Blood Pressure Control Rates Are Falling in the United States: Why and What Can We Do About It

AUTHOR: Michael J. Bloch, MD Associate Professor, University of Nevada School of Medicine Medical Director, Renown Vascular Care, Renown Institute for Heart and Vascular Health President, Blue Spruce Medical Consultants, PLLC   After decades of improvement, for the first time we have seen blood pressure (BP) control rates decrease in this country.1 According to recently published data from the National Health and Nutrition Examination Survey (NHANES), nationwide BP control rates decreased to 43.7% in 2017-2018. This comes after the rate of controlled BP had increased from 31.8% in 1999-2000 to 48.5% in 2007-2008 and then to 53.8% in 2013-2014. Notably, all of these reports, including the most recent, use the older definition of BP control of less than 140/90 mm Hg rather than the more aggressive goal of less than 130/80 mm Hg, which has been recently promoted by the American Heart Association/American College of cardiology (AHA/ACC). As such, even this distressing most recent report underestimates the true burden of uncontrolled hypertension in the United States. Drilling down further into these data highlights some of the important potential contributors to this decrease in BP control rates. BP control was better among those aged 45 to 64 years (49.7%) vs those who were older than 75 years of age (36.7%). This suggests that the aging of our population may be contributing to reduced BP control rates but also highlights the importance of clinicians treating these patients more aggressively. BP control was more likely among patients with private or public insurance than among those without health care coverage (24.2%). Control was also more likely among those with close ties to a specific health care facility (48.4%) as compared with those without a working relationship with a health care facility. Additionally, control rates were higher among those who had had a health care visit in the past year (49.1%) vs those who had not seen a provider in the previous year (8.0%). Certainly, these data highlight the fact that expanding health care coverage, effective primary care networks, and lowering barriers to accessing care may be important ways to improve BP control rates. But given the low absolute levels of control even in these less-disadvantaged groups, these certainly are not the only factors involved. BP control rates among patients with known hypertension who have been prescribed antihypertensive medications decreased to 64.8% in 2017-2018. This failing grade suggests that adherence to medications and provider inertia in up-titrating medication in the face of poorly controlled BP are also critical factors. As the US Surgeon General Jerome Adams highlights in the recently published “Call to Action to Control Hypertension,”2 all providers can impact these control rates by putting in place standardized protocols in our practices to effectively measure BP, including BP control in quality improvement efforts, and implementing standardized systems-based treatment protocols including stepped care medication titration schemes. Additionally, patients need to be empowered to measure their own BP at home, take their medications as prescribed every day, and make appropriate lifestyle changes to improve BP control. There is also increasing interest in looking at “adherence independent” treatment strategies like renal denervation and other device therapies. Even in the midst of our the current COVID-19 pandemic, we need to realize that cardiovascular disease remains the number 1 cause of death in this country and that patients with uncontrolled hypertension have worse outcomes when faced with acute infectious diseases like COVID-19 than those whose BP is controlled. This surprising decrease in BP control rates should be seen as an indictment of our usual care and provide a much-needed wake up call to individuals with high BP and their families, clinicians, third-party payers, professional organizations and societies, employers, and governments. When patients’ BP is not controlled, their cardiovascular risk remains unacceptably high. We must remember that every clinical encounter where we document uncontrolled hypertension is an opportunity for a potentially lifesaving intervention. References: Muntner P, Hardy ST, Fine LJ, et al. Trends in blood pressure control among US adults with hypertension, 1999-2000 to 2017-2018. JAMA. 2020;324(12):1190-1200. doi:10.1001/jama.2020.14545 Adams JM, Wright JS. A national commitment to improve the care of patients with hypertension in the US. JAMA. 2020;324(18):1825-1826. doi:10.1001/jama.2020.20356