Trends in Initial Antihypertensive Medication Prescribing Among >2.8 Million Veterans Newly Diagnosed With Hypertension, 2000 to 2019

Abstract

Background: Among patients diagnosed with high blood pressure (BP), initial dual therapy has been recommended for patients with high pretreatment systolic BP (≥160 mm Hg) since 2003, and first-line β-blocker use without a compelling condition has fallen out of favor in US guidelines.

Methods and results: This serial cross-sectional study of national Veterans Health Administration data included adult Veterans with incident hypertension initiating antihypertensive medication between January 1, 2000, and December 31, 2019. We assessed annual trends in initial regimens dispensed (index date: first antihypertensive dispense date) by number of classes and unique class combinations used overall and by pretreatment systolic BP (<140, 140 to <160, and ≥160 mm Hg), as well as trends in subgroups (age, sex, race and ethnicity, and comorbidities warranting β-blocker use). Among 2 832 684 eligible Veterans (average age 61 years, 95% men, 65% non-Hispanic White, and 8% with cardiovascular disease), from 2000-2004 to 2015-2019, initial monotherapy increased across all pretreatment systolic BP levels (<140 mm Hg: 62.1% to 66.4%; 140 to <160 mm Hg: 70.7% to 76.8%; ≥160 mm Hg: 64.2% to 69.7%). Initiation of dual therapy decreased across all pretreatment systolic BP levels (<140 mm Hg: 25.0% to 24.2%; 140 to <160 mm Hg: 20.4% to 17.6%; ≥160 mm Hg: 22.7% to 22.0%). Among 2 521 696 Veterans (89% of overall) without a β-blocker-indicated condition in 2015 to 2019, 20% initiated a β-blocker, most commonly as monotherapy.

Conclusions: More than half of US Veterans diagnosed with hypertension with a pretreatment systolic BP ≥160 mm Hg were started on antihypertensive monotherapy. There are disparities between guideline-recommended first-line treatments and the actual regimens initiated for newly diagnosed Veterans with hypertension.

Keywords: antihypertensive medication; blood pressure; treatment initiation; trends; veteran.

Figure 1. Number of antihypertensive medication classes initiated, by pretreatment systolic blood pressure level.

The figure shows the proportion of Veterans within each systolic blood pressure subgroup [(A) SBP <140 mm Hg; (B) SBP 140–<160 mm Hg]) initiating 1, 2, 3, and 4 or more antihypertensive medication classes. SBP indicates systolic blood pressure.

Figure 2. Initiation of β‐blockers among Veterans without compelling indications for β‐blocker use, by year of initiation.

The figure shows the proportion initiating antihypertensive regimens with and without a β‐blocker over the 20‐year study period among 2 521 696 Veterans without compelling indications for a β‐blocker (89.0% of the overall cohort). Compelling indications for a β‐blocker at the time of antihypertensive medication initiation included a history of history of cardiovascular disease, myocardial infarction, chronic liver disease, cirrhosis, heart failure, angina, other CHD/angina, atrial fibrillation, and aortic aneurysm or disease. CHD indicates congestive heart disease.