Awareness of Uncontrolled Hypertension Low, Particularly Among Young Adults, Study Warns

More than half of adults with uncontrolled hypertension in the US were not aware of their condition and more than two-thirds (70.8%) of individuals who were treated had elevated blood pressure that was consistently uncontrolled, according to new research.

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The findings, published in JAMA Network Open this week, come from a cross-sectional study of National Health and Nutrition Examination Survey (NHANES) data for more than 3000 individuals aged 18 years and older with uncontrolled disease. The research also revealed that prevalence of the condition was highest (93.4%) among younger adults, aged 18 to 44 years, a group that investigators found had particularly low disease awareness.

Approximately half (48.1%) of US adults have hypertension and more than three-quarters of those (77.4%) have uncontrolled hypertension, study authors wrote, adding that there are significant disparities in prevalence and control by sex, age, and race and ethnicity. In addition to the exorbitant cost it levies on the health care system, uncontrolled hypertension increases the risk of cardiovascular disease (CVD)-related events and mortality and is also linked to greater risk of diabetes, chronic kidney disease, and cognitive decline.

Examining the hypertension control cascade

Citing evidence of a decline in control of hypertension across the country, senior author Fátima Coronado, MD, and colleagues from the CDC, analyzed the NHANES data across the elements of the hypertension “control cascade,” a framework that allows investigators to better understand the condition at 3 different levels, awareness, diagnosis and treatment, management and control, and to better tailor interventions.

For the study researchers used the American College of Cardiology/American Heart Association (ACC/AHA) 2017 hypertension guidelines updated definition of the disease: systolic BP (SBP) greater than or equal to 130 mm Hg and diastolic BP (DBP) greater than or equal to 80 mm Hg, and regardless of medication use.

The analysis used data for 3129 adults (aged 18 years or older) with uncontrolled hypertension from the January 2017 to March 202 NHANES cycles, which Coronado et al stratified by demographic and socioeconomic factors. The study outcomes included individual awareness of hypertension, treatment recommendations, and use of medication.

Sidbar to explain

Study cohort. The final study sample, based on weighted percentages, included slightly more men (52.3%) than women. The group was stratified by age into 3 subgroups: those aged 18 to 44 years (29.4%), aged 45 to 64 years (41.4%), and 65 years or older (29.2%). Racial and ethnic groups represented were non-Hispanic White (63.2%), on-Hispanic Black (13.7%), Hispanic (13.4%), non-Hispanic Asian (5.3%), and non-Hispanic other (4.5%), according to the study. More than two-thirds (69.2%) had seen a health care professional 2 or more times in the past year.

FINDINGS

The researchers calculated that the weighted percentage of individuals with uncontrolled hypertension (83.7%; 95% CI, 80.6%-86.8%) corresponded with an estimated 100.4 million US adults. They found that more than half (57.6%) with uncontrolled disease were not aware of that fact. Less than 1 in 5 (17.8%) were aware they met criteria for uncontrolled hypertension and so were eligible for lifestyle modification measures recommended in the ACC/AHA 2017 guidelines.

Among the 35 million participants whose hypertension was uncontrolled and met guideline criteria for antihypertensive medication from January 2017 to March 2020, less than three-quarters of them (70.8%) reported doing so and so remained uncontrolled.

Age. The prevalence of uncontrolled hypertension was high across the 3 age subgroups, according to study findings, and ranged from 69.7% (95% CI, 66.7%-72.7%) among adults aged 65 years or older to 93.4% (95% CI, 90.3%-96.4%) among adults aged 18 to 44 years. Coronado and colleagues found a high rate of unawareness of the condition among the youngest group (68.4%) as well. Among the oldest group, they emphasized, nearly all (91.1%) of those who required pharmacotherapy reported taking it.

Race/ethnicity. When the researchers analyzed data from the racial and ethnic groups represented, measures of the hypertension control cascade were high with the greatest level of unawareness measured among non-Hispanic Asian adults (60.5%) compared with less than half (47.4%) of non-Hispanic black adults and just more than half (57.8%) of non-Hispanic White adults. A bright spot here, according to the findings, most adults across these racial/ethnic groups who had uncontrolled hypertension and were eligible for medication were taking it.

Sex. Examining their findings stratified by sex, Coronado and team reported high age-standardized prevalence of uncontrolled hypertension with the highest levels among those aged 18 to 44 years for both men (94.3%) and women (91.8%).

Men. Among the youngest group of men, more than two-thirds (68.1%) were unaware of their condition. Of those who were aware and met criteria for medication (69.8%), only 58.4% reported taking the medication. Among non-Hispanic Black men, among the 95% who were aware of their poorly controlled blood pressure and eligible for medication, only two-thirds (64.8%) reported currently doing so.

Women. Among the youngest women, unawareness of having uncontrolled hypertension (68.8%), was the same as for men of the same age. One half of women aged 45 to 64 years reported being unaware of the condition (vs 73.2% of same-aged men) but just one-third (36.1%) of the oldest group (65 years+) were unaware (compared with two thirds [67.2%] of comparable men).

The youngest women, aged 18 to 44 years, were also the least likely to be taking medication for uncontrolled hypertension if they met guideline criteria to do so. Less than two-thirds (62.4%) of women in this group reported taking antihypertensive medication compared with 82.6% of females aged 45 to 64 years who met the criteria for medication and more than 93.2% of females aged 65 years or older and eligible.

Additional findings

No Healthcare Visits: Among adults with uncontrolled hypertension, 75.7% had not visited a healthcare provider in the past year and were unaware of their condition.

Multiple Healthcare Visits: Approximately 51.8% of adults with uncontrolled hypertension who had 2 or more healthcare visits in the past year were still unaware of their condition.

Medication Adherence: Among the 29.0 million adults who were aware of their uncontrolled hypertension and met criteria for antihypertensive medication, 79.4% reported taking medication. Despite this, hypertension remained uncontrolled for these individuals.

Authors' thoughts

The high prevalence of unawareness among the youngest adults was of great concern to Coronado and colleagues given the importance of early CV health to later CVD prevention. Further, the age range of this group, 18 to 44 years, includes women’ optimal childbearing years, raising red flags for the potential of hypertensive disorders of pregnancy, already a significant contributor to pregnancy related death in the US.

More than one-half of adults with uncontrolled hypertension remained unaware of their hypertension status, despite nearly 70% reporting 2 or more health care visits within the past year, the authors wrote. Further, just 70% of adults who said they were aware of their condition reported adherence with blood pressure medication, a finding, the authors said, supporting well-recognized evidence that “a prescription alone does not guarantee improved hypertension control at the individual or population level.”

Overall, the data highlight widespread issues with uncontrolled hypertension awareness and control, with significant variability by age, race/ethnicity, and sex. The statistics emphasize significant challenges across the elements of the control cascade. “Future 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,” they concluded.

Source: Richardson LC, Vaughan AS, Wright JS, Coronado F. Examining the hypertension control cascade in adults with uncontrolled hypertension in the US. JAMA Netw Open. 2024;7(9):e2431997. doi:10.1001/jamanetworkopen.2024.31997