State of hypertension management in the United States: confluence of risk factors and the prevalence of resistant hypertension

Abstract

An improvement in the awareness and treatment of hypertension in the United States has occurred, resulting in the best control rates in the world, which unfortunately are far below the goals of Healthy People 2000 or 2010. This failure to achieve blood pressure (BP) goals is attributed to many factors, including an aging population, higher prevalence of kidney disease and obesity, high salt intake, physician inertia to increase dose and number of antihypertensive medications prescribed, and patient nonadherence with medication regimens. Resistant hypertension is defined as a failure to achieve goal BP in patients who adhere to full doses of an appropriate antihypertensive regimen of 3 drugs that includes a diuretic. The problem of resistant hypertension is projected to increase as the population ages. Efforts on the part of the Veterans Administration hospitals and others clearly indicate that a system can be implemented to help increase the percentage of persons in whom BP goal is achieved and reduce the prevalence of resistant hypertension. Medications specific to the problem of resistant hypertension are also under development. This review analyzes the status of hypertension control in the United States, the frequency of associated diseases, and adherence to guidelines; it further discusses strategies to reduce the prevalence of resistant hypertension.

Figure 1

Comparison of hypertension awareness, treatment, and control in the United States in 14,653 patients from the National Health and Nutrition Examination Survey database. Note differences in control between all treated hypertensive patients and treated hypertensive diabetic patients. BP indicates blood pressure. ^aP<.05 for the difference between 1999–2000 and 2003–2004. Modified from Ong et al. ⁵

Figure 2

Number of blood pressure (BP) medications needed to achieve systolic BP goal in large clinical trials. Most of the trials involved patients with multiple risk factors or comorbidities. CKD indicates chronic kidney disease; HOT, Hypertension Optimal Treatment trial; UKPDS, United Kingdom Prospective Diabetes Study; ALLHAT, Antihypertensive and Lipid‐Lowering Treatment to Prevent Heart Attack Trial; INVEST, International Verapamil‐Trandolapril Study; MDRD, Modification of Diet in Renal Disease study; ABCD, Appropriate Blood Pressure Control in Diabetes trial; AASK, African American Study of Kidney Disease and Hypertension; IDNT, Irbesartan in Diabetic Nephropathy Trial; RENAAL, Reduction in Endpoints in NIDDM With the Angiotensin II Antagonist Losartan study.

Figure 3

An approach to improve blood pressure (BP) control in resistant hypertension. NSAIDs indicates nonsteroidal anti‐inflammatory drugs. Reproduced with permission from Moser and Setaro. ²⁹