Edward J. Roccella

Trends in the Prevalence, Awareness, Treatment, and Control of Hypertension in the Adult US Population: Data From the Health Examination Surveys, 1960 to 1991

The objective of this study was to describe secular trends in the distribution of blood pressure and prevalence of hypertension in US adults and changes in rates of awareness, treatment, and control of hypertension. The study design comprised nationally representative cross-sectional surveys with both an in-person interview and a medical examination that included blood pressure measurement. Between 6530 and 13,645 adults, aged 18 through 74 years, were examined in each of four separate national surveys during 1960-1962, 1971-1974, 1976-1980, and 1988-1991. Protocols for blood pressure measurement varied significantly across the surveys and are presented in detail. Between the first (1971-1974) and second (1976-1980) National Health and Nutrition Examination Surveys (NHANES I and NHANES II, respectively), age-adjusted prevalence of hypertension at > or = 160/95 mm Hg remained stable at approximately 20%. In NHANES III (1988-1991), it was 14.2%. Age-adjusted prevalence at > or = 140/90 mm Hg peaked at 36.3% in NHANES I and declined to 20.4% in NHANES III. Age-specific prevalence rates have decreased for every age-sex-race subgroup except for black men aged 50 and older. Age-adjusted mean systolic pressures declined progressively from 131 mm Hg at the NHANES I examination to 119 mm Hg at the NHANES III examination. The mean systolic and diastolic pressures of every sex-race subgroup declined between NHANES II and III (3 to 6 mm Hg systolic, 6 to 9 mm Hg diastolic). During the interval between NHANES II and III, the threshold for defining hypertension was changed from 160/95 to 140/90 mm Hg.(ABSTRACT TRUNCATED AT 250 WORDS)

Recommendations for Blood Pressure Measurement in Humans and Experimental Animals Part 1: Blood Pressure Measurement in Humans: A Statement for Professionals From the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research

Accurate measurement of blood pressure is essential to classify individuals, to ascertain blood pressure-related risk, and to guide management. The auscultatory technique with a trained observer and mercury sphygmomanometer continues to be the method of choice for measurement in the office, using the first and fifth phases of the Korotkoff sounds, including in pregnant women. The use of mercury is declining, and alternatives are needed. Aneroid devices are suitable, but they require frequent calibration. Hybrid devices that use electronic transducers instead of mercury have promise. The oscillometric method can be used for office measurement, but only devices independently validated according to standard protocols should be used, and individual calibration is recommended. They have the advantage of being able to take multiple measurements. Proper training of observers, positioning of the patient, and selection of cuff size are all essential. It is increasingly recognized that office measurements correlate poorly with blood pressure measured in other settings, and that they can be supplemented by self-measured readings taken with validated devices at home. There is increasing evidence that home readings predict cardiovascular events and are particularly useful for monitoring the effects of treatment. Twenty-four-hour ambulatory monitoring gives a better prediction of risk than office measurements and is useful for diagnosing white-coat hypertension. There is increasing evidence that a failure of blood pressure to fall during the night may be associated with increased risk. In obese patients and children, the use of an appropriate cuff size is of paramount importance.

The Burden of Adult Hypertension in the United States 1999 to 2000: A Rising Tide

This study aims to estimate the absolute number of persons with hypertension (the hypertension burden) and time trends using data from the National Health and Nutrition Examination Survey of United States resident adults who had hypertension in 1999 to 2000. This information is vitally important for health policy, medical care, and public health strategy and resource allocation. At least 65 million adults had hypertension in 1999 to 2000. The total hypertension prevalence rate was 31.3%. This value represents adults with elevated systolic or diastolic blood pressure, or using antihypertensive medications (rate of 28.4%; standard error [SE], 1.1), and adults who otherwise by medical history were told at least twice by a physician or other health professional that they had high blood pressure (rate of 2.9%; SE, 0.4). The number of adults with hypertension increased by ≈30% for 1999 to 2000 compared with at least 50 million for 1988 to 1994. The 50 million value was based on a rate of 23.4% for adults with elevated blood pressure or using antihypertensive medications and 5.5% for adults classified as hypertensive by medical history alone (28.9% total; P<0.001). The ≈30% increase in the total number of adults with hypertension was almost 4-times greater than the 8.3% increase in total prevalence rate. These trends were associated with increased obesity and an aging and growing population. Approximately 35 million women and 30 million men had hypertension. At least 48 million non-Hispanic white adults, ≈ 9 million non-Hispanic black adults, 3 million Mexican American, and 5 million other adults had hypertension in 1999 to 2000.

Trends in Hypertension Prevalence, Awareness, Treatment, and Control Rates in United States Adults Between 1988–1994 and 1999–2004

This study assesses trends in hypertension prevalence, blood pressure distributions and mean levels, and hypertension awareness, treatment, and control among US adults, age ≥18 years, between the third National Health and Nutrition Examination Survey (1988–1994) and the 1999–2004 National Health and Nutrition Examination Survey, a period of ≈10 years. The age-standardized prevalence rate increased from 24.4% to 28.9% (P<0.001), with the largest increases among non-Hispanic women. Depending on gender and race/ethnicity, from one fifth to four fifths of the increase could be accounted for by increasing body mass index. Among hypertensive persons, there were modest increases in awareness (P=0.04), from 68.5% to 71.8%. The rate for men increased from 61.6% to 69.3% (P=0.001), whereas the rate for women did not change significantly. Rates remained higher for women than for men, although the difference narrowed considerably. Improvements in treatment and control rates were larger: 53.1% to 61.4% and 26.1% to 35.1%, respectively (both P<0.001). The greatest increases occurred among non-Hispanic white men and non-Hispanic black persons, especially men. Mexican American persons showed improvement in treatment and control rates, but these rates remained the lowest among race/ethnic subgroups (47.4% and 24.3%, respectively). Among all of the race/ethnic groups, women continued to have somewhat better awareness, treatment, and control, except for control rates among non-Hispanic white persons, which became higher in men. Differences between non-Hispanic black and white persons in awareness, treatment, and control were small. These divergent trends may translate into disparate trends in cardiovascular disease morbidity and mortality.

Differential Control of Systolic and Diastolic Blood Pressure Factors Associated With Lack of Blood Pressure Control in the Community

Data from the Third National Health and Nutrition Examination Survey, phase 2 (1991 to 1994), indicate that among hypertensive individuals in the United States, 53.6% are treated and only 27.4% are controlled to goal levels. We sought to determine whether poor hypertension control is due to lack of systolic or diastolic blood pressure control, or both. We studied Framingham Heart Study participants examined between 1990 and 1995 and determined rates of control to systolic goal (<140 mm Hg), diastolic goal (<90 mm Hg), or both (systolic <140 and diastolic <90 mm Hg). Of 1959 hypertensive subjects (mean age 66 years, 54% women), 32.7% were controlled to systolic goal, 82.9% were controlled to diastolic goal, and only 29.0% were controlled to both. Among the 1189 subjects who were receiving antihypertensive therapy (60.7% of all hypertensive subjects), 49.0% were controlled to systolic goal, 89.7% were controlled to diastolic goal, and only 47.8% were controlled to both. Thus, poor systolic blood pressure control was overwhelmingly responsible for poor rates of overall control to goal. Covariates associated with lack of systolic control in treated subjects included older age (OR for age 61 to 75 years, 2.43, 95% CI 1.79 to 3.29; OR for age >75 years, 4.34, 95% CI 3.10 to 6.09), left ventricular hypertrophy (OR 1.63, 95% CI 1.04 to 2.54), and obesity (OR for body mass index ≥30 versus <25 kg/m2, 1.49, 95% CI 1.08 to 2.06). In this community-based sample of middle-aged and older subjects, overall rates of hypertension control were remarkably similar to those in the Third National Health and Nutrition Examination Survey. Poor blood pressure control was overwhelmingly due to lack of systolic control, even among treated subjects. Therefore, clinicians and policymakers should place greater emphasis on the achievement of goal systolic levels in all hypertensive patients, especially those who are older or obese or have target organ damage.

Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) Resetting the Hypertension Sails

The National High Blood Pressure Education Program (NHBPEP), coordinated by the National Heart, Lung, and Blood Institute (NHLBI), has released its long-awaited Joint National Committee (JNC) 7 report.1 The report will be made available in 2 forms: the “Express” or short version and a longer version that will be published in Hypertension and will provide more detail regarding the recommendations. On its surface, it resembles the 6 predecessors, but to fully appreciate this new landmark document, one must recognize the process and context from which it is derived and what it is about to do. You cannot direct the winds; you can adjust the sails. Approximately 35 years ago, clinicians were busy managing severe and malignant hypertension. Hospitals filled their beds with stroke patients and stroke wards were commonplace. Coronary heart disease and stroke prevalence and accompanying mortality rates were the highest ever recorded. During the next generation, different classes of antihypertensive agents were developed and tested in a variety of settings and among different patients. The studies independently and collectively contributed to a universal finding: lowering arterial pressure can remarkably reduce cardiovascular morbidity and mortality rates as well as slow the progression of renal disease, retinopathy, and all-cause deaths. When these findings first became available, the NHLBI formed the NHBPEP, designed to translate this information through public and professional education programs. …

Recommendations for blood pressure measurement in humans: An AHA scientific statement from the council on high blood pressure research professional and public education subcommittee

VOL. 7 NO. 2 FEBRUARY 2005 102 Ten years have passed since the last version of the American Heart Association (AHA) blood pressure (BP) measurement recommendations,1 during which time there have been major changes in the ways in which BP is measured in clinical practice and research; hence this document represents a major revision of previous versions.2 BP determination continues to be one of the most important measurements in clinical medicine, and still one of the most inaccurately performed. The gold standard for clinical BP measurement has always been readings taken by a trained health care provider using a mercury sphygmomanometer and the Korotkoff sound technique. There is increasing evidence, however, that this procedure may lead to the misclassification of large numbers of individuals as hypertensive, and fail to diagnose other individuals whose BP may be normal in the clinic setting but elevated at other times. There are three reasons for this: 1) inaccuracies in the methods, some of which are avoidable; 2) the inherent variability of BP; and 3) the tendency for BP to increase in the presence of a physician (the so-called “white coat effect”). Numerous surveys have shown that physicians and other health care providers rarely follow established guidelines for BP measurement, but when they do, the readings they get correlate more closely with more objective measures of BP than the usual clinic readings. It is generally agreed that conventional clinic readings, when made correctly, are a surrogate marker for a patient’s true BP, which is conceived as the average level over prolonged periods of time, and which is thought to be the most important component of BP in determining its adverse effects. Usual clinic readings give a poor estimate of this, not only because of poor technique, but also because they typically consist only of one or two individual measurements, and the beat-to-beat BP variability is such that a small number of readings may only give a crude estimate of the average level. The recognition of these limitations of traditional clinic readings has led to two parallel developments: first, increasing use of measurements out of the clinic, Recommendations for Blood Pressure Measurement in Humans: An AHA Scientific Statement from the Council on High Blood Pressure Research Professional and Public Education Subcommittee

Seventh report of the joint national committee on the prevention, detection, evaluation, and treatment of high blood pressure (JNC 7): Resetting the hypertension sails

The National High Blood Pressure Education Program (NHBPEP), coordinated by the National Heart, Lung, and Blood Institute (NHLBI), has released its long-awaited Joint National Committee (JNC) 7 report.1 The report will be made available in 2 forms: the “Express” or short version and a longer version that will be published in Hypertension and will provide more detail regarding the recommendations. On its surface, it resembles the 6 predecessors, but to fully appreciate this new landmark document, one must recognize the process and context from which it is derived and what it is about to do. You cannot direct the winds; you can adjust the sails. Approximately 35 years ago, clinicians were busy managing severe and malignant hypertension. Hospitals filled their beds with stroke patients and stroke wards were commonplace. Coronary heart disease and stroke prevalence and accompanying mortality rates were the highest ever recorded. During the next generation, different classes of antihypertensive agents were developed and tested in a variety of settings and among different patients. The studies independently and collectively contributed to a universal finding: lowering arterial pressure can remarkably reduce cardiovascular morbidity and mortality rates as well as slow the progression of renal disease, retinopathy, and all-cause deaths. When these findings first became available, the NHLBI formed the NHBPEP, designed to translate this information through public and professional education programs. One important step …

Hypertension Prevalence, Awareness, Treatment, and Control in Egypt Results From the Egyptian National Hypertension Project (NHP)

This report from the Egyptian National Hypertension Project presents national estimates of the prevalence of hypertension and the extent to which high blood pressure is being detected, treated with medications, and controlled in the Egyptian population. The results are based on findings from a national probability survey of adults > or = 25 years of age conducted in six Egyptian governorates. With the use of a stratified multistage probability design, 6733 people (85% response rate) were examined. Hypertension was defined as systolic pressure > or = 140 mm Hg, and/or diastolic pressure > or = 90 mm Hg, and/or reported treatment with one or more antihypertensive medications. Overall, the estimated prevalence of hypertension in Egypt was 26.3%. Hypertension prevalence increased progressively with age, from 7.8% in 25- to 34-year-olds to 56.6% in those 75 years or older. Hypertension was slightly more common in women than in men (26.9% versus 25.7%, respectively). Overall, 37.5% of hypertensive individuals were aware that they had high blood pressure, 23.9% were being treated with antihypertensive medications, and 8.0% were under control (systolic pressure < 140 mm Hg and diastolic pressure < 90 mm Hg). Hypertension prevalence as well as awareness, treatment, and control rates varied by region, with Cairo having the highest prevalence (31.0%) and the Coastal Region having the highest control rate (15.9%). Rates of awareness, treatment, and control tended to be lowest in areas of lower socioeconomic status. Our results indicate that hypertension is highly prevalent in Egypt and that the rates of hypertension is awareness, treatment, and control are relatively low.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiovascular Risk Assessment Based on US Cohort Studies Findings From a National Heart, Lung, and Blood Institute Workshop

This report was derived from a workshop on cardiovascular risk assessment sponsored by the National Heart, Lung, and Blood Institute, which addressed whether risk equations developed in the Framingham Heart Study (FHS) for predicting new-onset coronary heart disease (CHD) apply to diverse population groups. Preparation for the workshop included a reanalysis and comparison of prospective studies in several different populations in which risk factors were related to cardiovascular outcomes. Some studies included fatal and nonfatal CHD end points, whereas others contained only CHD mortality. Extensive collaboration provided as much uniformity as possible with respect to both risk factors and CHD end points. The FHS has led in defining the quantitative impact of risk factors.1 Many potential risk factors were measured and related to cardiovascular outcomes. Several risk factors proved to be strong, largely independent predictors of cardiovascular disease (CVD). These factors—advancing age, cigarette smoking, blood pressure (particularly systolic), cholesterol in total serum and HDL, and diabetes—served as the basis for the development of risk prediction equations.1 If FHS risk estimates are to be widely used, they must apply widely in the US population. To document their transportability, they must be compared with prospective studies in other populations. Although the FHS is the longest running prospective study, there are other major studies. The cardiovascular end points of these other studies have varied. Some include cardiovascular morbidity and mortality; others have only cardiovascular mortality. Among the end points, CHD is the most extensively reported; for this reason, CHD was the primary focus of the workshop. ### Multivariate Relative Risk Comparisons In preparation for the workshop, multivariate regression coefficients for each risk factor were compared in different populations with those of the FHS. Adjusted relative risk estimates make it possible to determine whether each independent risk factor confers a similar or different relative risk among different …