a case study on hypertension

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Clinical management and treatment decisions, hypertension in black americans, pharmacologic treatment of hypertension in black americans.

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Suzanne Oparil, Case study, American Journal of Hypertension , Volume 11, Issue S8, November 1998, Pages 192S–194S, https://doi.org/10.1016/S0895-7061(98)00195-2

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Ms. C is a 42-year-old black American woman with a 7-year history of hypertension first diagnosed during her last pregnancy. Her family history is positive for hypertension, with her mother dying at 56 years of age from hypertension-related cardiovascular disease (CVD). In addition, both her maternal and paternal grandparents had CVD.

At physician visit one, Ms. C presented with complaints of headache and general weakness. She reported that she has been taking many medications for her hypertension in the past, but stopped taking them because of the side effects. She could not recall the names of the medications. Currently she is taking 100 mg/day atenolol and 12.5 mg/day hydrochlorothiazide (HCTZ), which she admits to taking irregularly because “... they bother me, and I forget to renew my prescription.” Despite this antihypertensive regimen, her blood pressure remains elevated, ranging from 150 to 155/110 to 114 mm Hg. In addition, Ms. C admits that she has found it difficult to exercise, stop smoking, and change her eating habits. Findings from a complete history and physical assessment are unremarkable except for the presence of moderate obesity (5 ft 6 in., 150 lbs), minimal retinopathy, and a 25-year history of smoking approximately one pack of cigarettes per day. Initial laboratory data revealed serum sodium 138 mEq/L (135 to 147 mEq/L); potassium 3.4 mEq/L (3.5 to 5 mEq/L); blood urea nitrogen (BUN) 19 mg/dL (10 to 20 mg/dL); creatinine 0.9 mg/dL (0.35 to 0.93 mg/dL); calcium 9.8 mg/dL (8.8 to 10 mg/dL); total cholesterol 268 mg/dL (< 245 mg/dL); triglycerides 230 mg/dL (< 160 mg/dL); and fasting glucose 105 mg/dL (70 to 110 mg/dL). The patient refused a 24-h urine test.

Taking into account the past history of compliance irregularities and the need to take immediate action to lower this patient’s blood pressure, Ms. C’s pharmacologic regimen was changed to a trial of the angiotensin-converting enzyme (ACE) inhibitor enalapril, 5 mg/day; her HCTZ was discontinued. In addition, recommendations for smoking cessation, weight reduction, and diet modification were reviewed as recommended by the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI). 1

After a 3-month trial of this treatment plan with escalation of the enalapril dose to 20 mg/day, the patient’s blood pressure remained uncontrolled. The patient’s medical status was reviewed, without notation of significant changes, and her antihypertensive therapy was modified. The ACE inhibitor was discontinued, and the patient was started on the angiotensin-II receptor blocker (ARB) losartan, 50 mg/day.

After 2 months of therapy with the ARB the patient experienced a modest, yet encouraging, reduction in blood pressure (140/100 mm Hg). Serum electrolyte laboratory values were within normal limits, and the physical assessment remained unchanged. The treatment plan was to continue the ARB and reevaluate the patient in 1 month. At that time, if blood pressure control remained marginal, low-dose HCTZ (12.5 mg/day) was to be added to the regimen.

Hypertension remains a significant health problem in the United States (US) despite recent advances in antihypertensive therapy. The role of hypertension as a risk factor for cardiovascular morbidity and mortality is well established. 2–7 The age-adjusted prevalence of hypertension in non-Hispanic black Americans is approximately 40% higher than in non-Hispanic whites. 8 Black Americans have an earlier onset of hypertension and greater incidence of stage 3 hypertension than whites, thereby raising the risk for hypertension-related target organ damage. 1 , 8 For example, hypertensive black Americans have a 320% greater incidence of hypertension-related end-stage renal disease (ESRD), 80% higher stroke mortality rate, and 50% higher CVD mortality rate, compared with that of the general population. 1 , 9 In addition, aging is associated with increases in the prevalence and severity of hypertension. 8

Research findings suggest that risk factors for coronary heart disease (CHD) and stroke, particularly the role of blood pressure, may be different for black American and white individuals. 10–12 Some studies indicate that effective treatment of hypertension in black Americans results in a decrease in the incidence of CVD to a level that is similar to that of nonblack American hypertensives. 13 , 14

Data also reveal differences between black American and white individuals in responsiveness to antihypertensive therapy. For instance, studies have shown that diuretics 15 , 16 and the calcium channel blocker diltiazem 16 , 17 are effective in lowering blood pressure in black American patients, whereas β-adrenergic receptor blockers and ACE inhibitors appear less effective. 15 , 16 In addition, recent studies indicate that ARB may also be effective in this patient population.

Angiotensin-II receptor blockers are a relatively new class of agents that are approved for the treatment of hypertension. Currently, four ARB have been approved by the US Food and Drug Administration (FDA): eprosartan, irbesartan, losartan, and valsartan. Recently, a 528-patient, 26-week study compared the efficacy of eprosartan (200 to 300 mg/twice daily) versus enalapril (5 to 20 mg/daily) in patients with essential hypertension (baseline sitting diastolic blood pressure [DBP] 95 to 114 mm Hg). After 3 to 5 weeks of placebo, patients were randomized to receive either eprosartan or enalapril. After 12 weeks of therapy within the titration phase, patients were supplemented with HCTZ as needed. In a prospectively defined subset analysis, black American patients in the eprosartan group (n = 21) achieved comparable reductions in DBP (−13.3 mm Hg with eprosartan; −12.4 mm Hg with enalapril) and greater reductions in systolic blood pressure (SBP) (−23.1 with eprosartan; −13.2 with enalapril), compared with black American patients in the enalapril group (n = 19) ( Fig. 1 ). 18 Additional trials enrolling more patients are clearly necessary, but this early experience with an ARB in black American patients is encouraging.

Efficacy of the angiotensin II receptor blocker eprosartan in black American with mild to moderate hypertension (baseline sitting DBP 95 to 114 mm Hg) in a 26-week study. Eprosartan, 200 to 300 mg twice daily (n = 21, solid bar), enalapril 5 to 20 mg daily (n = 19, diagonal bar). †10 of 21 eprosartan patients and seven of 19 enalapril patients also received HCTZ. Adapted from data in Levine: Subgroup analysis of black hypertensive patients treated with eprosartan or enalapril: results of a 26-week study, in Programs and abstracts from the 1st International Symposium on Angiotensin-II Antagonism, September 28–October 1, 1997, London, UK.

Approximately 30% of all deaths in hypertensive black American men and 20% of all deaths in hypertensive black American women are attributable to high blood pressure. Black Americans develop high blood pressure at an earlier age, and hypertension is more severe in every decade of life, compared with whites. As a result, black Americans have a 1.3 times greater rate of nonfatal stroke, a 1.8 times greater rate of fatal stroke, a 1.5 times greater rate of heart disease deaths, and a 5 times greater rate of ESRD when compared with whites. 19 Therefore, there is a need for aggressive antihypertensive treatment in this group. Newer, better tolerated antihypertensive drugs, which have the advantages of fewer adverse effects combined with greater antihypertensive efficacy, may be of great benefit to this patient population.

1. Joint National Committee : The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure . Arch Intern Med 1997 ; 24 157 : 2413 – 2446 .

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3. Veterans Administration Cooperative Study Group on Antihypertensive Agents : Effects of treatment on morbidity in hypertension: II. Results in patients with diastolic blood pressures averaging 90 through 114 mm Hg . JAMA 1970 ; 213 : 1143 – 1152 .

4. Pooling Project Research Group : Relationship of blood pressure, serum cholesterol, smoking habit, relative weight and ECG abnormalities to the incidence of major coronary events: Final report of the pooling project . J Chronic Dis 1978 ; 31 : 201 – 306 .

5. Hypertension Detection and Follow-Up Program Cooperative Group : Five-year findings of the hypertension detection and follow-up program: I. Reduction in mortality of persons with high blood pressure, including mild hypertension . JAMA 1979 ; 242 : 2562 – 2577 .

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8. Burt VL , Whelton P , Roccella EJ et al.  : Prevalence of hypertension in the US adult population: Results from the third National Health and Nutrition Examination Survey, 1988–1991 . Hypertension 1995 ; 25 : 305 – 313 .

9. Klag MJ , Whelton PK , Randall BL et al.  : End-stage renal disease in African-American and white men: 16-year MRFIT findings . JAMA 1997 ; 277 : 1293 – 1298 .

10. Neaton JD , Kuller LH , Wentworth D et al.  : Total and cardiovascular mortality in relation to cigarette smoking, serum cholesterol concentration, and diastolic blood pressure among black and white males followed up for five years . Am Heart J 1984 ; 3 : 759 – 769 .

11. Gillum RF , Grant CT : Coronary heart disease in black populations II: Risk factors . Heart J 1982 ; 104 : 852 – 864 .

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13. Hypertension Detection and Follow-up Program Cooperative Group : Five-year findings of the Hypertension Detection and Follow-up Program: mortality by race-sex and blood pressure level: a further analysis . J Community Health 1984 ; 9 : 314 – 327 .

14. Ooi WL , Budner NS , Cohen H et al.  : Impact of race on treatment response and cardiovascular disease among hypertensives . Hypertension 1989 ; 14 : 227 – 234 .

15. Weinberger MH : Racial differences in antihypertensive therapy: evidence and implications . Cardiovasc Drugs Ther 1990 ; 4 ( suppl 2 ): 379 – 392 .

16. Materson BJ , Reda DJ , Cushman WC et al.  : Single-drug therapy for hypertension in men: A comparison of six antihypertensive agents with placebo . N Engl J Med 1993 ; 328 : 914 – 921 .

17. Materson BJ , Reda DJ , Cushman WC for the Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents : Department of Veterans Affairs single-drug therapy of hypertension study: Revised figures and new data . Am J Hypertens 1995 ; 8 : 189 – 192 .

18. Levine B : Subgroup analysis of black hypertensive patients treated with eprosartan or enalapril: results of a 26-week study , in Programs and abstracts from the first International Symposium on Angiotensin-II Antagonism , September 28 – October 1 , 1997 , London, UK .

19. American Heart Association: 1997 Heart and Stroke Statistical Update . American Heart Association , Dallas , 1997 .

• hypertension
• blood pressure
• african american

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Chapter 6:  10 Real Cases on Hypertensive Emergency and Pericardial Disease: Diagnosis, Management, and Follow-Up

Niel Shah; Fareeha S. Alavi; Muhammad Saad

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Case review, case discussion.

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Case 1: Management of Hypertensive Encephalopathy

A 45-year-old man with a 2-month history of progressive headache presented to the emergency department with nausea, vomiting, visual disturbance, and confusion for 1 day. He denied fever, weakness, numbness, shortness of breath, and flulike symptoms. He had significant medical history of hypertension and was on a β-blocker in the past, but a year ago, he stopped taking medication due to an unspecified reason. The patient denied any history of tobacco smoking, alcoholism, and recreational drug use. The patient had a significant family history of hypertension in both his father and mother. Physical examination was unremarkable, and at the time of triage, his blood pressure (BP) was noted as 195/123 mm Hg, equal in both arms. The patient was promptly started on intravenous labetalol with the goal to reduce BP by 15% to 20% in the first hour. The BP was rechecked after an hour of starting labetalol and was 165/100 mm Hg. MRI of the brain was performed in the emergency department and demonstrated multiple scattered areas of increased signal intensity on T2-weighted and fluid-attenuated inversion recovery (FLAIR) images in both the occipital and posterior parietal lobes. There were also similar lesions in both hemispheres of the cerebellum (especially the cerebellar white matter on the left) as well as in the medulla oblongata. The lesions were not associated with mass effect, and after contrast administration, there was no evidence of abnormal enhancement. In the emergency department, his BP decreased to 160/95 mm Hg, and he was transitioned from drip to oral medications and transferred to the telemetry floor. How would you manage this case?

The patient initially presented with headache, nausea, vomiting, blurred vision, and confusion. The patient’s BP was found to be 195/123 mm Hg, and MRI of the brain demonstrated scattered lesions with increased intensity in the occipital and posterior parietal lobes, as well as in cerebellum and medulla oblongata. The clinical presentation, elevated BP, and brain MRI findings were suggestive of hypertensive emergency, more specifically hypertensive encephalopathy. These MRI changes can be seen particularly in posterior reversible encephalopathy syndrome (PRES), a sequela of hypertensive encephalopathy. BP was initially controlled by labetalol, and after satisfactory control of BP, the patient was switched to oral antihypertensive medications.

Hypertensive emergency refers to the elevation of systolic BP >180 mm Hg and/or diastolic BP >120 mm Hg that is associated with end-organ damage; however, in some conditions such as pregnancy, more modest BP elevation can constitute an emergency. An equal degree of hypertension but without end-organ damage constitutes a hypertensive urgency, the treatment of which requires gradual BP reduction over several hours. Patients with hypertensive emergency require rapid, tightly controlled reductions in BP that avoid overcorrection. Management typically occurs in an intensive care setting with continuous arterial BP monitoring and continuous infusion of antihypertensive agents.

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Newly diagnosed hypertension: case study

Angela Brown

Trainee Advanced Nurse Practitioner, East Belfast GP Federation, Northern Ireland

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The role of an advanced nurse practitioner encompasses the assessment, diagnosis and treatment of a range of conditions. This case study presents a patient with newly diagnosed hypertension. It demonstrates effective history taking, physical examination, differential diagnoses and the shared decision making which occurred between the patient and the professional. It is widely acknowledged that adherence to medications is poor in long-term conditions, such as hypertension, but using a concordant approach in practice can optimise patient outcomes. This case study outlines a concordant approach to consultations in clinical practice which can enhance adherence in long-term conditions.

Hypertension is a worldwide problem with substantial consequences ( Fisher and Curfman, 2018 ). It is a progressive condition ( Jamison, 2006 ) requiring lifelong management with pharmacological treatments and lifestyle adjustments. However, adopting these lifestyle changes can be notoriously difficult to implement and sustain ( Fisher and Curfman, 2018 ) and non-adherence to chronic medication regimens is extremely common ( Abegaz et al, 2017 ). This is also recognised by the National Institute for Health and Care Excellence (NICE) (2009) which estimates that between 33.3% and 50% of medications are not taken as recommended. Abegaz et al (2017) furthered this by claiming 83.7% of people with uncontrolled hypertension do not take medications as prescribed. However, leaving hypertension untreated or uncontrolled is the single largest cause of cardiovascular disease ( Fisher and Curfman, 2018 ). Therefore, better adherence to medications is associated with better outcomes ( World Health Organization, 2003 ) in terms of reducing the financial burden associated with the disease process on the health service, improving outcomes for patients ( Chakrabarti, 2014 ) and increasing job satisfaction for professionals ( McKinnon, 2013 ). Therefore, at a time when growing numbers of patients are presenting with hypertension, health professionals must adopt a concordant approach from the initial consultation to optimise adherence.

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Newly diagnosed hypertension: case study

Affiliation.

• 1 Trainee Advanced Nurse Practitioner, East Belfast GP Federation, Northern Ireland.
• PMID: 37344134
• DOI: 10.12968/bjon.2023.32.12.556

The role of an advanced nurse practitioner encompasses the assessment, diagnosis and treatment of a range of conditions. This case study presents a patient with newly diagnosed hypertension. It demonstrates effective history taking, physical examination, differential diagnoses and the shared decision making which occurred between the patient and the professional. It is widely acknowledged that adherence to medications is poor in long-term conditions, such as hypertension, but using a concordant approach in practice can optimise patient outcomes. This case study outlines a concordant approach to consultations in clinical practice which can enhance adherence in long-term conditions.

Keywords: Adherence; Advanced nurse practitioner; Case study; Concordance; Hypertension.

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Patient Case Presentation

Mr. E.A. is a 40-year-old black male who presented to his Primary Care Provider for a diabetes follow up on October 14th, 2019. The patient complains of a general constant headache that has lasted the past week, with no relieving factors. He also reports an unusual increase in fatigue and general muscle ache without any change in his daily routine. Patient also reports occasional numbness and tingling of face and arms. He is concerned that these symptoms could potentially be a result of his new diabetes medication that he began roughly a week ago. Patient states that he has not had any caffeine or smoked tobacco in the last thirty minutes. During assessment vital signs read BP 165/87, Temp 97.5 , RR 16, O 98%, and HR 86. E.A states he has not lost or gained any weight. After 10 mins, the vital signs were retaken BP 170/90, Temp 97.8, RR 15, O 99% and HR 82. Hg A1c 7.8%, three months prior Hg A1c was 8.0%.  Glucose  180 mg/dL (fasting).  FAST test done; negative for stroke. CT test, Chem 7 and CBC have been ordered.

Past medical history

Diagnosed with diabetes (type 2) at 32 years old

Overweight, BMI of 31

Had a cholecystomy at 38 years old

Diagnosed with dyslipidemia at 32 years old

Past family history

Mother alive, diagnosed diabetic at 42 years old 

Father alive with Hypertension diagnosed at 55 years old

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Evan M. Benjamin; Case Study: Treating Hypertension in Patients With Diabetes. Clin Diabetes 1 July 2004; 22 (3): 137–138. https://doi.org/10.2337/diaclin.22.3.137

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L.N. is a 49-year-old white woman with a history of type 2 diabetes,obesity, hypertension, and migraine headaches. The patient was diagnosed with type 2 diabetes 9 years ago when she presented with mild polyuria and polydipsia. L.N. is 5′4″ and has always been on the large side,with her weight fluctuating between 165 and 185 lb.

Initial treatment for her diabetes consisted of an oral sulfonylurea with the rapid addition of metformin. Her diabetes has been under fair control with a most recent hemoglobin A 1c of 7.4%.

Hypertension was diagnosed 5 years ago when blood pressure (BP) measured in the office was noted to be consistently elevated in the range of 160/90 mmHg on three occasions. L.N. was initially treated with lisinopril, starting at 10 mg daily and increasing to 20 mg daily, yet her BP control has fluctuated.

One year ago, microalbuminuria was detected on an annual urine screen, with 1,943 mg/dl of microalbumin identified on a spot urine sample. L.N. comes into the office today for her usual follow-up visit for diabetes. Physical examination reveals an obese woman with a BP of 154/86 mmHg and a pulse of 78 bpm.

What are the effects of controlling BP in people with diabetes?

What is the target BP for patients with diabetes and hypertension?

Which antihypertensive agents are recommended for patients with diabetes?

Diabetes mellitus is a major risk factor for cardiovascular disease (CVD). Approximately two-thirds of people with diabetes die from complications of CVD. Nearly half of middle-aged people with diabetes have evidence of coronary artery disease (CAD), compared with only one-fourth of people without diabetes in similar populations.

Patients with diabetes are prone to a number of cardiovascular risk factors beyond hyperglycemia. These risk factors, including hypertension,dyslipidemia, and a sedentary lifestyle, are particularly prevalent among patients with diabetes. To reduce the mortality and morbidity from CVD among patients with diabetes, aggressive treatment of glycemic control as well as other cardiovascular risk factors must be initiated.

Studies that have compared antihypertensive treatment in patients with diabetes versus placebo have shown reduced cardiovascular events. The United Kingdom Prospective Diabetes Study (UKPDS), which followed patients with diabetes for an average of 8.5 years, found that patients with tight BP control (< 150/< 85 mmHg) versus less tight control (< 180/< 105 mmHg) had lower rates of myocardial infarction (MI), stroke, and peripheral vascular events. In the UKPDS, each 10-mmHg decrease in mean systolic BP was associated with a 12% reduction in risk for any complication related to diabetes, a 15% reduction for death related to diabetes, and an 11% reduction for MI. Another trial followed patients for 2 years and compared calcium-channel blockers and angiotensin-converting enzyme (ACE) inhibitors,with or without hydrochlorothiazide against placebo and found a significant reduction in acute MI, congestive heart failure, and sudden cardiac death in the intervention group compared to placebo.

The Hypertension Optimal Treatment (HOT) trial has shown that patients assigned to lower BP targets have improved outcomes. In the HOT trial,patients who achieved a diastolic BP of < 80 mmHg benefited the most in terms of reduction of cardiovascular events. Other epidemiological studies have shown that BPs > 120/70 mmHg are associated with increased cardiovascular morbidity and mortality in people with diabetes. The American Diabetes Association has recommended a target BP goal of < 130/80 mmHg. Studies have shown that there is no lower threshold value for BP and that the risk of morbidity and mortality will continue to decrease well into the normal range.

Many classes of drugs have been used in numerous trials to treat patients with hypertension. All classes of drugs have been shown to be superior to placebo in terms of reducing morbidity and mortality. Often, numerous agents(three or more) are needed to achieve specific target levels of BP. Use of almost any drug therapy to reduce hypertension in patients with diabetes has been shown to be effective in decreasing cardiovascular risk. Keeping in mind that numerous agents are often required to achieve the target level of BP control, recommending specific agents becomes a not-so-simple task. The literature continues to evolve, and individual patient conditions and preferences also must come into play.

While lowering BP by any means will help to reduce cardiovascular morbidity, there is evidence that may help guide the selection of an antihypertensive regimen. The UKPDS showed no significant differences in outcomes for treatment for hypertension using an ACE inhibitor or aβ-blocker. In addition, both ACE inhibitors and angiotensin II receptor blockers (ARBs) have been shown to slow the development and progression of diabetic nephropathy. In the Heart Outcomes Prevention Evaluation (HOPE)trial, ACE inhibitors were found to have a favorable effect in reducing cardiovascular morbidity and mortality, whereas recent trials have shown a renal protective benefit from both ACE inhibitors and ARBs. ACE inhibitors andβ-blockers seem to be better than dihydropyridine calcium-channel blockers to reduce MI and heart failure. However, trials using dihydropyridine calcium-channel blockers in combination with ACE inhibitors andβ-blockers do not appear to show any increased morbidity or mortality in CVD, as has been implicated in the past for dihydropyridine calcium-channel blockers alone. Recently, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) in high-risk hypertensive patients,including those with diabetes, demonstrated that chlorthalidone, a thiazide-type diuretic, was superior to an ACE inhibitor, lisinopril, in preventing one or more forms of CVD.

L.N. is a typical patient with obesity, diabetes, and hypertension. Her BP control can be improved. To achieve the target BP goal of < 130/80 mmHg, it may be necessary to maximize the dose of the ACE inhibitor and to add a second and perhaps even a third agent.

Diuretics have been shown to have synergistic effects with ACE inhibitors,and one could be added. Because L.N. has migraine headaches as well as diabetic nephropathy, it may be necessary to individualize her treatment. Adding a β-blocker to the ACE inhibitor will certainly help lower her BP and is associated with good evidence to reduce cardiovascular morbidity. Theβ-blocker may also help to reduce the burden caused by her migraine headaches. Because of the presence of microalbuminuria, the combination of ARBs and ACE inhibitors could also be considered to help reduce BP as well as retard the progression of diabetic nephropathy. Overall, more aggressive treatment to control L.N.'s hypertension will be necessary. Information obtained from recent trials and emerging new pharmacological agents now make it easier to achieve BP control targets.

Hypertension is a risk factor for cardiovascular complications of diabetes.

Clinical trials demonstrate that drug therapy versus placebo will reduce cardiovascular events when treating patients with hypertension and diabetes.

A target BP goal of < 130/80 mmHg is recommended.

Pharmacological therapy needs to be individualized to fit patients'needs.

ACE inhibitors, ARBs, diuretics, and β-blockers have all been documented to be effective pharmacological treatment.

Combinations of drugs are often necessary to achieve target levels of BP control.

ACE inhibitors and ARBs are agents best suited to retard progression of nephropathy.

Evan M. Benjamin, MD, FACP, is an assistant professor of medicine and Vice President of Healthcare Quality at Baystate Medical Center in Springfield, Mass.

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• Introduction
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The population meeting lifestyle modification criteria and meeting lifestyle modifications and medication criteria were calculated among individuals who were aware of their hypertension status and were independent of medication use. The population taking blood pressure medication was calculated among those meeting lifestyle modifications and medication criteria. Adults aged 65 years or older with hypertension are not eligible for only lifestyle modification. Missing bars reflect estimates suppressed in accordance with National Center for Health Statistics Standards for presenting proportions 26 . Non-Hispanic other included those who self-reported multiracial or any non-Hispanic ethnicity other than Asian, Black, or White.

The population meeting lifestyle modification criteria and meeting lifestyle modifications and medication criteria were calculated among individuals who were aware of their hypertension status and were independent of medication use. The population taking blood pressure medication was calculated among those meeting lifestyle modifications and medication criteria. Missing bars reflect estimates suppressed in accordance with National Center for Health Statistics Standards for presenting proportions. 26

eTable. Age-Standardized Hypertension Cascade Prevalence Estimates Among Adults Aged 18 Years or Older in the US with Hypertension by Sociodemographic and Health Characteristics, January 2017-March 2020

eFigure 1. Hypertension Control Cascade Population Estimates Among Adults Aged 18 Years or Older in the US with Uncontrolled Hypertension by Age and Race and Ethnicity and Stratified by Sex, January 2017-March 2020

eFigure 2. Hypertension Control Cascade Population Estimates Among Adults Aged 18 Years or Older in the US with Uncontrolled Hypertension by Select Risk Factors and Sociodemographic Variables, January 2017-March 2020

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• Implementation of Hypertension Control Based on the Population JAMA Network Open Invited Commentary September 11, 2024 Daniel T. Lackland, DrPH

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Richardson LC , Vaughan AS , Wright JS , Coronado F. Examining the Hypertension Control Cascade in Adults With Uncontrolled Hypertension in the US. JAMA Netw Open. 2024;7(9):e2431997. doi:10.1001/jamanetworkopen.2024.31997

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Examining the Hypertension Control Cascade in Adults With Uncontrolled Hypertension in the US

• 1 Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
• Invited Commentary Implementation of Hypertension Control Based on the Population Daniel T. Lackland, DrPH JAMA Network Open

Question   What are the hypertension control cascade estimates among adults with uncontrolled hypertension in the US?

Findings   This cross-sectional study of 3129 adults aged 18 years or older with uncontrolled hypertension found that uncontrolled hypertension prevalence overall was high at 83.7%. Younger adults aged 18 to 44 years with hypertension had especially high prevalence of uncontrolled hypertension of which they were unaware, with marked differences by health care utilization.

Meaning   The findings of this study suggest there are opportunities to increase hypertension awareness and treatment to reduce cardiovascular disease and improve the nation’s overall health.

Importance   Uncontrolled hypertension is a major contributor to cardiovascular disease (CVD) in the US.

Objective   To determine the prevalence of hypertension control cascade outcomes (hypertension awareness, treatment recommendations, and medication use) among individuals with uncontrolled hypertension to inform action across cascade levels.

Design, Setting, and Participants   This weighted cross-sectional study used January 2017 to March 2020 National Health and Nutrition Examination Survey (NHANES) data from noninstitutionalized adults aged 18 years or older in the US with uncontrolled hypertension. Data analysis occurred from January to February 2024.

Exposure   Calendar year of response to the NHANES survey.

Main Outcomes and Measures   Mean blood pressure (BP) was computed using up to 3 measurements. Uncontrolled hypertension was defined as systolic BP of 130 mm Hg or greater or diastolic BP of 80 mm Hg or greater, regardless of medication use. Outcomes included patient awareness of hypertension, treatment recommendations, and medication use. To estimate population totals by subgroup, the age-standardized proportion of each outcome was multiplied by the estimated number of adults with uncontrolled hypertension.

Results   The study included 3129 US adults with uncontrolled hypertension (1675 male [weighted percentage, 52.3%]; 775 aged 18 to 44 years [weighted percentage, 29.4%]; 1306 aged 45 to 64 years [weighted percentage, 41.4%]; 1048 aged 65 years or older [weighted percentage, 29.2%]), resulting in a population estimate of 100.4 million adults (weighted percentage, 83.7%) with uncontrolled hypertension. More than one-half of study participants (57.8 million adults [weighted percentage, 57.6%]) were unaware that they had hypertension, and of the 35.0 million who were aware and met criteria for antihypertensive medication, 24.8 million (weighted percentage, 70.8%) took the medication but had hypertension that remained uncontrolled. These negative outcomes in the hypertension control cascade occurred across demographic groups, with notably high prevalence among younger adults and individuals engaged in health care. Among an estimated 30.1 million adults aged 18 to 44 years with hypertension, 10.4 of 11.3 million females (weighted percentage, 91.8%) and 17.7 million of 18.8 million males (weighted percentage, 94.3%) had uncontrolled hypertension. Of the 10.4 million females, 7.2 million (weighted percentage, 68.8%) were unaware of their hypertension status, and of the 17.7 million males, 12.0 million (weighted percentage, 68.1%) were unaware. Additionally, 9.9 of 13.0 million adults with uncontrolled hypertension (weighted percentage, 75.7%) reported no health care visits in the past year and were unaware. Conversely, among 70.6 million adults with uncontrolled hypertension reporting 2 or more health care visits, approximately one-half (36.6 million [weighted percentage, 51.8%]) were unaware.

Conclusions and Relevance   In this cross-sectional study, more than 50% of adults with uncontrolled hypertension in the US were unaware of their hypertension and were untreated, and 70.8% of those who were treated had hypertension that remained uncontrolled. These findings have serious implications for the nation’s overall health given the association of hypertension with increased risk for CVD.

Approximately 120 million adults in the US (48.1%) have hypertension; of those, 92.9 million (77.4%) have uncontrolled hypertension, 1 with disparities in hypertension prevalence and control by sex, 2 - 4 age group, 5 , 6 and race and ethnicity. 7 - 10 Uncontrolled hypertension, which costs the nation $131 to $198 billion yearly, 11 is a leading factor associated with increased risk of cardiovascular disease (CVD) mortality and events, including heart attack and stroke, and is also associated with an increased risk of diabetes, chronic kidney disease (CKD), and cognitive decline. 12 , 13

The hypertension control cascade is a nested framework for understanding and intervening on hypertension at different levels including awareness, treatment, and control. 1 , 14 - 16 Individuals must first be aware of their diagnosis to be eligible for recommended treatments and must then be treated to achieve control. Prior studies have examined the hypertension cascade by applying the previous Joint National Committee (JNC) blood pressure (BP) guidelines 17 to the total US population singly stratified by various sociodemographic variables. 9 , 15 , 18 However, assessing the cascade among all adults in the US, including those with controlled hypertension, obscures variation by control status. Therefore, limiting cascade outcome measures to individuals with uncontrolled hypertension can inform at which cascade level evidence-based strategies, programs, and interventions may be most useful among this at-risk population. Additionally, presenting results by sociodemographic groups and by subgroups within sex can help to tailor solutions and inform efforts to reduce disparities.

In 2017, the American College of Cardiology/American Heart Association (ACC/AHA) updated hypertension guidelines for adults aged 18 years or older, defining hypertension as systolic BP (SBP)greater than or equal to 130 mm Hg and diastolic BP (DBP) greater than or equal to 80 mm Hg. This definition expanded eligibility for pharmacologic treatment and lifestyle modification for BP management, replacing the prior JNC guidelines. 16 , 19 Therefore, this study uses current hypertension guidelines to present the hypertension control cascade (awareness, treatment eligibility, and medication use) from January 2017 to March 2020 among adults aged 18 years or older in the US with uncontrolled hypertension, stratified by demographic and socioeconomic factors.

This cross-sectional study was approved by the Centers for Disease Control and Prevention (CDC) and followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline. We used the January 2017 to March 2020 National Health and Nutrition Examination Survey (NHANES), a nationally representative, cross-sectional survey of the US civilian, noninstitutionalized population. NHANES methodology, including the process for obtaining written informed consent from all study participants, has been described elsewhere. 20 NHANES data are typically published as 2-year survey cycles. Data for the 2019 to 2020 survey cycle, which stopped collection in March 2020 due to the COVID-19 pandemic and therefore excludes pandemic-related impacts, were combined with 2017 to 2018 data to achieve a nationally representative sample and released as a public use dataset. 21 We used this combined dataset.

Overall, 8965 persons aged 18 years or older completed the NHANES examination during January 2017 to March 2020. We excluded participants who reported pregnancy during the survey (87 participants), had missing BP measurements (930 participants), had missing current BP medication use (3 participants), or had unknown values for other covariates (617 participants).

NHANES data are publicly available. This secondary analysis was reviewed by CDC and was conducted in adherence with applicable federal law and CDC policy.

SBP and DBP were calculated as the mean of up to 3 consecutive BP measurements. We defined hypertension as having a BP reading meeting the 2017 ACC/AHA guidelines definition (SBP ≥130 mm Hg or DBP ≥80 mm Hg) or self-reported current use of BP-lowering medication (regardless of BP reading). We defined uncontrolled hypertension consistent with the 2017 ACC/AHA guidelines, with or without current use of BP-lowering medication.

Participants were asked the question, “Have you ever been told by a doctor or health professional that you had hypertension, also called high blood pressure?” Those who responded yes were considered aware of their hypertension status.

Based on the 2017 ACC/AHA guidelines, participants who were aware of their hypertension status were considered as meeting criteria for lifestyle modifications and pharmacologic treatment if they reported current BP medication use, had stage 2 hypertension (SBP ≥140 mm Hg or DBP ≥90 mm Hg), had stage 1 hypertension (SBP, 130-139 mm Hg; DBP, 80-89 mm Hg) and an existing or high risk of developing CVD (atherosclerotic CVD [ASCVD] score ≥10%), or were aged 65 years or older. 16 Meeting criteria for lifestyle modifications alone was defined as having stage 1 hypertension with a low risk of developing CVD (ASCVD score <10%). Participants unaware of their hypertension status were considered to not meet criteria for any recommendations.

Among participants meeting criteria for lifestyle modifications and pharmacologic treatment, we defined participants as currently taking BP-lowering medication. This was determined using self-reported status.

Age was categorized as 18 to 44 years, 45 to 64 years, and 65 years or older. Self-reported race and ethnicity were queried in the same survey question and categorized as Hispanic (Mexican American and other Hispanic combined), non-Hispanic Asian, non-Hispanic Black, non-Hispanic White, and non-Hispanic other (includes multiracial individuals and any other non-Hispanic group other than non-Hispanic Asian, non-Hispanic Black, and non-Hispanic White). We further analyzed age and race and ethnicity within 2 sex categories: male and female. Race and ethnicity were assessed due to racial disparities in hypertension prevalence and control. 7 - 10

Self-reported educational attainment was categorized as less than high school, high school graduate or equivalent, some college or associate’s degree, and college graduate or above. Federal income-to-poverty ratio was defined as the participant’s family income divided by the federal poverty level and categorized as less than 1.30%, 1.30% to 3.50%, and greater than 3.50%. 22 Participants reporting having Medicare, private, or other public health insurance were considered to have health insurance. We determined the number of health care visits during the past year based on the question, “During the last 12 months how many times have you seen a doctor or other health professional about your health at a doctor’s office, a clinic, hospital emergency department, at home or some other place? Do not include times you were hospitalized overnight.” Responses were categorized as 0 visits, 1 visit, and 2 or more visits.

We further analyzed cooccurring health conditions. Participants were categorized based on body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) as normal or underweight (<25.0), overweight (25.0-29.9), and obese (≥30.0); BMI was predetermined in the downloaded NHANES dataset. Participants were considered to have diabetes based on self-report, having a hemoglobin A1c value of 6.5% or greater (to convert to proportion of total hemoglobin, multiply by 0.01), or having a fasting plasma glucose level of 126 mg/dL or greater (to convert to millimoles per liter, multiply by 0.0555). We defined participants as having CKD based on an estimated glomerular filtration rate less than 60 mL/min/1.73 m 2 or a urine albumin-to-creatinine ratio of 30 mg/g or greater. Participants were considered to have a history of clinical CVD based on self-reported diagnosis of coronary heart disease, congestive heart failure, acute myocardial infarction, angina, or stroke.

We determined unweighted counts, age-standardized weighted counts, age-standardized weighted prevalence and corresponding 95% CIs for each participant characteristic. Values were age-standardized to the 2000 standard US population. 23 , 24

To estimate population totals by subgroup, we multiplied the age-standardized proportion of each outcome by the estimated number of adults with uncontrolled hypertension, which was calculated based on the National Center for Health Statistics (NCHS) civilian noninstitutionalized population totals for adults aged 18 years or older from January 2017 to March 2020 25 and NHANES estimated proportions of adults with hypertension and uncontrolled hypertension. Using the stepped approach of the hypertension control cascade, we calculated weighted prevalence and 95% CIs for (1) uncontrolled hypertension (among all with hypertension), (2) hypertension awareness (among all with uncontrolled hypertension), (3) meeting criteria for treatment recommendations (among those aware of their hypertension status), and (4) antihypertensive medication use (among those aware and meeting criteria for lifestyle modifications plus medication).

We calculated prevalence estimates overall and by age, sex, race and ethnicity, age within sex, race and ethnicity within sex, and sociodemographic variables. Prevalence data and population estimates were suppressed in accordance with NCHS standards for presenting proportions. 26

All analyses used sampling weights 16 (SAS version9.4 [SAS Institute]) to account for NHANES multistage, clustered sample design. We used R software version 4.0.5 (R Foundation for Statistical Computing) for visualizations. Statistical significance was considered a 2-sided P  < .05. Data analysis was conducted from January to February 2024.

After applying exclusionary criteria to those who had completed the NHANES examination, there were 7328 individuals, of which 3954 (54.0%) had hypertension, and 3129 of those with hypertension (79.1%) were uncontrolled. These 3129 adults with uncontrolled hypertension constituted our study sample and had the following characteristics: 1675 male (weighted percentage, 52.3%), 775 aged 18 to 44 years (weighted percentage, 29.4%), 1306 aged 45 to 64 years (weighted percentage, 41.4%), 1048 aged 65 years or older (weighted percentage 29.2%), 589 Hispanic (weighted percentage 13.4%), 324 non-Hispanic Asian (weighted percentage, 5.3%), 973 non-Hispanic Black (weighted percentage 13.7%]), 148 non-Hispanic other (weighted percentage, 4.5%), 1095 non-Hispanic White (weighted percentage 63.2%) ( Table 1 ). Most study participants were privately insured (1569 participants [weighted percentage, 60.3%]) and saw a health care clinician 2 or more times in the past year (2181 participants [weighted percentage, 69.2%]). Furthermore, approximately one-half of participants had obesity (1505 participants [weighted percentage, 50.3%]), 1 in 5 participants had a history of diabetes (806 participants [weighted percentage, 20.7%]) or CKD (806 participants [weighted percentage, 20.7%]), and 561 (weighted percentage, 16.0%) had a history of ASCVD. After population estimation, there were an estimated 120 million individuals with hypertension among whom 100.4 million were uncontrolled (weighted percentage 83.7%).

Among adults in the US aged 18 years or older with hypertension from January 2017 to March 2020, the age-standardized prevalence of uncontrolled hypertension was 83.7% (95% CI, 80.6%-86.8%) ( Table 2 and Figure 1 ). Overall, an estimated 57.8 million adults (weighted percentage, 57.6%) with uncontrolled hypertension were unaware, while 7.6 million (weighted percentage, 17.8%) were aware and met lifestyle modification criteria. Among 35.0 million adults with uncontrolled hypertension who met criteria for medication from January 2017 to March 2020, 24.8 million (weighted percentage, 70.8%) reported taking medication.

Across age groups, the prevalence of uncontrolled hypertension was high, ranging from 69.7% (95% CI, 66.7%-72.7%) among adults aged 65 years or older to 93.4% (95% CI, 90.3%-96.4%) among adults aged 18 to 44 years. Unawareness was high among adults aged 18 to 44 years (19.4 million individuals [weighted percentage, 68.4%]). Among 17.3 million adults aged 65 years or older with uncontrolled hypertension who met criteria for medication, nearly all (15.8 million individuals [weighted percentage, 91.1%]) took medication.

Across racial and ethnic groups, measures of the hypertension control cascade remained high, with a high age-standardized prevalence of uncontrolled hypertension for most groups ( Table 2 and Figure 1 ). Nearly two-thirds of non-Hispanic Asian adults (3.4 of 5.7 million [weighted percentage, 60.5%) were unaware that they had hypertension, compared with less than one-half of non-Hispanic Black adults (7.1 of 14.9 million [weighted percentage, 47.4%]) and more than one-half of non-Hispanic White adults (36.7 million of 63.4 million [weighted percentage, 57.8%]). Across racial and ethnic groups, most adults with uncontrolled hypertension who met criteria for medication reported taking antihypertensive medication.

The prevalence of uncontrolled hypertension and other measures of the hypertension control cascade remained high across subgroups defined by BMI status, educational attainment, income level, and insurance status (eTable and eFigure 1 in Supplement 1 ). Notably, 9.9 of 13.0 million adults with uncontrolled hypertension (weighted percentage, 75.7%) reported no health care visits in the past year between January 2017 and March 2020 and were unaware (eTable in Supplement 1 and Figure 2 ). Conversely, approximately one-half of adults with uncontrolled hypertension reporting 2 or more health care visits in the past year were unaware (36.6 of 70.6 million adults [weighted percentage, 51.8%]). Of the 29.0 million who were aware and met criteria for BP medication, 23.0 million (weighted percentage, 79.4%) reported taking medication to control hypertension, despite hypertension remaining uncontrolled.

When stratified by sex, hypertension control cascade measures generally were high across age groups and race and ethnicity groups ( Table 2 and eFigure 2 in Supplement 1 ). The age-standardized prevalence of uncontrolled hypertension was 94.3% (95% CI, 90.8%-97.7%) among males aged 18 to 44 years, 73.2% (95% CI, 68.6%-77.7%) among males aged 45 to 64 years, and 67.2% (95% CI, 62.9%-71.5%) among males aged 65 years or older. More than two-thirds of males aged 18 to 44 years (12.0 of 17.7 million males [weighted percentage, 68.1%]) were unaware of their hypertension status. Although more than two-thirds of males aged 18 to 44 years who were aware of their uncontrolled hypertension status met the criteria for antihypertension medication (3.9 of 5.6 million males [weighted percentage, 69.8%]), more than one-half (2.3 million males [weighted percentage, 58.4%]) reported currently taking medication. For each race and ethnicity group with reportable data, the age-standardized prevalence of uncontrolled hypertension was more than 80.0%. Nearly all non-Hispanic Black males who were aware of their uncontrolled hypertension status met criteria for BP medication (3.3 of 3.5 million males [weighted percentage, 95.0%]), but only about two-thirds of those meeting the criteria (2.1 million of 3.3 million males [weighted percentage, 64.8%]) reported currently taking medication.

Of an estimated 11.3 million females aged 18 to 44 years with hypertension, 10.4 million (weighted percentage, 91.8%) were uncontrolled. Although more than two-thirds of females aged 18 to 44 years with uncontrolled hypertension (7.2 million females [weighted percentage, 68.8%]) and one-half of females aged 45 to 64 years (9.3 of 18.5 million females [weighted percentage, 50.0%]) with uncontrolled hypertension were unaware of their hypertension status, less than one-half of females aged 65 years or older were unaware (5.8 of 15.9 million females [weighted percentage, 36.1%]). Furthermore, although more than 80% of females aged 45 to 64 years who met the criteria for medication reported taking medication (7.1 of 8.6 million females [weighted percentage, 82.6%]) and more than 90% of females aged 65 years or older reported taking BP medication (9.5 million of 10.2 million females who were aware and met criteria for medication [weighted percentage, 93.2%]) approximately two-thirds of females aged 18 to 44 years (1.5 million of 2.4 million females who were aware and met criteria for medication [weighted percentage, 62.4%]) reported taking medication.

For each race and ethnicity group with reportable data, more than 80% of females had uncontrolled hypertension (eFigure 2 in Supplement 1 ). Nearly one-half of non-Hispanic Black females with uncontrolled hypertension were unaware of their status (3.7 of 8.1 million females [weighted percentage, 45.8%]), and although 4.1 million non-Hispanic Black females (weighted percentage, 93.2%) were aware of their status and met the criteria for BP medication, only 3.0 million (weighted percentage, 72.3%) reported taking medication.

In this nationally representative cross-sectional study, we examined the hypertension control cascade among adults in the US with uncontrolled hypertension. From January 2017 to March 2020, more than three-quarters (100.4 of 120 million [weighted percentage, 83.7%]) of adults in the US aged 18 years or older with hypertension had uncontrolled hypertension, with approximately one-half (57.8 of 100.4 million, [weighted percentage, 57.6) being unaware of their condition (and therefore remaining untreated). Of the 35.0 million individuals with uncontrolled hypertension meeting criteria for antihypertensive medication, more than two-thirds (24.8 million individuals) reported taking medication but remained uncontrolled. These negative outcomes occurred across sociodemographic groups. Notably, we identified high unawareness and lack of control among younger adults aged 18 to 44 years, including both males and females, and marked differences across the measures of the cascade by health care utilization. Our findings emphasize the pressing need for implementing evidence-based strategies to improve hypertension awareness and management among adults with uncontrolled hypertension in the US, including among females of reproductive age, and to address sociodemographic differences in the hypertension control cascade. 7 - 10

Our analysis applied the 2017 ACC/AHA guidelines for hypertension. 19 Prior guidelines from JNC and other organizations (notably, the American Academy of Family Physicians) define hypertension as SBP greater than 140 mm Hg and DBP greater than 90 mm Hg. 27 Consequently, adults in our study classified as having uncontrolled hypertension according to the 2017 ACC/AHA definition may have met hypertension control criteria using earlier or different guidelines. A previous study 28 documented increased prevalence of hypertension and of antihypertensive medication recommendations using the 2017 ACC/AHA guideline. Additionally, our results may reflect the slow adoption of the updated guidelines.

Among adults aged 18 to 44 years, the high prevalence and lack of awareness of uncontrolled hypertension is concerning given the importance of early cardiovascular health in preventing negative CVD outcomes later in life. 29 For females in this age group, uncontrolled hypertension during pregnancy increases the mother’s lifetime risk of CVD and is a leading cause of pregnancy-related death and pregnancy complications. 30 , 31 In 2020, hypertensive disorders of pregnancy was the sixth most frequent underlying cause of pregnancy-related death in the US. 32 Additionally, children born to mothers with uncontrolled hypertension have a greater risk of future adverse health outcomes, including hypertension and CVD. 31

A prior study 33 found that hypertension affects approximately 1 in 8 adults aged 20 to 40 years. In our study, the lack of hypertension awareness, and subsequent lack of control among younger adults may reflect this group’s more limited engagement with the health care system compared with older adults. 34 Even those who are engaged with the health care system are less likely than older adults to be aware of their hypertension status and to subsequently receive and continue treatment for hypertension. 15 , 35 Furthermore, studies have demonstrated a lack of persistence in blood pressure lowering among young people following the initial intervention. Additionally, certain life events in young people, such as pregnancy, may require tailored advice from health care professionals on the management of blood pressure. 15 , 33 , 35 Effective management strategies and efforts are needed to increase hypertension awareness among young adults, especially young females. Examples may include improving patient engagement through shared decision-making and assisting patients with obtaining validated self-measured blood pressure monitors. 36

Our study also revealed a lack of awareness among individuals already engaged with the health care system. More than one-half of adults with uncontrolled hypertension (57.8 million people) remained unaware of their hypertension status, despite nearly 70% reporting 2 or more health care clinician visits within the past year. Previous studies 37 have documented that poor medication adherence and clinical time pressures, therapeutic inertia, and clinical workloads are barriers to hypertension diagnosis and control. Additionally, despite engagement with the health care system, we found that 70% of adults with uncontrolled hypertension who were aware of their condition reported taking antihypertensive medication. While antihypertensive medications are effective in reducing BP and preventing CVD across demographic groups, 38 our results support existing evidence that a prescription alone does not guarantee improved hypertension control at the individual or population level. Efforts are needed to improve hypertension awareness and ensure effective control among those prescribed antihypertensive medications.

Evidence-based clinical and community-based efforts can improve outcomes across the hypertension control cascade. Clinical initiatives may include training and evaluation of accurate BP measurement using evidence-based hypertension guidelines, such as the American Medical Association Hypertension Treatment Algorithm. 39 These guidelines can improve hypertension control through medication treatment intensification, fixed dose combination therapy, nonadherence assessment, and frequent follow-up. Comprehensive process improvements, as outlined in the US Surgeon General’s Call to Action to Control Hypertension, 40 and the Million Hearts Hypertension and Hypertension in Pregnancy Change Packages 41 can further support these strategies.

Within the context of these established strategies, future reports and surveillance metrics may support their implementation across the hypertension control cascade. Possible metrics could include increasing health care visits for patients unaware of their hypertension status or with no visits in the past year, enhancing adherence to recommended BP medications, improving medication adherence rates, and increasing clinician adherence to the 2017 AHA/ACC guidelines. A 2023 AHA scientific statement 42 addressing approaches to improving hypertension control, as well as specific strategies for priority populations, may guide strategies to achieve blood pressure control. 43 Future research may explore engaging individuals with uncontrolled hypertension, particularly younger adults aged 18 to 44 years, individuals of reproductive age, and those who seldom visit health care clinicians. Enhancing clinical and patient awareness may be key for improving these cascade measures.

Our study has several limitations. First, our findings are not generalizable to individuals who are institutionalized or to military personnel. Second, this study relied on self-reported antihypertensive medication use. Third, NHANES combines several race groups into non-Hispanic other, limiting interpretation and action within this groups. Third, our definition of hypertension is based on BP measurements taken during a single NHANES encounter, but 2017 ACC/AHA guidelines recommend diagnosing hypertension using multiple BP readings from separate occasions.

This cross-sectional study found a concerning gap in hypertension awareness among adults in the US with uncontrolled hypertension aged 18 to 44 years and those with more than 1 physician visit in the past year. Notably, most adults with uncontrolled hypertension reported using antihypertensive medications. These findings underscore the need for efforts to improve outcomes across levels of the hypertension control cascade.

Accepted for Publication: June 30, 2024.

Published: September 11, 2024. doi:10.1001/jamanetworkopen.2024.31997

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Richardson LC et al. JAMA Network Open .

Corresponding Author: LaTonia C. Richardson, PhD, Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, 4770 Buford Hwy, Atlanta, GA 30341 ( [email protected] ).

Author Contributions: Dr Richardson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Vaughan, Wright, Coronado.

Acquisition, analysis, or interpretation of data: Richardson, Vaughan, Coronado.

Drafting of the manuscript: Richardson, Vaughan, Coronado.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Richardson.

Administrative, technical, or material support: Vaughan, Coronado.

Supervision: Wright, Coronado.

Conflict of Interest Disclosures: None reported.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Data Sharing Statement: See Supplement 2 .

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Book series

Practical Case Studies in Hypertension Management

About this book series.

• Giuliano Tocci

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Hypertension and 24-hour ambulatory blood pressure monitoring.

• Julian Segura
• Copyright: 2019

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Hypertension and Renal Organ Damage

• Roberto Pontremoli
• Copyright: 2018

Hypertension and Cardiac Organ Damage

• Raffaele Izzo
• Copyright: 2017

Hypertension and Metabolic Cardiovascular Risk Factors

• Arrigo F. G. Cicero
• Copyright: 2016

Hypertension and Comorbidities

• Agostino Virdis

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Nursing case management for people with hypertension

To explore the effect of management of nursing case on blood pressure control in hypertension patients.

This is a randomized controlled study which will be carried out from May 2021 to May 2022. The experiment was granted through the Research Ethics Committee of the People's Hospital of Chengyang District (03982808). Our research includes 200 patients. Patients who meet the following conditions will be included in this experiment: the patients aged 18 to 60 years; the patients had the diagnosis of hypertension; and the urban residents. While patients with the following conditions will be excluded: having renal failure, liver failure, heart and respiratory failure; and known pregnancy. Primary result is blood pressure, while secondary results are treatment compliance, waist circumference, body mass index (BMI), type and number of antihypertensive agents used, and the existence of metabolic and cardiovascular comorbidities.

Table 1 shows the clinical outcomes between the two groups.

Conclusion:

Nursing case management is effective to improve the prognosis of hypertension patients.

1. Introduction

Hypertension is one of the cause of death worldwide, which is preventable. [ 1 , 2 ] It is also a significant risk factor for myocardial infarction, heart failure, stroke, as well as other serious renal and cardiovascular diseases. [ 3 – 5 ] The incidence rate of hypertension rises with the age of adults. It is reported that 36% of the adults aged 40 to 64 suffer from hypertension; among adults aged 65 and above, the proportion has increased to 70%. [ 6 , 7 ] It has become a serious problem of public health. Since the hypertension is asymptomatic, its detection and control remains a challenge. The hypertension patients are managed via the primary health care provider. [ 8 ] Nevertheless, although the progress has been made in the management of chronic diseases, the hypertensive patients who receive regular treatment from primary care providers do not meet their targets of blood pressure.

In recent years, more and more researches begin to pay attention to the significant role of the management of nursing case in treating hypertension. [ 9 , 10 ] It requires a complex care, involving major lifestyle changes such as adherence to medication, reduced salt intake, the measurement of blood pressure and exercise. Nevertheless, the hypertension patients have poor self-management behaviors. The self-care and self-efficacy behavior of uncontrolled hypertension patients are lower. Case management is a kind of healthcare strategy that determines patients at high risk, prevents complications and disease progression, and promotes the patients participation in self-care. Other targets involve caring for the perspectives and needs of patients, developing personalized care programs, improving the quality of health care, and decreasing decentralized patient care. The former researches have suggested that management of case may have a positive effect on hypertension. [ 11 – 13 ] In addition, it can increase the knowledge about the disease; adhere to the treatment plans and help the patients improve their own lifestyle. Although it has achieved positive results in the case management of chronic disease, it has not been applied in patients with hypertension. Hence, we conduct the randomized controlled study protocol to explore the effect of management of nursing case on blood pressure control in hypertension patients.

2. Materials and methods

This is a randomized controlled study which will be carried out from May 2021 to May 2022 at the People's Hospital of Chengyang District. The experiment was granted through the Research Ethics Committee of the People's Hospital of Chengyang District (03982808) and recorded in research registry (researchregistry6244).

2.1. Inclusion criteria and exclusion criteria

Patients who meet the following conditions will be included in this experiment: the patients aged 18 to 60 years; the patients had the diagnosis of hypertension; and the urban residents. While patients with the following conditions will be excluded: having renal failure, liver failure, heart and respiratory failure; and known pregnancy. All the patients are randomly assigned to the random number through utilizing a random-number table, and the result of distribution is kept in a random envelope and is invisible. All the patients are randomly divided to the control group and study group, and there are 100 patients in each group.

2.2. Nursing case management

The nursing standards of the control group are as follows: renewal of prescriptions in meetings, free distribution of hypertension medication, and the monitor of blood pressure every 2 months, nursing and medical appointments, and consultation with psychologists and nutritionists based on the needs of patients.

In intervention group, patients are given management of nursing case. From the existing management activities, the arrangements are as follows: telephone contacts, nursing consultations, personal health education activities, and home visits. The nursing consultations are implemented every 6 months. The purpose of the consultation is to gather information that can be utilized to draft personal care plans and to set mutually agreed targets. The consultation lasts about an hour, involving the targeted health education, the measurement of waist circumference and blood pressure, and the calculation of BMI. Telephone contact is conducted every 1 month to reassess the healthcare plans of patients and remind the patients to consult the agendas in a timely manner. WeChat is a kind of instant messaging tool, which allows the voice calls through using the mobile phone, and it is also utilized for communication. Each telephone meeting lasts about 10 min. In the process of home visits, the case manager will observe the home environment, for instance, the living conditions and family's interaction. They offer the health education, check the weight of patient and their blood pressure, and then review the targets and medical plans. All the verbal instructions will be recorded and the patients will be provided the copy for consultation if needed. For the home visits, it lasts about 45 min. And the group activities contain the interactive activities and informational lectures. The focus of these activities is to develop healthy habits. The theme of educational activities is selected according to patients’ main needs. The activities of collective health education are carried out in community space. These group activities last about 1 h. Personalized educational activities are offered in the process of nursing consultation, telephone consultation, and home visit. All information acquired in the process of nursing management will be recorded.

2.3. Outcomes

Primary result is blood pressure, while secondary results are treatment compliance, waist circumference, BMI, type and number of antihypertensive agents used, and the existence of metabolic and cardiovascular comorbidities.

2.4. Statistical analysis

The analysis of all the data are conducted with the software of IBM SPSS Statistics for Windows, version 20 (IBM Corp, Armonk, NY). Afterwards, all the data acquired are represented through the appropriate characteristics, for example, standard deviation, and mean, median as well as percentage. And independent t tests and χ 2 -tests are respectively utilized to analyze the categorical variable and continuous variable. P value < .05 indicates that there is statistical significance.

Table ​ Table1 1 shows the clinical outcomes between the two groups.

The clinical outcomes between the two groups.

4. Discussion

Hypertension is the most significant risk factor for disability and death worldwide, which affects more than one billion people and causes ∼9.4 million deaths each year. [ 14 ] On the basis of a report by the World Health Organization, hypertension is the single most significant risk factor, which accounts for 13% of global mortality. Human hypertension may be the result of lifestyle and genetic factors. [ 15 , 16 ] The current evidence-based treatment for the hypertension is a key intervention measure to reduce the incidence rate and mortality of cardiovascular diseases. Researches have determined a variety of barriers to the control of hypertension in routine care that are composed of factors related to patients, physicians, healthcare system, and healthcare services.

People with lower income and education levels are more likely to be insufficiently physically active, which predisposes them to the risk of complications associated with chronic diseases, particularly the hypertension. [ 17 ] In contrast, people with higher educational and economic levels tend to be more effective at controlling the levels of blood pressure. Therefore, it is essential to consider the effect of these variables and then incorporate these variables into the development of nursing planning and educational activities for hypertension patients. Case management can be utilized for this objective by providing a personalized plan based on each person's needs.

5. Conclusion

Author contributions.

Shiqiang Song designs the protocol. Xianhong Li reviews the protocol. Xueling Ning performs the data collection. Chunjing Song finishes the manuscript. All of the authors approved the submission.

Conceptualization: Xianhong Li.

Data curation: Xianhong Li.

Funding acquisition: Shiqiang Song.

Investigation: Xueling Ning.

Methodology: Xueling Ning.

Writing – original draft: Chunjing Song.

Abbreviations: BMI = body mass index, Trial registration = The protocol was registered in Research Registry (researchregistry6244).

How to cite this article: Song C, Li X, Ning X, Song S. Nursing case management for people with hypertension: A randomized controlled trial protocol. Medicine . 2020;99:52(e23850).

Qingdao Health Bureau project (2013-WSZD120).

The authors have no conflicts of interest to disclose.

The datasets generated during and/or analyzed during the present study are publicly available.

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Making Best Practice, Every Day Practice

Case study: The hypertensive patient

Working with patients who are not willing to engage fully with healthcare services is a common occurrence. The process requires patience and a focus on providing the patient with full information about their condition and then allowing them to make decisions about their treatment. Here, Dr Terry McCormack (GP and Cardiovascular Lead, North Yorks) describes the approach of his practice to a man with hypertension.

A 57-year old man Mr ‘Hawk’ Ward attends a routine NHS Health Check with a health care assistant (HCA) in the local surgery. He had had no contact with healthcare for many years and was not keen on any interventions. Repeated blood pressure (BP) measurements showed very high BP of 205/91 mmHg. The assessment also showed:

• A strong family history of CV disease (brother
• Smoker 30/day
• Appearance healthy
• Alcohol intake 100 units/week

The HCA immediately referred him to the GP who had a long discussion with him and was able to persuade him to take a blood test and have home blood pressure monitoring (HBPM) although he declined ambulatory blood pressure monitoring.

He returned to see the practice senior nurse after HBPM and further investigations showed:

• HBPM average of 8 readings (first 2 discounted) 180/95 mmHg
• Total cholesterol 7.2 mmol/L, HDL 1.4 mmol/L, non-HDL 5.8 mmol/L
• QRISK2 36.1
• Liver Function Tests normal

Mr Ward agreed with the senior nurse to stop smoking, excess alcohol intake, adding salt to food, but would not take medication.  He reluctantly agreed to make an appointment to see Dr McCormack.

At the GP appointment

• Mr Ward announces that ‘medication is not an option’
• The GP explains all his risks (including the relevance of non-HDL cholesterol and QRISK2 assessment) and then ask him what he would like to do about it.
• Shared, informed decision making explained
• The GP offers ABPM to confirm the diagnosis

After some time spent considering the GPs evidence and advice, the patient decided to accept some medication and was put on amlodipine 5mg.  

Current situation

At a later visit Mr Ward’s blood pressure had reduced to 147/84 mmHg. He has cut down on alcohol and was less agitated. He agreed to take atorvastatin 20 mg and is continuing on therapy and has improved his engagement with the practice team. This patient and ongoing approach has produced significant improvements in his condition, lowered his risk of subsequent events and provides promise for ongoing interaction with health care services.

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Hypertension: A Case Study

• January 2022
• 8(7):379 - 381

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• Akal College of Nursing Eternal University Baru Sahib.

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