Initial antihypertensive therapy with single-pill combinations produced more rapid blood pressure control than initial monotherapy in clinical trials. Other studies reported better cardiovascular outcomes in patients achieving lower blood pressure during the first treatment year. We assessed the effectiveness of initial antihypertensive monotherapy, free combinations, and single-pill combinations in controlling untreated, uncontrolled hypertensives during their first treatment year. Electronic record data were obtained from 180 practice sites; 106,621 hypertensive patients seen from 01/2004–06/2009 had uncontrolled blood pressure, were untreated for ≥6 months before therapy, and had ≥1 one-year follow-up blood pressure data. Control was determined by the first follow-up visit with blood pressure <140/<90 mm Hg for patients without diabetes mellitus or chronic kidney disease and <130/<80 for patients with either or both conditions. Multivariable hazards regression ratios (HR) and 95% confidence intervals (95%CI) for time-to-control were calculated adjusting for age, sex, baseline blood pressure, body mass index, diabetes, chronic kidney disease, cardiovascular disease, initial therapy, final blood pressure medication number, and therapeutic inertia. Patients on initial single-pill combinations (N=9,194) were more likely to have Stage 2 hypertension than those on free combinations (N=18,328) or monotherapy (N=79,099 [all p<0.001]). Initial therapy with single-pill combinations (HR 1.53, 95%CI 1.47–1.58) provided better hypertension control in the first year than free combinations (HR 1.34, 95%CI 1.31–1.37) or monotherapy (reference) with benefits in black and white patients. Greater use of single-pill combinations as initial therapy may improve hypertension control and cardiovascular outcomes in the first treatment year.

Pre-hypertension is a major risk factor for hypertension. African Americans (blacks) have more prevalent and severe hypertension than whites, but it is unknown whether progression from pre-hypertension is accelerated in blacks. We examined this question in a prospective cohort study of 18,865 non-hypertensive persons (5,733 [30.4% black, 13,132 [69.6%]) white) 18–85 years old. Electronic health record data were obtained from 197 community-based outpatient clinics in the Southeast U.S. Days elapsing from study entry to hypertension diagnosis, mainly blood pressure [BP] ≥140 systolic and/or ≥90 mmHg diastolic on two consecutive visits established conversion time within a maximum observation period of 2550 days. Cox regression modeling was used to examine conversion to hypertension as a function of race, while controlling for age, sex, baseline systolic and diastolic BP, body mass index [BMI], diabetes mellitus and chronic kidney disease. The covariable adjusted median conversion time when 50% became hypertensive was 365 days earlier for blacks than whites (626 vs 991 days, p<0.001). Among covariables, baseline systolic BP 130–139 (Hazard Ratio 1.77, 95% Confidence Intervals [1.69–1.86]) and 120–129 mmHg (1.52 [1.44–1.60] as well as age ≥75 (1.40 [1.29–1.51] and 55–74 years (1.29 [1.23–1.35] were the strongest predictors of hypertension. Additional predictors included age 35–54 years, diastolic BP 80–89 mmHg, overweight and obesity, and diabetes mellitus (all p<0.001). Conversion from pre-hypertension to hypertension is accelerated in blacks, which suggests that effective interventions in pre-hypertension could reduce racial disparities in prevalent hypertension.

Hypertension control may offer less protection from incident cardiovascular disease (CVDi) in adults with than without apparent treatment resistant hypertension (aTRH), i.e., blood pressure uncontrolled on ≥3 or controlled to <140/<90 on ≥4 antihypertensive medications. Electronic health data were matched to health claims for 2006–2012. Patients with CVDi in 2006–2007 or untreated hypertension were excluded leaving 118,356 treated hypertensives, including 40,690 aTRH patients, ) with 460,599 observation years. Blood pressure and medication number were determined by all clinic visit means from 2008 to CVDi or end of study. Primary outcome was first CVDi (stroke; coronary heart disease, heart failure) from hospital and emergency department claims. Controlling for age, race, sex, diabetes, chronic kidney disease, and statin use, hypertension control afforded less CVDi protection in patients with (hazard ratio 0.87, 95% confidence interval [0.82–0.93]) than without aTRH (0.69 [0.65–0.74]), p<0.001. Strategies beyond hypertension control may prevent more CVDi in aTRH.