Study shows decline in awareness, treatment and control of high blood pressure

The trend could threaten decades of public health work against heart disease.

After nearly 15 years on an upward trend, awareness among Americans about high blood pressure and how to control and treat it is now on the decline, according to a new study. Even with the help of blood pressure medications, some groups, including older adults, are less likely than they were in earlier years to adequately control their blood pressure, the research found.

The study, funded by the National Heart, Lung, and Blood Institute (NHLBI), part of the National Institutes of Health, appears online on Sept. 9 in JAMA(link is external). The authors say the trend could make longstanding efforts to fight heart disease and stroke—leading causes of death in the United States—even more challenging. High blood pressure, also called hypertension, is a major risk factor for heart disease. According to the Centers for Disease Control and Prevention (CDC), nearly 108 million Americans have hypertension, with a blood pressure reading of 130/80 millimeters of mercury (mm Hg) or higher or are taking medication for their blood pressure, but only 27 million are considered to have their blood pressure under control, despite it being a condition that can be managed.

“Reversing this decline is important because we don’t want to lose public health achievements built over prior decades,” said Lawrence Fine, M.D., chief of the Clinical Applications and Prevention Branch at NHLBI and a study co-author. “It is a challenge for the scientific community to investigate the causes of this unexpected downward trend, but developing more effective strategies to reverse and substantially improve blood pressure control is critical for the health of many Americans.”

The study included 18,262 U.S. adults age 18 and older, with high blood pressure. The definition of hypertension at the time of the study was defined by a blood pressure reading of 140/90 mm Hg or higher or by treating the condition with blood pressure medications. Participants with a blood pressure reading of less than 140/90 mm Hg were categorized as having controlled blood pressure.

With data from the National Health and Nutrition Examination Survey (NHANES) taken between1999 and 2018, the study authors looked at 20-year trends in high blood pressure awareness and treatment and blood pressure control. The CDC’s National Center for Health Statistics conducts NHANES.

At the beginning of the survey, participants had their blood pressure measured three times, then averaged. Participants answered yes or no when asked if their doctors told them they had high blood pressure and if they currently took prescribed medication for high blood pressure.

The authors found that in 1999-2000, just 70% of participants showed an awareness of their condition. That number increased steadily to 85% in 2013-2014, but declined to 77% in 2017-2018. Of those “aware” adults, the number who also were taking blood pressure medications remained relatively consistent—85% in 1999-2000, 89% in 2013-2014, and 88% in 2017-2018.

“The reversal in hypertension awareness is a real set back in the fight to reduce heart disease and stroke,” said Paul Muntner, Ph.D., the lead study author who also is professor and Associate Dean for Research in the School of Public Health at the University of Alabama at Birmingham. “While lifestyle factors are big contributors to hypertension, awareness and appropriate treatment are key to lowering blood pressure and keeping it in a healthy range to greatly reduce the risk for heart disease and stroke.”

Of all adults with high blood pressure, the number who managed to control their condition increased from 32% in 1999-2000 to 54% in 2013-2014, but then declined to 44% in 2017-2018. Of those adults with controlled blood pressure, the number taking blood pressure medication increased from 53% in 1999-2000 to 72% in 2013-2014, then declined to 65% in 2017-2018.

These observations, Muntner said, underscore the importance of continuity of care, including having a usual source of care and regularly scheduled healthcare visits that could increase high blood pressure awareness and treatment and blood pressure control among adults.

Between 2015 to 2018, adults age 60 and older, as well as Black Americans as a group, were less likely than adults ages 18 to 44 and whites as a group to have controlled blood pressure. But participants with Medicaid as their health insurance were more likely to have their blood pressure under control than those without health insurance.

There are several effective approaches to combat high blood pressure.

“Educating patients and providers on blood pressure goals, adding effective blood pressure medications when lifestyle changes aren’t enough, and reducing barriers to achieve high medication adherence in a variety of clinical practice settings are just a few strategies that may facilitate increases in blood pressure control rates and reduce health disparities we identified in the current study, added Muntner.”

About the National Heart, Lung, and Blood Institute (NHLBI): NHLBI is the global leader in conducting and supporting research in heart, lung, and blood diseases and sleep disorders that advances scientific knowledge, improves public health, and saves lives. For more information, visit www.nhlbi.nih.gov.

About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.

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