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

This cross-sectional study provides estimates of hypertension awareness, treatment recommendations, and medication use among individuals with uncontrolled hypertension in the US.


Introduction
][9][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. 12,135][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. 9,15,18However, 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. 16,19Therefore, 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.

Data Source
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. 20NHANES data are typically published as 2-year survey cycles.Data for the 2019 to 2020 survey cycle, which stopped

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Hypertension Control Cascade Among Adults With Uncontrolled Hypertension 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. 21We 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.

Hypertension Definition
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 Ն130 mm Hg or DBP Ն80 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.

Hypertension Awareness Definition
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.

Treatment Recommendation Definitions
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 Ն140 mm Hg or DBP Ն90 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 Ն10%), or were aged 65 years or older. 16eting 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.

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

Population Characteristics
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.9][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%. 22rticipants 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 (Ն30.0);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/1.73m 2 or a urine albumin-tocreatinine 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.

Statistical Analysis
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 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. 26l analyses used sampling weights 16

Hypertension Control Cascade Among Adults in the US with Uncontrolled Hypertension
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).

Uncontrolled hypertension
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.

Uncontrolled hypertension
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. 26revalence 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. 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.9][10] Our analysis applied the 2017 ACC/AHA guidelines for hypertension. 19Prior 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

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Hypertension Control Cascade Among Adults With Uncontrolled Hypertension 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. 29For females in this age group, uncontrolled hypertension during pregnancy increases the mother's lifetime risk of CVD and is a leading cause of pregnancyrelated death and pregnancy complications. 30,31In 2020, hypertensive disorders of pregnancy was the sixth most frequent underlying cause of pregnancy-related death in the US. 32Additionally, 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. 34Even 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. 15,35Furthermore, 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. 15,33,35Effective 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. 36r 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. 39These 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 JAMA Network Open | Cardiology 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. 43Future 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.

Limitations
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.

Conclusions
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.

National Association of
(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.

Figure 2 .
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 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.DiscussionIn 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)

Table 1 .
Characteristics of US Adults Aged 18 Years or Older With Uncontrolled Hypertension, January 2017 to March 2020 (continued) Includes those who self-reported being multiracial or a non-Hispanic race other than Asian, Black, or White.Estimate suppressed in accordance with National Center for Health Statistics standards for presenting proportions. 26c Body mass index is calculated as weight in kilograms divided by height in meters squared; body mass index was predetermined in the downloaded National Health and Nutrition Examination Survey dataset.
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%)amongadultsaged65yearsorolder to 93.4% (95% CI, 90.3%-96.4%)amongadultsaged18 to 44 years.Unawareness was high among adults aged 18 to 44 years(19.4millionindividuals[weightedpercentage,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 (Table2and Figure1).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 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 a b

Table 2 .
Age-Standardized Hypertension Cascade Prevalence Estimates Among Adults Aged 18 Years or Older in the US With Hypertension, Overall and by Age, Race And Ethnicity, and Sex,

Table 2 .
Age-Standardized Hypertension Cascade Prevalence Estimates Among Adults Aged 18 Years or Older in the US With Hypertension, Overall and by Age, Race And Ethnicity, and Sex, 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.

Control Cascade in Adults in the US With Uncontrolled Hypertension, Stratified by Sex When
stratified by sex, hypertension control cascade measures generally were high across age groups and race ethnicity groups (Table2and eFigure 2 in Supplement 1).The age-standardized 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 Community Health Centers.Improving blood pressure control for African Americans roadmap.Accessed June 28, 2024.https://www.nachc.org/wp-content/uploads/2021/09/BPAA-Roadmap_08252021.pdfSUPPLEMENT 1. 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