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

Abstract

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.

Figure 1.. Hypertension Control Cascade Population Estimates Among Adults Aged 18 Years or Older in the US With Uncontrolled Hypertension, Overall and by Age, Sex, and Race and Ethnicity, January 2017 to March 2020

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. Non-Hispanic other included those who self-reported multiracial or any non-Hispanic ethnicity other than Asian, Black, or White.

Figure 2.. Hypertension Control Cascade Population Estimates Among Adults Aged 18 Years or Older in the US With Uncontrolled Hypertension by Number of Health Care Visits in the Past Year, January 2017 to March 2020

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.