Blood pressure was controlled in an estimated 50.1% of all patients with hypertension in NHANES 2007-2008, with most of the improvement since 1988 occurring after 1999-2000. Hypertension control was significantly lower among younger than middle-aged individuals and older adults, and Hispanic vs white individuals.

Resistant hypertension (RH) is defined as above-goal elevated blood pressure (BP) in a patient despite the concurrent use of 3 antihypertensive drug classes, commonly including a long-acting calcium channel blocker, a blocker of the renin-angiotensin system (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker), and a diuretic. The antihypertensive drugs should be administered at maximum or maximally tolerated daily doses. RH also includes patients whose BP achieves target values on ≥4 antihypertensive medications. The diagnosis of RH requires assurance of antihypertensive medication adherence and exclusion of the “white-coat effect” (office BP above goal but out-of-office BP at or below target). The importance of RH is underscored by the associated risk of adverse outcomes compared with non-RH. This article is an updated American Heart Association scientific statement on the detection, evaluation, and management of RH. Once antihypertensive medication adherence is confirmed and out-of-office BP recordings exclude a white-coat effect, evaluation includes identification of contributing lifestyle issues, detection of drugs interfering with antihypertensive medication effectiveness, screening for secondary hypertension, and assessment of target organ damage. Management of RH includes maximization of lifestyle interventions, use of long-acting thiazide-like diuretics (chlorthalidone or indapamide), addition of a mineralocorticoid receptor antagonist (spironolactone or eplerenone), and, if BP remains elevated, stepwise addition of antihypertensive drugs with complementary mechanisms of action to lower BP. If BP remains uncontrolled, referral to a hypertension specialist is advised.

Over a period of four years, stage 1 hypertension developed in nearly two thirds of patients with untreated prehypertension (the placebo group). Treatment of prehypertension with candesartan appeared to be well tolerated and reduced the risk of incident hypertension during the study period. Thus, treatment of prehypertension appears to be feasible. (ClinicalTrials.gov number, NCT00227318.).

Background Despite progress, many hypertensive patients remain uncontrolled. Defining characteristics of uncontrolled hypertensives may facilitate efforts to improve blood pressure (BP) control. Methods and Results Subjects included 13,375 hypertensive adults from National Health and Nutrition Examination Surveys (NHANES) subdivided into 1988–1994, 1999–2004, 2005–2008. Uncontrolled hypertension was defined as BP ≥140/≥90 mmHg and apparent treatment resistant (aTRH) when subjects reported taking ≥3 antihypertensive medications. Framingham 10-year coronary risk (FCR) was calculated. Multivariable logistic regression was used to identify clinical characteristics associated with untreated, treated uncontrolled on 1–2 BP medications, and aTRH across all three survey periods. More than half of uncontrolled hypertensives were untreated across surveys including 52.5% in 2005–2008. Clinical factors linked with untreated hypertension included male sex, infrequent healthcare visits (0–1/yr), body mass index <25 kg/m2, absence of chronic kidney disease (CKD), and FCR <10% (p<0.01). Most treated, uncontrolled patients reported taking 1–2 BP medications, a proxy for therapeutic inertia. This group was older, had higher FCR than patients controlled on 1–2 medications (p<0.01), and comprised 34.4% of all uncontrolled and 72.0% of treated uncontrolled patients in 2005–2008. Apparent TRH increased from 15.9% (1998–2004) to 28.0% (2005–2008) of treated patients, p<0.001. Clinical characteristics associated with aTRH included ≥4 visits/yr, obesity, CKD and FCR >20% (p<0.01). Conclusions Untreated, under-treated, and aTRH patients have consistent characteristics that could inform strategies to improve BP control by decreasing untreated hypertension, reducing therapeutic inertia in under-treated patients, and enhancing therapeutic efficiency in aTRH.

Abstract-Therapeutic inertia (TI), defined as the providers' failure to increase therapy when treatment goals are unmet, contributes to the high prevalence of uncontrolled hypertension (Ն140/90 mm Hg), but the quantitative impact is unknown. To address this gap, a retrospective cohort study was conducted on 7253 hypertensives that had Ն4 visits and Ն1 elevated blood pressure (BP) 1999 -2000. 2,3 Despite an increase in the number and tolerability of antihypertensive medications, goal BP has been difficult to attain. Clinical trials, including the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack trial, 4 with 66% control rates and the Controlled Onset Verapamil Investigation of Cardiovascular Endpoints study 5 with 70% control rates have shown that the BP control rates reported in national data can be substantially improved. Of note, the majority of uncontrolled hypertensive subjects in the United States are older individuals with systolic BP (SBP) 140 to 159 mm Hg who are seen an average of 6 times annually in a primary care setting. 6 Even with substantial reductions in the number of unaware and untreated hypertensive patients, controlling BP in Ն70% of treated patients is a vital component of reaching the Healthy People 2010 goal of controlling hypertension in 50% of all affected patients. 7 Hypertension control rates nearly tripled from 10% in 1976 -1980 to 29% in 1988 -1991. 8 The improvements in hypertension control coincided temporally with a large decline in the age-adjusted rates for stroke and coronary heart disease (CHD).Unfortunately, BP control rates have changed little in the past 15 years, especially in women. Patient factors, such as compliance, 9,10 knowledge, 11 and lack of insurance, 12 and system factors, such as limited access to care and medications 13 and lack of appointment reminders, 14 have been cited for the low rates of BP control. Of note, BP control remains suboptimal in systems such as the Veterans Administration where financial barriers to health care are less. 15,16 Physician factors, such as therapeutic inertia (TI), that is, failure of providers to begin new medications or increase dosages of existing medications when an abnormal clinical parameter is recorded, are becoming more evident. TI represents a significant barrier to better hypertension control. TI impacts not only control of BP but of other chronic diseases, including diabetes mellitus and hyperlipidemia. [17][18][19][20][21][22][23][24] Although data suggest that TI contributes to the high prevalence of uncontrolled hypertension, the quantitative impact is not clear. This article examines the impact of TI on

The global epidemic of hypertension is largely uncontrolled and hypertension remains the leading cause of noncommunicable disease deaths worldwide. Suboptimal adherence, which includes failure to initiate pharmacotherapy, to take medications as often as prescribed, and to persist on therapy long-term, is a well-recognized factor contributing to the poor control of blood pressure in hypertension. Several categories of factors including demographic, socioeconomic, concomitant medical-behavioral conditions, therapy-related, healthcare team and system-related factors, and patient factors are associated with nonadherence. Understanding the categories of factors contributing to nonadherence is useful in managing nonadherence. In patients at high risk for major adverse cardiovascular outcomes, electronic and biochemical monitoring are useful for detecting nonadherence and for improving adherence. Increasing the availability and affordability of these more precise measures of adherence represent a future opportunity to realize more of the proven benefits of evidence-based medications. In the absence of new antihypertensive drugs, it is important that healthcare providers focus their attention on how to do better with the drugs they have. This is the reason why recent guidelines have emphasize the important need to address drug adherence as a major issue in hypertension management.

Low birth weights, which reflect adverse effects on development in utero, contribute to the early onset of ESRD in South Carolina. Since low birth weight increases the risk of ESRD from multiple causes, the data suggest that an adverse environment in utero impairs kidney development and makes it more vulnerable to damage from a range of pathological processes.

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