were searched to identify randomized clinical trials comparing efficacy and safety of RDN versus control in patients with uncontrolled hypertension. Subgroup analyses were conducted for sham-controlled trials and studies that used RDN devices that have gained or are currently seeking US Food and Drug Administration approval. Fifteen trials with 2581 patients (RDN, 1723; sham, 858) were included. In patients off antihypertensive medications undergoing RDN, a significant reduction in 24-hour ambulatory (-3.70 [95% CI, -5.41 to -2.00] mm Hg), office (-4.76 [95% CI, -7.57 to -1.94] mm Hg), and home (-3.28 [95% CI, -5.96 to -0.61] mm Hg) systolic blood pressures was noted. In patients on antihypertensive medications, a significant reduction was observed in 24-hour ambulatory (-2.23 [95% CI, -3.56 to -0.90] mm Hg), office (-6.39 [95% CI, -11.49 to -1.30]), home (-6.08 [95% CI, -11.54 to -0.61] mm Hg), daytime (-2.62 [95% CI, -4.14 to -1.11]), and nighttime (-2.70 [95% CI, -5.13 to -0.27]) systolic blood pressures, as well as 24-hour ambulatory (-1.16 [95% CI, -1.96 to -0.35]), office (-3.17 [95% CI, -5.54 to -0.80]), and daytime (-1.47 [95% CI, -2.50 to -0.27]) diastolic blood pressures.

CONCLUSIONS

RDN significantly lowers blood pressure in patients with uncontrolled hypertension, in patients off and on antihypertensive medications, with a favorable safety profile. The efficacy of RDN was consistent in sham-controlled trials and contemporary trials using US Food and Drug Administration-approved devices.

Trends in Black-White Differences of Antihypertensive Treatment in Individuals With and Without History of Stroke

BACKGROUND

Recent hypertension guidelines for the general population have included race-specific recommendations for antihypertensives, whereas current stroke-specific recommendations for antihypertensives do not vary by race. The impact of these guidelines on antihypertensive regimen changes over time, and if this has varied by prevalent stroke status, is unclear.

METHODS

The use of antihypertensive medications was studied cross-sectionally among self-identified Black and White participants, aged ≥45 years, with and without history of stroke, from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke). Participants completed an in-home examination in 2003-2007 (visit 1) with/without an examination in 2013-2016 (visit 2). Stratified by prevalent stroke status, logistic regression mixed models examined associations between antihypertensive class use for visit 2 versus visit 1 and Black versus White individuals with an interaction adjusted for demographics, socioeconomic status, and vascular risk factors/vital signs.

RESULTS

Of 17 244 stroke-free participants at visit 1, Black participants had greater adjusted odds of angiotensin-converting enzyme inhibitor usage than White participants (odds ratio [OR], 1.51 [95% CI, 1.30-1.77]). This difference was smaller in the 7476 stroke-free participants at visit 2 (OR, 1.16 [95% CI, 1.08-1.25]). In stroke-free participants at visit 1, Black participants had lower odds of calcium channel blocker (CCB) usage than White participants (OR, 0.47 [95% CI, 0.41-0.55]), but CCB usage did not differ significantly between Black and White stroke-free participants at visit 2 (OR, 1.02 [95% CI, 0.95-1.09]). Among 1437 stroke survivor participants at visit 1, Black participants had lower odds of CCB use than White participants (OR, 0.34 [95% CI, 0.26-0.45]). In 689 stroke survivor participants at visit 2, CCB use did not differ between Black and White participants (OR, 0.80 [95% CI, 0.61-1.06]).

CONCLUSIONS

Racial differences in the use of guideline-recommended antihypertensives decreased between 2003-2007 and 2013-2016 in stroke-free individuals. In stroke survivors, racial differences in CCB usage narrowed over the time periods. These findings suggest there is still a mismatch between race-specific hypertension guidelines and recent clinical practice.

Equitable Care for Hypertension: Blood Pressure and Patient-Reported Outcomes of the RICH LIFE Cluster Randomized Trial

BACKGROUND

Disparities in hypertension control are well documented but underaddressed.

METHODS

RICH LIFE (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) was a 2-arm, cluster randomized trial comparing the effect on blood pressure (BP) control (systolic BP ≤140 mm Hg, diastolic BP ≤90 mm Hg), patient activation, and disparities in BP control of 2 multilevel interventions, standard of care plus (SCP) and collaborative care/stepped care (CC/SC). SCP included BP measurement standardization, audit and feedback, and equity-leadership training. CC/SC added roles to address social or medical needs. Primary outcomes were BP control and patient activation at 12 months. Generalized estimating equations and mixed-effects regression models with fixed effects of time, intervention, and their interaction compared change in outcomes at 12 months from baseline.

RESULTS

A total of 1820 adults with uncontrolled BP and ≥1 other risk factors enrolled in the study. Their mean age was 60.3 years, and baseline BP was 152.3/85.5 mm Hg; 59.4% were women; 57.4% were Black, 33.2% were White, and 9.4% were Hispanic; 74% had hyperlipidemia; and 45.1% had type 2 diabetes. CC/SC did not improve BP control rates more than SCP. Both groups achieved statistically and clinically significant BP control rates at 12 months (CC/SC: 57.3% [95% CI, 52.7%-62.0%]; SCP: 56.7% [95% CI, 51.9%-61.5%]). Pairwise comparisons between racial and ethnic groups showed overall no significant differences in BP control at 12 months. Patients with coronary heart disease showed greater achievement of BP control in CC/SC than in SCP (64.0% [95% CI, 54.1%-73.9%] versus 50.8% [95% CI, 42.6%-59.0%]; P=0.04), as did patients in rural areas (67.3% [95% CI, 49.8%-84.8%] versus 47.8% [95% CI, 32.4%-63.2%]; P=0.01). Individuals in both arms experienced statistically and clinically significant reductions in mean systolic BP (CC/SC: -13.8 mm Hg [95% CI, -15.2 to -12.5]; SCP: -14.6 mm Hg [95% CI, -15.9 to -13.2]) and diastolic BP (CC/SC: -6.9 mm Hg [95% CI, -7.8 to -6.1]; SCP: -5.5 mm Hg [95% CI, -6.4 to -4.6]) over time. The difference in diastolic BP reduction between CC/SC and SCP over time was statistically significant (-1.4 mm Hg [95% CI, -2.6 to -0.2). Patient activation did not differ between arms. CC/SC showed greater improvements in patient ratings of chronic illness care (Patient Assessment of Chronic Illness Care score) over 12 months (0.12 [95% CI, 0.02-0.22]).

CONCLUSIONS

Adding a collaborative care team to enhanced standard of care did not improve BP control but did improve patient ratings of chronic illness 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.

Remote Blood Pressure Monitoring With Social Support for Patients With Hypertension: A Randomized Clinical Trial

Importance

Hypertension management has traditionally been based on office visits. Integrating remote monitoring into routine clinical practices and leveraging social support might improve blood pressure (BP) control.

Objective

To evaluate the effectiveness of a bidirectional text monitoring program focused on BP control and medication adherence with and without social support in adults with hypertension.

Design, Setting, and Participants

This randomized clinical trial included adults aged 18 to 75 treated at an academic family medicine practice in Philadelphia in 2018 and 2019. Patients had been seen at least twice in the prior 24 months and had at least 2 elevated BP measurements (>150/90 mm Hg or >140/90 mm Hg for patients aged 18-59 years or with diabetes or chronic kidney disease) during visits. All participants had a cell phone with text messaging, offered at least 1 support partner, and were taking maintenance medications to treat hypertension. Patients were randomized 2:2:1 to remote monitoring of BP and medication adherence (RM), remote monitoring of BP and medication adherence with feedback provided to a social support partner (SS), or usual care (UC). Data were analyzed on an intention-to-treat basis between October 14, 2019, and May 30, 2020, and were revisited from May 23 through June 2, 2023.

Interventions

The RM and SS groups received an automatic home BP monitor, 3 weekly texts requesting BP measurements, 1 weekly text inquiring about medication adherence, and a weekly text with feedback. In the SS arm, support partners received a weekly progress report. The UC group received UC through their primary care practice. Clinicians caring for the patients in the intervention groups received nudges via electronic health records to adjust medications when 3 of 10 reported BP measurements were elevated. Patients were followed up for 4 months.

Main Outcomes and Measures

The primary outcome was systolic BP at 4 months measured during the final follow-up visit. Secondary outcomes included achievement of normotension and diastolic BP.

Results

In all, 246 patients (mean [SD] age, 50.9 [11.4] years; 175 females [71.1%]; 223 Black individuals [90.7%] and 13 White individuals [5.3%]) were included in the intention-to-treat analysis: 100 patients in the RM arm, 97 in the SS arm, and 49 in the UC arm. Compared with the UC arm, there was no significant difference in systolic or diastolic BP at the 4-month follow-up visit in the RM arm (systolic BP adjusted mean difference, -5.25 [95% CI, -10.65 to 0.15] mm Hg; diastolic BP adjusted mean difference, -1.94 [95% CI, -5.14 to 1.27] mm Hg) or the SS arm (systolic BP adjusted mean difference, -0.91 [95% CI, -6.37 to 4.55] mm Hg; diastolic BP adjusted mean difference, -0.63 [95% CI, -3.77 to 2.51] mm Hg). Of the 206 patients with a final BP measurement at 4 months, BP was controlled in 49% (41 of 84) of patients in the RM arm, 31% (27 of 87) of patients in the SS arm, and 40% (14 of 35) of patients in the UC arm; these rates did not differ significantly between the intervention arms and the UC group.

Conclusions and Relevance

In this randomized clinical trial, neither remote BP monitoring nor remote BP monitoring with social support improved BP control compared with UC in adults with hypertension. Additional efforts are needed to examine whether interventions directed at helping patients remember to take their BP medications can lead to improved BP control.

Trial Registration

ClinicalTrials.gov Identifier: NCT03416283.

Efficacy and safety of a four-drug, quarter-dose treatment for hypertension: the QUARTET USA randomized trial

New approaches are needed to lower blood pressure (BP) given persistently low control rates. QUARTET USA sought to evaluate the effect of four-drug, quarter-dose BP lowering combination in patients with hypertension. QUARTET USA was a randomized (1:1), double-blinded trial conducted in federally qualified health centers among adults with hypertension. Participants received either a quadpill of candesartan 2 mg, amlodipine 1.25 mg, indapamide 0.625 mg, and bisoprolol 2.5 mg or candesartan 8 mg for 12 weeks. If BP was >130/>80 mm Hg at 6 weeks in either arm, then participants received open label add-on amlodipine 5 mg. The primary outcome was mean change in systolic blood pressure (SBP) at 12 weeks, controlling for baseline BP. Secondary outcomes included mean change in diastolic blood pressure (DBP), and safety included serious adverse events, relevant adverse drug effects, and electrolyte abnormalities. Among 62 participants randomized between August 2019-May 2022 (n = 32 intervention, n = 30 control), mean (SD) age was 52 (11.5) years, 45% were female, 73% identified as Hispanic, and 18% identified as Black. Baseline mean (SD) SBP was 138.1 (11.2) mmHg, and baseline mean (SD) DBP was 84.3 (10.5) mmHg. In a modified intention-to-treat analysis, there was no significant difference in SBP (-4.8 mm Hg [95% CI: -10.8, 1.3, p = 0.123] and a -4.9 mmHg (95% CI: -8.6, -1.3, p = 0.009) greater mean DBP change in the intervention arm compared with the control arm at 12 weeks. Adverse events did not differ significantly between arms. The quadpill had a similar SBP and greater DBP lowering effect compared with candesartan 8 mg. Trial registration number: NCT03640312.

NETosis Drives Blood Pressure Elevation and Vascular Dysfunction in Hypertension

BACKGROUND

Neutrophil extracellular traps (NETs) are composed of DNA, enzymes, and citrullinated histones that are expelled by neutrophils in the process of NETosis. NETs accumulate in the aorta and kidneys in hypertension. PAD4 (protein-arginine deiminase-4) is a calcium-dependent enzyme that is essential for NETosis. TRPV4 (transient receptor potential cation channel subfamily V member 4) is a mechanosensitive calcium channel expressed in neutrophils. Thus, we hypothesize that NETosis contributes to hypertension via NET-mediated endothelial cell (EC) dysfunction.

METHODS

NETosis-deficient Padi4-/- mice were treated with Ang II (angiotensin II). Blood pressure was measured by radiotelemetry, and vascular reactivity was measured with wire myography. Neutrophils were cultured with or without ECs and exposed to normotensive or hypertensive uniaxial stretch. NETosis was measured by flow cytometry. ECs were treated with citrullinated histone H3, and gene expression was measured by quantitative reverse transcription PCR. Aortic rings were incubated with citrullinated histone H3, and wire myography was performed to evaluate EC function. Neutrophils were treated with the TRPV4 agonist GSK1016790A. Calcium influx was measured using Fluo-4 dye, and NETosis was measured by immunofluorescence.

RESULTS

Padi4-/- mice exhibited attenuated hypertension, reduced aortic inflammation, and improved EC-dependent vascular relaxation in response to Ang II. Coculture of neutrophils with ECs and exposure to hypertensive uniaxial stretch increased NETosis and accumulation of neutrophil citrullinated histone H3. Histone H3 and citrullinated histone H3 exposure attenuates EC-dependent vascular relaxation. Treatment of neutrophils with the TRPV4 agonist GSK1016790A increases intracellular calcium and NETosis.

CONCLUSIONS

These observations identify a role of NETosis in the pathogenesis of hypertension. Moreover, they define an important role of EC stretch and TRPV4 as initiators of NETosis. Finally, they define a role of citrullinated histones as drivers of EC dysfunction in hypertension.

Genetics of Hypertension: From Monogenic Analysis to GETomics

Arterial hypertension is the most frequent cardiovascular risk factor all over the world, and it is one of the leading drivers of the risk of cardiovascular events and death. It is a complex trait influenced by heritable and environmental factors. To date, the World Health Organization estimates that 1.28 billion adults aged 30-79 years worldwide have arterial hypertension (defined by European guidelines as office systolic blood pressure ≥ 140 mmHg or office diastolic blood pressure ≥ 90 mmHg), and 7.1 million die from this disease. The molecular genetic basis of primary arterial hypertension is the subject of intense research and has recently yielded remarkable progress. In this review, we will discuss the genetics of arterial hypertension. Recent studies have identified over 900 independent loci associated with blood pressure regulation across the genome. Comprehending these mechanisms not only could shed light on the pathogenesis of the disease but also hold the potential for assessing the risk of developing arterial hypertension in the future. In addition, these findings may pave the way for novel drug development and personalized therapeutic strategies.

Trends of Antihypertensive Prescription Among US Adults From 2010 to 2019 and Changes Following Treatment Guidelines: Analysis of Multicenter Electronic Health Records

BACKGROUND

Guidelines for the use of antihypertensives changed in 2014 and 2017. To understand the effect of these guidelines, we examined trends in antihypertensive prescriptions in the United States from 2010 to 2019 using a repeated cross-sectional design.

METHODS AND RESULTS

Using electronic health records from 15 health care institutions for adults (20-85 years old) who had ≥1 antihypertensive prescription, we assessed whether (1) prescriptions of beta blockers decreased after the 2014 Eighth Joint National Committee (JNC 8) report discouraged use for first-line treatment, (2) prescriptions for calcium channel blockers and thiazide diuretics increased among Black patients after the JNC 8 report encouraged use as first-line therapy, and (3) prescriptions for dual therapy and fixed-dose combination among patients with blood pressure ≥140/90 mm Hg increased after recommendations in the 2017 Hypertension Clinical Practice Guidelines. The study included 1 074 314 patients with 2 133 158 prescription episodes. After publication of the JNC 8 report, prescriptions for beta blockers decreased (3% lower in 2018-2019 compared to 2010-2014), and calcium channel blockers increased among Black patients (20% higher in 2015-2017 and 41% higher in 2018-2019, compared to 2010-2014), in accordance with guideline recommendations. However, contrary to guidelines, dual therapy and fixed-dose combination decreased after publication of the 2017 Hypertension Clinical Practice Guidelines (9% and 11% decrease in 2018-2019 for dual therapy and fixed-dose combination, respectively, compared to 2015-2017), and thiazide diuretics decreased among Black patients after the JNC 8 report (6% lower in 2018-2019 compared to 2010-2014).

CONCLUSIONS

Adherence to guidelines on prescribing antihypertensive medication was inconsistent, presenting an opportunity for interventions to achieve better blood pressure control in the US population.

Resistant Hypertension: Disease Burden and Emerging Treatment Options

PURPOSE OF REVIEW

To define resistant hypertension (RHT), review its pathophysiology and disease burden, identify barriers to effective hypertension management, and to highlight emerging treatment options.

RECENT FINDINGS

RHT is defined as uncontrolled blood pressure (BP) ≥ 130/80 mm Hg despite concurrent prescription of ≥ 3 or ≥ 4 antihypertensive drugs in different classes or controlled BP despite prescription of  ≥ to 4 drugs, at maximally tolerated doses, including a diuretic. BP is regulated by a complex interplay between the renin-angiotensin-aldosterone system, the sympathetic nervous system, the endothelin system, natriuretic peptides, the arterial vasculature, and the immune system; disruption of any of these can increase BP. RHT is disproportionately manifest in African Americans, older patients, and those with diabetes and/or chronic kidney disease (CKD). Amongst drug-treated hypertensives, only one-quarter have been treated intensively enough (prescribed > 2 drugs) to be considered for this diagnosis. New treatment strategies aimed at novel therapeutic targets include inhibition of sodium-glucose cotransporter 2, aminopeptidase A, aldosterone synthesis, phosphodiesterase 5, xanthine oxidase, and dopamine beta-hydroxylase, as well as soluble guanylate cyclase stimulation, nonsteroidal mineralocorticoid receptor antagonism, and dual endothelin receptor antagonism. The burden of RHT remains high. Better use of currently approved therapies and integrating emerging therapies are welcome additions to the therapeutic armamentarium for addressing needs in high-risk aTRH patients.

Hypertension in Pregnancy: Current Challenges and Future Opportunities for Surveillance and Research

Hypertension in pregnancy (HP) includes eclampsia/preeclampsia, chronic hypertension, superimposed preeclampsia, and gestational hypertension. In the United States, HP prevalence doubled over the last three decades, based on birth certificate data. In 2019, the estimated percent of births with a history of HP varied from 10.1% to 15.9% for birth certificate data and hospital discharge records, respectively. The use of electronic medical records may result in identifying an additional third to half of undiagnosed cases of HP. Individuals with gestational hypertension or preeclampsia are at 3.5 times higher risk of progressing to chronic hypertension and from 1.7 to 2.8 times higher risk of developing cardiovascular disease (CVD) after childbirth compared with individuals without these conditions. Interventions to identify and address CVD risk factors among individuals with HP are most effective if started during the first 6 weeks postpartum and implemented during the first year after childbirth. Providing access to affordable health care during the first 12 months after delivery may ensure healthy longevity for individuals with HP. Average attendance rates for postpartum visits in the United States are 72.1%, but the rates vary significantly (from 24.9% to 96.5%). Moreover, even among individuals with CVD risk factors who attend postpartum visits, approximately 40% do not receive counseling on a healthy lifestyle. In the United States, as of the end of September 2023, 38 states and the District of Columbia have extended Medicaid coverage eligibility, eight states plan to implement it, and two states proposed a limited coverage extension from 2 to 12 months after childbirth. Currently, data gaps exist in national health surveillance and health systems to identify and monitor HP. Using multiple data sources, incorporating electronic medical record data algorithms, and standardizing data definitions can improve surveillance, provide opportunities to better track progress, and may help in developing targeted policy recommendations.

Trends in All-Cause, Cardiovascular, and Noncardiovascular Mortality Among US Adults With Hypertension

BACKGROUND

Death certificate data indicate that hypertension may have increased as a contributing cause of death among US adults. Hypertension is not commonly recorded on death certificates although it contributes to a substantial proportion of cardiovascular disease (CVD) deaths.

METHODS

We estimated changes in all-cause, CVD, and non-CVD mortality over 5 years of follow-up among 4 cohorts of US adults with hypertension using mortality follow-up data from National Health and Nutrition Examination Survey III in 1988 to 1994, and National Health and Nutrition Examination Survey cycles from 1999 to 2000 through 2015 to 2016 (n=20 927). Hypertension was defined as systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or antihypertensive medication use. Participants were grouped according to the date of their National Health and Nutrition Examination Survey study visit (1988-1994, 1999-2004, 2005-2010, 2011-2016).

RESULTS

There were 2646, 1048, and 1598 all-cause, CVD, and non-CVD deaths, respectively. After age, gender, and race/ethnicity adjustment and compared with the 1988 to 1994 cohort, the hazard ratio of all-cause mortality was 0.88 (95% CI, 0.76-1.01) for the 1999 to 2004 cohort, 0.82 (95% CI, 0.70-0.95) for the 2005 to 2010 cohort, and 0.89 (95% CI, 0.75-1.05) for the 2011 to 2016 cohort (P trend=0.123). The age, gender, and race/ethnicity-adjusted hazard ratios for CVD mortality compared with the 1988 to 1994 cohort were 0.74 (95% CI, 0.60-0.90) for the 1999 to 2004 cohort, 0.61 (95% CI, 0.50-0.74) for the 2005 to 2010 cohort, and 0.57 (95% CI, 0.44-0.74) for the 2011 to 2016 cohort (P trend <0.001). There was no evidence of a change in CVD mortality between the 2005 to 2010 and 2011 to 2016 cohorts (P=0.661). Noncardiovascular mortality did not decline over the study period (P trend=0.145).

CONCLUSIONS

The decline in CVD mortality among US adults with hypertension stalled after 2005 to 2010.

Blood Pressure Control and Maintenance in a Prospective Cohort of Younger Veterans: Roles of Sex, Race, Ethnicity, and Social Determinants of Health

Background

Proactive blood pressure (BP) management is particularly beneficial for younger Veterans, who have a greater prevalence and earlier onset of cardiovascular disease than non-Veterans. It is unknown what proportion of younger Veterans achieve and maintain BP control after hypertension onset and if BP control differs by demographics and social deprivation.

Methods

Electronic health records were merged from Veterans who enrolled in VA care 10/1/2001-9/30/2017 and met criteria for hypertension - first diagnosis or antihypertensive fill. BP control (140/90 mmHg), was estimated 1, 2, and 5 years post-hypertension documentation, and characterized by sex, race, and ethnicity. Adjusted logistic regressions assessed likelihood of BP control by these demographics and with the Social Deprivation Index (SDI).

Results

Overall, 17% patients met criteria for hypertension (n=198,367; 11% of women, median age 41). One year later, 59% of men and 65% of women achieved BP control. After adjustment, women had a 72% greater odds of BP control than men, with minimal change over 5 years. Black adults had a 22% lower odds of BP control than White adults. SDI did not significantly change these results.

Conclusions

In the largest study of hypertension in younger Veterans, 41% of men and 35% of women did not have BP control after 1 year, and BP control was consistently better for women through 5 years. Thus, the first year of hypertension management portends future, long-term BP control. As social deprivation did not affect BP control, the VA system may protect against disadvantages observed in the general U.S. population.

Managing Hypertension in Older Adults

PURPOSE OF REVIEW

The population of older adults 60-79 years globally is projected to double from 800 million to 1.6 billion between 2015 and 2050, while adults ≥ 80 years were forecast to more than triple from 125 to 430 million. The risk for cardiovascular events doubles with each decade of aging and each 20 mmHg increase of systolic blood pressure. Thus, successful management of hypertension in older adults is critical in mitigating the projected global health and economic burden of cardiovascular disease.

RECENT FINDINGS

Women live longer than men, yet with aging systolic blood pressure and prevalent hypertension increase more, and hypertension control decreases more than in men, i.e., hypertension in older adults is disproportionately a women's health issue. Among older adults who are healthy to mildly frail, the absolute benefit of hypertension control, including more intensive control, on cardiovascular events is greater in adults ≥ 80 than 60-79 years old. The absolute rate of serious adverse events during antihypertensive therapy is greater in adults ≥ 80 years older than 60-79 years, yet the excess adverse event rate with intensive versus standard care is only moderately increased. Among adults ≥ 80 years, benefits of more intensive therapy appear non-existent to reversed with moderate to marked frailty and when cognitive function is less than roughly the twenty-fifth percentile. Accordingly, assessment of functional and cognitive status is important in setting blood pressure targets in older adults. Given substantial absolute cardiovascular benefits of more intensive antihypertensive therapy in independent-living older adults, this group merits shared-decision making for hypertension targets.

Podocytes from hypertensive and obese mice acquire an inflammatory, senescent, and aged phenotype

Patients with hypertension or obesity can develop glomerular dysfunction characterized by injury and depletion of podocytes. To better understand the molecular processes involved, young mice were treated with either deoxycorticosterone acetate (DOCA) or fed a high-fat diet (HFD) to induce hypertension or obesity, respectively. The transcriptional changes associated with these phenotypes were measured by unbiased bulk mRNA sequencing of isolated podocytes from experimental models and their respective controls. Key findings were validated by immunostaining. In addition to a decrease in canonical proteins and reduced podocyte number, podocytes from both hypertensive and obese mice exhibited a sterile inflammatory phenotype characterized by increases in NLR family pyrin domain containing 3 (NLRP3) inflammasome, protein cell death-1, and Toll-like receptor pathways. Finally, although the mice were young, podocytes in both models exhibited increased expression of senescence and aging genes, including genes consistent with a senescence-associated secretory phenotype. However, there were differences between the hypertension- and obesity-associated senescence phenotypes. Both show stress-induced podocyte senescence characterized by increased p21 and p53. Moreover, in hypertensive mice, this is superimposed upon age-associated podocyte senescence characterized by increased p16 and p19. These results suggest that senescence, aging, and inflammation are critical aspects of the podocyte phenotype in experimental hypertension and obesity in mice.NEW & NOTEWORTHY Hypertension and obesity can lead to glomerular dysfunction in patients, causing podocyte injury and depletion. Here, young mice given deoxycorticosterone acetate or a high-fat diet to induce hypertension or obesity, respectively. mRNA sequencing of isolated podocytes showed transcriptional changes consistent with senescence, a senescent-associated secretory phenotype, and aging, which was confirmed by immunostaining. Ongoing studies are determining the mechanistic roles of the accelerated aging podocyte phenotype in experimental hypertension and obesity.

Hypertension clinical pathway: Experience of Aseer region, Saudi Arabia

BACKGROUND

Hypertension (HTN) is a common chronic health problem with many complications and high morbidity rates. This study aimed to describe the HTN pathway, to assess the performance of screening and registration programs, to explore the challenges and suggest solutions for those challenges.

MATERIALS AND METHODS

This study was conducted in primary care centers in the Aseer region, Saudi Arabia, at the end of 2022. The study consisted of three parts namely: Screening for HTN, registration of known hypertensive patients and opinions of representatives of Primary Healthcare Centers (PHCs) on challenges to the implementation of HTN pathway and suggestions for overcoming these challenges. Three Google forms were developed by the investigators to achieve the objectives of this study. The first two forms were completed by doctors and nurses at each PHC and reviewed by the leader of HTN pathway, and the third form completed by a representative of each PHC. SPSS version 26 was used for data management and analysis. Chi-square test was used to determine association between categorical variables; binary logistic regression analysis was performed to determine the correlates of being hypertensive and having good control of HTN.

RESULTS

A total of 159,243 individuals were screened for HTN, 55% of whom were females and 94% were Saudis. The prevalence of HTN was 13%; 70% were overweight or obese and 14% had diabetes. The total registered number of patients was 55,628; 50% had good HTN control. Major challenges were inadequate health coaches, care coordinators, laboratory and radiology facilities, lack of coordination with hospitals, and ineffective appointment system.

CONCLUSION

This study revealed that the current HTN pathway was successful with regard to screening and registration of patients with HTN. Many challenges need an executive plan with SMART objectives to optimize the care for HTN patients in the region.

Greater use of antihypertensive medications explains lower blood pressures and better control in statin-treated than statin-eligible untreated adults

OBJECTIVE

Statins appear to have greater antihypertensive effects in observational studies than in randomized controlled trials. This study assessed whether more frequent treatment of hypertension contributed to better blood pressure (BP, mmHg) control in statin-treated than statin-eligible untreated adults in observational studies.

METHODS

National Health and Nutrition Examination Surveys 2009-2020 data were analyzed for adults 21-75 years ( N  = 3814) with hypertension (BP ≥140/≥90 or treatment). The 2013 American College of Cardiology/American Heart Association Cholesterol Guideline defined statin eligibility. The main analysis compared BP values and hypertension awareness, treatment, and control in statin-treated and statin-eligible but untreated adults. Multivariable logistic regression was used to assess the association of statin therapy to hypertension control and the contribution of antihypertensive therapy to that relationship.

RESULTS

Among adults with hypertension in 2009-2020, 30.3% were not statin-eligible, 36.9% were on statins, and 32.8% were statin-eligible but not on statins. Statin-treated adults were more likely to be aware of (93.4 vs. 80.6%) and treated (91.4 vs. 70.7%) for hypertension than statin-eligible adults not on statins. The statin-treated group had 8.3 mmHg lower SBP (130.3 vs. 138.6), and 22.8% greater control (<140/<90: 69.0 vs. 46.2%; all P values <0.001). The association between statin therapy and hypertension control [odds ratio 1.94 (95% confidence interval 1.53-2.47)] in multivariable logistic regression was not significant after also controlling for antihypertensive therapy [1.29 (0.96-1.73)].

CONCLUSION

Among adults with hypertension, statin-treated adults have lower BP and better control than statin-eligible untreated adults, which largely reflects differences in antihypertensive therapy.

Antihypertensive medication persistence and adherence among non-Hispanic Asian US patients with hypertension and fee-for-service Medicare health insurance

BACKGROUND

Less than 50% of non-Hispanic Asian adults taking antihypertensive medication have controlled blood pressure.

METHODS

We compared non-persistence and low adherence to antihypertensive medication between non-Hispanic Asian and other race/ethnicity groups among US adults ≥66 years who initiated antihypertensive medication between 2011 and 2018 using a 5% random sample of Medicare beneficiaries (non-Hispanic Asian, n = 2,260; non-Hispanic White, n = 56,000; non-Hispanic Black, n = 5,792; Hispanic, n = 4,212; and Other, n = 1,423). Non-persistence was defined as not having antihypertensive medication available to take in the last 90 of 365 days following treatment initiation. Low adherence was defined as having antihypertensive medication available to take on <80% of the 365 days following initiation.

RESULTS

In 2011-2012, 2013-2014, 2015-2016 and 2017-2018, the proportion of non-Hispanic Asian Medicare beneficiaries with non-persistence was 29.1%, 25.6%, 25.4% and 26.7% (p-trend = 0.381), respectively, and the proportion with low adherence was 58.1%, 54.2%, 53.4% and 51.6%, respectively (p-trend = 0.020). In 2017-2018, compared with non-Hispanic Asian beneficiaries, non-persistence was less common among non-Hispanic White beneficiaries (risk ratio 0.74 [95%CI, 0.64-0.85]), non-Hispanic Black beneficiaries (0.80 [95%CI 0.68-0.94]) and those reporting Other race/ethnicity (0.68 [95%CI, 0.54-0.85]) but not among Hispanic beneficiaries (1.04 [95%CI, 0.88-1.23]). Compared to non-Hispanic Asian beneficiaries, non-Hispanic White beneficiaries and beneficiaries reporting Other race/ethnicity were less likely to have low adherence to antihypertensive medication (relative risk 0.78 [95%CI 0.72-0.84] and 0.84 [95%CI 0.74-0.95], respectively); there was no association for non-Hispanic Black or Hispanic beneficiaries.

CONCLUSIONS

Non-persistence and low adherence to antihypertensive medication were more common among older non-Hispanic Asian than non-Hispanic White adults.