Update on Hypertension Epidemiology and Treatment for 2021

Recently the National Health and Nutrition Examination Survey (NHANES) from 2017-2018 was published.¹ Hypertension control to < 140/90 mmHg has declined to 43.7% from 53.8% in 2013-2014 NHANES report.  Importantly, the number of adults who knew they had hypertension declined from 84.7% (2013-2014) to 77% in 2017-2018 and with this drop the number of individuals taking antihypertensive medications dropped from 92.7% to 88.2%.  This data is supported by another study recently presented at the AHA Hypertension 2020 Scientific Sessions.²

The NHANES report included 51,761 participants.  Of these persons, 18,262 had hypertension defined as SBP > 140 mmHg or higher, DBP > 90 mmHg or higher or use of an antihypertensive medication.  It is important to note that 2017-2018 NHANES did not use the ACC/AHA recommendation of 130/80 mmHg to define hypertension.  Obviously if they had, the numbers of individuals with HTN would be much higher, but treatment and control would be much lower.  Although efforts are underway to address hypertension in public health announcements, ³ a greater collective effort including government (i.e., national, state, and local levels), all healthcare workers including pharmacists, and the public will be needed to continue to improve awareness, treatment and control of hypertension.  This is critically important to reducing downstream atherosclerotic cardiovascular disease, stroke, chronic kidney disease, and vascular dementia.⁴ An evaluation of 30 environmental, behavioral, and metabolic risk factors for diseases resulting in the highest levels of disability-adjusted life years, hypertension was ranked number 1.⁵

The above results are despite recent studies showing how effective current antihypertensive agents are at reducing cardiovascular events.  In a systematic review and network meta-analysis of 46 eligible clinical trials involving approximately 250,000 participants with a mean age of 65.6±5.8 years (52.8% men) several agents were shown to reduce cardiovascular events.⁶ Angiotensin-converting enzyme inhibitors (ACEi), dihydropyridine calcium channel blockers (CCBs), and thiazide diuretics similarly reduced overall cardiovascular events by 25%, cardiovascular death by 20%, and stroke by 35%.  ACEi were the most effective in reducing acute myocardial infarction by 28%, and diuretics in reducing revascularization by 33%.  A 10/5 mmHg reduction in SBP/DBP was significantly associated with reducing risk of cardiovascular death, stroke and overall cardiovascular events.

Why is treatment important?  Because intensive blood pressure control has a positive impact on lifespan.  When comparing intensive blood pressure versus standard blood pressure control, the estimated residual survival was 37.3 versus 34.4 years at age 50 years.⁷ Residual survival was 24.5 and 23.3 years with intensive versus standard treatment at age 65 years.  With increasing age, there is a decrease in absolute survival gain, but the relative benefits are consistent at 4-9%.

In summary, hypertension has a major impact on downstream disease progression and events. Effective well-tolerated treatments are available to abate or reverse disease progression and add quality life years to our patients’ lives.

Mark A. Munger, PharmD, FCCP, FACC, is a professor of pharmacotherapy and adjunct professor of internal medicine, at the University of Utah, where he also serves as the associate dean of Academic Affairs for the College of Pharmacy.

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References 

1. Muntner P, Hardy ST, Fine LJ, Jaeger BC, Wozniak G, Levitan EB, Colantonio LD. Trends in blood pressure control among US adults with hypertension. 1999-2000 to 2017-2018. JAMA published online 09/09/2020. doi: 10.1001/jama.2020.14545  
2. Americans continue to struggle controlling high blood pressure: 11% fewer adults have it in check. https://newsroom.heart.org/news/americans-continue-to-struggle-controlling-high-blood-pressure-11-fewer-adults-have-it-in-check  Accessed 01/27/2021.
3. World Health Organization High Blood Pressure: A Public Health Problem. https://www.emro.who.int/media/world-health-day/public-health-problem-factsheet-2013.html   Accessed 01/27/2021.
4. Curfman G, Bauchner H, Greenland P. Treatment and control of hypertension in 2020.  The Need for substantial improvement. JAMA published online 09/09/2020. doi: 10.1001/jama.2020.13322
5. Forquzanfar MH, Liu P, Rother GA, et al. Global burden of hypertension and systolic blood pressure of at least 110 to 115 mmHg. 1990-2005. JAMA  2017;317(2):165-182.
6. Wei J, Galviz KI, Kowalski AJ, et al. Comparison of cardiovascular events among users of different classes of antihypertensive medications. A systematic review and network meta-analysis. JAMA Net Open 2020;3(2):E1921618
7. Vaduganathan M, Claggett BL, Juraschek SP, Solomon SD. Assessment of long-term benefit of intensive blood pressure control on residual life span. Secondary analysis of the systolic blood pressure intervention trial. (SPRINT). JAMA published 02/26/2020. doi: 10.1001/jamacardio.2019.6192.