Background To reduce the cardiovascular disease burden, Healthy People 2020 established U.S. hypertension goals for adults to: (1) decrease prevalence to 26.9%. (2) raise treatment to 69.5% and control to 61.2%, which requires controlling 88.1% on treatment. Methods and Results To assess current status and progress toward these Healthy People 2020 goals, time trends in National Health and Nutrition Examination Surveys 1999–2012 data in twoyear blocks were assessed in adults ≥18 years old age-adjusted to U.S. 2010. From 1999–2000 to 2011–2012, prevalent hypertension was unchanged (30.1% vs. 30.8%, p=0.32). Hypertension treatment (59.8% vs. 74.7%, p<0.001) and proportion of treated adults controlled (53.3% to 68.9%, p=0.0015) increased. Hypertension control to <140/<90 mmHg rose every two years from 1999–2000 to 2009–2010 (32.2% vs. 53.8%, p<0.001) before declining to 51.2% in 2011–2012. Modifiable factor(s) significant in multivariable logistic regression modeling include: (a) increasing body mass index with prevalent hypertension (odds ratio [OR] 1.44). (b) lack of health insurance (OR 1.68) and <2 healthcare visits/year (OR 4.24) with untreated hypertension. (c) healthcare insurance (OR 1.69), ≥2 healthcare visits/year (OR 3.23) and cholesterol treatment (OR 1.90) with controlled hypertension. Conclusions The NHANES 1999–2012 analysis suggests that Healthy People 2020 goals for hypertension: (1) prevalence show no progress (2) treatment was exceeded (3) control has flattened below target. Findings are consistent with evidence that: (a) obesity prevention and treatment could reduce prevalent hypertension (b) healthcare insurance, ≥2 healthcare visits/year, and guideline-based cholesterol treatment could improve hypertension control.

Hypertensive patients with clinic blood pressure (BP) uncontrolled on ≥3 antihypertensive medications, i.e., apparent treatment resistant hypertension (aTRH) comprise ~28%–30% of all uncontrolled patients in the U.S. However, the proportion receiving these medications in optimal doses is unknown; aTRH is used, since treatment adherence, BP measurement artifacts, and optimal therapy were not available in electronic record data from our >200 community-based clinics Outpatient QUuality Improvement Network (OQUIN). This study sought to define the proportion of uncontrolled hypertensives with aTRH on optimal regimens and clinical factors associated with optimal therapy. During 2007–2010, 468,877 hypertensive patients met inclusion criteria. BP <140/<90 defined control. Multivariable logistic regression was used to assess variables independently associated with ‘optimal therapy’ (prescription of diuretic and ≥2 other BP medications at ≥50% of maximum recommended hypertension doses). Among 468,877 hypertensives, 147,635 (31.5%) were uncontrolled; among uncontrolled hypertensives, 44,684 were prescribed ≥3 BP medications (30.3%) of which 22,189 (15.0%) were prescribed ‘optimal’ therapy. Clinical factors independently associated with optimal BP therapy included black race (OR 1.40 [95% CI 1.32–1.49]), chronic kidney disease (1.31 [1.25–1.38]) diabetes (1.30 [1.24–1.37]), and coronary heart disease risk equivalent status (1.29 [1.14–1.46]). Clinicians more often prescribe optimal therapy for aTRH when cardiovascular risk is greater and treatment goals lower. Approximately one in seven of all uncontrolled hypertensives and one in two with uncontrolled aTRH are prescribed ≥3 BP medications in optimal regimens. Prescribing more optimal pharmacotherapy, for uncontrolled hypertensives including aTRH, confirmed with out-of-office BP, could improve hypertension control.

Prehypertension is associated with increased risk for hypertension and cardiovascular disease. Data are limited on the temporal changes in the prevalence of prehypertension and risk factors for hypertension and cardiovascular disease among United States adults with prehypertension. We analyzed data from 30,958 United States adults aged ≥20 years who participated in the National Health and Nutrition Examination Surveys between 1999 and 2012. Using the mean of three blood pressure measurements from a study examination, prehypertension was defined as systolic blood pressure of 120 to 139 mmHg and diastolic blood pressure <90 mmHg or diastolic blood pressure of 80 to 89 mmHg and systolic blood pressure <140 mmHg among participants not taking antihypertensive medication. Between 1999–2000 and 2011–2012, the percentage of United States adults with prehypertension decreased from 31.2% to 28.2% (p-trend=0.007). During this time period, the prevalence of several risk factors for cardiovascular disease and incident hypertension increased among United States adults with prehypertension including prediabetes (9.6% to 21.6%) and diabetes (6.0% to 8.5%) and overweight (33.5% to 37.3%) and obesity (30.6% to 35.2%). There was a non-statistically significant increase in no weekly leisure-time physical activity (40.0% to 43.9%). Also, the prevalence of adhering to the Dietary Approaches to Stop Hypertension eating pattern decreased (18.4% to 11.9%). In contrast, there was a non-statistically significant decline in current smoking (25.9% to 23.2%). In conclusion, the prevalence of prehypertension has decreased modestly since 1999–2000. Population-level approaches directed at adults with prehypertension are needed to improve risk factors to prevent hypertension and cardiovascular disease.

Background Hypertension doubles coronary heart disease (CHD) risk. Treating hypertension only reduces CHD risk ~25%. Treating hypercholesterolemia in hypertensive patients reduces residual CHD risk >35%. Methods and Results To assess progress in concurrent hypertension and hypercholesterolemia control, National Health and Nutrition Examination Surveys 1988–1994, 1999–2004, and 2005–2010 were analyzed. Hypertension was defined by blood pressure (BP) ≥140/≥90 mmHg, current medication treatment, and twice-told hypertension status; BP <140/<90 defined control. Hypercholesterolemia was defined by ATP III criteria based on 10-yr CHD risk, low-density lipoprotein cholesterol (LDL-C) and non-high(H)DL-C; values below diagnostic thresholds defined control. Across surveys, 60.7%–64.3% of hypertensives were hypercholesterolemic. From 1988–1994 to 2005–2010, control of LDL-C rose (9.2% [6.6%–11.9%] to 45.4% [42.6%–48.3%]), concomitant hypertension and LDL-C (5.0% [3.3%–6.7%] to 30.7% [27.9%–33.4%]) and combined hypertension, LDL-C, and non-HDL-C (1.8% [0.4%–3.2%] to 26.9% [24.4%–29.5%]). By multivariable logistic regression, factors associated with concomitant hypertension, LDL-C and non-HDL-C control (odds ratio [95% CI]) were statin (10.7 [8.1–14.3]) and antihypertensive (3.32 [2.45–4.50]) medications, age (0.77 [0.69–0.88/10-yr increase), ≥2 healthcare visits/yr (1.96 [1.23–3.11]) black race (0.59 [0.44–0.80]), Hispanic ethnicity (0.62 [0.43–0.90]), cardiovascular disease ([CVD] 0.44 [0.34–0.56]), and diabetes mellitus (0.54 [0.42–0.70]). Conclusions Despite progress, opportunities for improving concomitant hypertension and hypercholesterolemia control persist. Prescribing antihypertensive and anti-hyperlipidemic medications to achieve treatment goals, especially for older, minority, diabetic and CVD patients, and accessing healthcare at least biannually could improve concurrent risk factor control and CHD prevention.

Hypertension control (United States) increased from 1999 to 2000 to 2009 to 2010, plateaued during 2009 to 2014, then fell during 2015 to 2018. We sought explanatory factors for declining hypertension control and assessed whether specific age (18–39, 40–59, ≥60 years) or race-ethnicity groups (Non-Hispanic White, NH [B]lack, Hispanic) were disproportionately impacted. Adults with hypertension in National Health and Nutrition Examination Surveys during the plateau (2009–2014) and decline (2015–2018) in hypertension control were studied. Definitions: hypertension, blood pressure (mm Hg) ≥140 and/or ≥90 mm Hg or self-reported antihypertensive medications (Treated); Aware, ‘Yes” to, “Have you been told you have hypertension?”; Treatment effectiveness, proportion of treated adults controlled; control, blood pressure <140/<90. Comparing 2009 to 2014 to 2015 to 2018, blood pressure control fell among all adults (−7.5% absolute, P <0.001). Hypertension awareness (−3.4%, P =0.01), treatment (−4.6%, P =0.004), and treatment effectiveness (−6.0%, P <0.0001) fell, despite unchanged access to care (health care insurance, source, and visits [−0.2%, P =0.97]). Antihypertensive monotherapy rose (+4.2%, P =0.04), although treatment resistance factors increased (obesity +4.0%, P =0.02, diabetes +2.3%, P =0.02). Hypertension control fell across age (18–39 [−4.9%, P =0.30]; 40–59 [−9.9%, P =0.0003]; ≥60 years [−6.5%, P =0.005]) and race-ethnicity groups (Non-Hispanic White [−8.5%, P =0.0007]; NHB −7.4%, P =0.002]; Hispanic [−5.2%, P =0.06]). Racial/ethnic disparities in hypertension control versus Non-Hispanic White were attenuated after adjusting for modifiable factors including education, obesity and access to care; NHB (odds ratio, 0.79 unadjusted versus 0.84 adjusted); Hispanic (odds ratio 0.74 unadjusted versus 0.98 adjusted). Improving hypertension control and reducing disparities require greater and more equitable access to high quality health care and healthier lifestyles.

BackgroundHealthy People 2020 aim to reduce fatal atherosclerotic cardiovascular disease (ASCVD) by 20%, which translates into 310 000 fewer events annually assuming proportional reduction in fatal and nonfatal ASCVD. We estimated preventable ASCVD events by implementing the American College of Cardiology/American Heart Association (ACC/AHA) 2013 Cholesterol Guideline in all statin‐eligible adults. Absolute risk reduction (ARR) and number needed‐to‐treat (NNT) were calculated.Methods and ResultsNational Health and Nutrition Examination Survey data for 2007–2012 were analyzed for adults aged 21 to 79 years and extrapolated to the US population. Literature‐guided assumptions were used including (1) low‐density lipoprotein cholesterol falls 33% with moderate‐intensity statins and 51% with high‐intensity statins; (2) for each 39 mg/dL decline in low‐density lipoprotein cholesterol, 10‐year ASCVD 10 risk would fall 21% when ASCVD 10 risk was ≥20% and 33% when ASCVD 10 risk was <20%; and (3) either all statin‐eligible untreated adults or all with ASCVD 10 risk ≥7.5% would receive statins. Of 175.9 million adults aged 21 to 79 years not taking statins, 44.8 million (25.5%) were statin eligible. Treating all statin‐eligible adults would prevent an estimated 243 589 ASCVD events annually (ARR 5.4%, 10‐year NNT 18). Treating all statin‐eligible adults with ASCVD 10 risk ≥7.5% reduces the number treated to 32.2 million (28.2% fewer), whereas ASCVD events prevented annually fall only 10.5% to 217 974 (6.8% ARR, NNT 15).ConclusionsImplementing the ACC/AHA 2013 Cholesterol Guideline in all untreated, statin‐eligible adults could achieve ≈78% of the Healthy People 2020 ASCVD prevention goal. Most of the benefit is attained by individuals with 10‐year ASCVD risk ≥7.5%.

Hypertension awareness, treatment and control are lower among uninsured than insured adults. Time trends in differences and underlying modifiable factors are important for informing strategies to improve health equity. National Health and Nutrition Examination Surveys 1988–1994, 1999–2004, 2005–2010 data in adults 18–64 years were analyzed to explore this opportunity. The proportion of adults with hypertension who were uninsured increased from 12.3% in 1988–1994 to 17.4% in 2005–2010. In 1988–1994, hypertension awareness, treatment and control to <140/<90 millimeters mercury (30.1% versus 26.5, p=0.27) were similar in insured and uninsured adults. By 2005–2010, the absolute gap in hypertension control between uninsured and insured adults of 21.9% (52.5% versus 30.6%, p<0.001]) was explained approximately equally by lower awareness (65.2% versus 80.7%), fewer aware adults treated (75.2% versus 88.5%,and fewer treated adults controlled (63.1% versus 73.5% [all p<0.001]). Publicly insured and uninsured adults had similar income. Yet, hypertension control was similar across time periods in publicly and privately insured adults, despite lower income and education in the former. In multivariable analysis, hypertension control in 2005–2010 was associated with visit frequency (odds ratio 3.4, 95% confidence interval [2.4–4.8]), statin therapy (1.8 [1.4–2.3]) and healthcare insurance (1.6 [1.2–2.2]) but not poverty index (1.04 [0.96–1.12]). Public or private insurance linked to more frequent healthcare, greater awareness and effective treatment of hypertension, and appropriate statin use could reverse a long-term trend of growing inequity in hypertension control between insured and uninsured adults.

Background Joint National Committee goal blood pressure (BP) for all adults was <140/<90 mmHg or lower from 1984 to 2013. Adults ≥60 years (older) have mainly isolated systolic hypertension (ISH) with major trials attaining systolic BP <150 but not <140. The main objective was to assess changes in hypertension control to <140/<90 in younger (<60 years) and older adults and <150/<90 in the latter. Methods and Results National Health and Nutrition Examination Surveys (NHANES) 1988–1994, 1999–2004, 2005–2010 were analyzed in adults ≥18 years. From 1988–1994 to 2005–2010, hypertension control to <140/<90 improved in older (31.6% to 53.1%, p<0.001) and younger (45.7% to 55.9%, p<0.001) patients. The age gap in control declined from 14.1% (p<0.01) in 1988–1994 to 2.8% (p=0.13) in 2005–2010. Better hypertension control reflected increased percentages of older (55.6% to 77.5%) and younger (34.6% to 54.7%) patients on treatment and treated older (45.7% to 64.9%) and younger patients (56.8% to 73.4%) controlled (all p<0.001). Control to <150/<90 rose from 48.8% to 69.9% in older adults. Antihypertensive medication number and percentages on ≥3 medications increased in both age groups but more in older patients (p<0.01). BP control was higher in both age groups with ≥2 healthcare visits/year and statin therapy. Conclusions The age gap in hypertension control to <140/<90 was virtually eliminated in 2005–2010 as clinicians intensified therapy, especially in older patients where ISH predominates controlling 70% to <150/<90. More frequent healthcare and statin therapy may improve hypertension control in all adults.