Carl J. Pepine, MD, MACC

I wonder how much this rise in the population without BP control is secondary to deprescribing medications in older patients. Of note, this report used definitions from the Seventh Joint National Committee (control being systolic BP < 140 mm Hg). The adverse outcome implications associated with this increase in U.S. population without BP control are enormous from a public health perspective.

Keith C. Ferdinand, MD, FACC, FAHA, FASPC

We have known for some time that hypertension was more prevalent and poorly controlled in the African American community. We also have seen poor control levels in certain Hispanic and Asian American populations. As the general population in the United States continues to have an increase in obesity, with persistence in prepared foods that are high in sodium and low in potassium, along with the general aging of the population, it would be expected that CV risk and eventually CVDs themselves would become more common in the upcoming years. Specifically as it relates to hypertension, having an identifiable source of care, especially with adequate insurance, predicts better control of risk factors. In the latest study using 140/90 mm Hg, there clearly is poor control in Black patients, patients who are uninsured, those who don't have an identifiable source of care and people who don't adhere to their medication.

Other conditions, because of the availability of branded medications, are getting much more public education. For instance, the use of new or novel anticoagulants for atrial fibrillation and the emerging new anti-diabetic medications. These medicines clearly have evidence base for improvement in outcomes. However, because the overwhelming majority of antihypertensive agents are now generic, there are unintended consequences of less public awareness of the need to control this potent and prevalent risk factor.

One of the solutions, maybe, is to make the general population, in which hypertension is very common, more aware of the importance of controlling BP and using out-of-office or self-monitored BP with validated devices to get a better assessment of their BP load and their need for therapy.

Indeed, the United States Preventive Services Task Force recently gave a class A recommendation that out-of-office BP monitoring be done, even before the initiation of treatment. Once a patient is on treatment, he or she can better control their BP by self-measuring BP, and then relating these to his or her provider for input on how to better manage.

This study confirmed the powerful impact of the social determinants of health on CV risk and eventually outcomes. It is important to recognize that those persons who don't have access to care by either having adequate insurance on identifiable usual source of care, who have worse control of blood pressure, and eventually this will translate to persistent gaps in morbidity and mortality.

Brent M. Egan, MD

The downward trend in hypertension control from 2013-2014 to 2017-2018 to levels seen in 2005-2006 is a serious health concern. Many years of hard work to improve hypertension control have been rapidly reversed in a relatively short period of time (2015–18) and will likely contribute to an increase in stroke and heart disease.

The downward trend in hypertension control from 2013-2014 to 2017-2018 reflected a fall in both the percentage of adults aware of their hypertension as well as the percentage receiving medication to control their BP.

While hypertension control clearly fell, the reason for the decline was unclear as key social determinants including health care insurance, income, and education, were relatively unchanged.  

There is major agreement between this research and the study I presented at the virtual AHA Hypertension Scientific Sessions. The two reports concur on the 11.1% absolute decline in hypertension control from 2013-2014 to 2017-2018, which is the main finding. There was also concurrence that mean systolic BP increased 3 to 4 mm Hg during that time period among adults with hypertension.  

Here are some differences.

Hypertension control rates in our report were slightly higher than in the JAMA report, as we excluded the first BP measurement when more than one BP was recorded as recommended in NHANES reporting guidelines.

The major focus of our report was impact of age on declining hypertension control rates. In 2014, the Committee Appointed to Eighth Joint National Committee (JNC 8) on High BP recommended a target BP of less than 150/90 mm Hg for adults 60 years and older without diabetes or chronic kidney disease. This recommendation was endorsed by the American College of Physicians and the American Academy of Family Practice. While the American College of Cardiology and AHA recommended a target BP less than 130/80 mm Hg for all adults in 2017, ACP and AAFP continued to endorse a BP target less than 150/90 mm Hg for adults 60 years and older.  

However, we found that the decline in hypertension control for adults aged 40 to 59 years was at least as large as for adults 60 years and older. Thus, controversy over target BP in adults 60 years and older did not explain the fall in hypertension control unless one assumes that most primary care physicians were unaware that the JNC 8 committee and ACP/AAFP guidance for a BP target less than 150/90 mm Hg was intended only for adults 60 years and older (without diabetes or chronic kidney disease).

In addition to a significant decline in hypertension awareness and treatment (both reports), we found that treatment effectiveness also declined, ie, the proportion of adults taking medication for hypertension who had their BP controlled.

I would encourage cardiologists to emphasize the importance of consistently controlling BP to less than 140/90 among your colleagues, including the primary care clinicians in your health system and referral networks. While the SPRINT trial design and BP measurement protocol raised some concerns, adults 75 years and older derived as much benefit from more intensive treatment (mean systolic BP ~123 mm Hg vs. ~135 mm Hg; Williamson JD, et al. JAMA. 2016:doi:10.1001/jama.2016.7050).

Not surprisingly, the substantial decline in hypertension control and the increase in mean systolic BP among adults with hypertension will likely increase clinical CV events including ACS, acute decompensated HF and chronic HF, as well as stroke. In other words, cardiac clinicians may be even busier in the future than currently.