Jiexiang Li

Prevalence of Optimal Treatment Regimens in Patients With Apparent Treatment-Resistant Hypertension Based on Office Blood Pressure in a Community-Based Practice Network

Hypertensive patients with clinical blood pressure (BP) uncontrolled on ≥3 antihypertensive medications (ie, apparent treatment-resistant hypertension [aTRH]) comprise ≈28% to 30% of all uncontrolled patients in the United States. However, the proportion receiving these medications in optimal doses is unknown; aTRH is used because treatment adherence and measurement artifacts were not available in electronic record data from our >200 community-based clinics Outpatient Quality Improvement Network. This study sought to define the proportion of uncontrolled hypertensives with aTRH on optimal regimens and clinical factors associated with optimal therapy. During 2007–2010, 468 877 hypertensive patients met inclusion criteria. BP <140/<90 mm Hg defined control. Multivariable logistic regression was used to assess variables independently associated with optimal therapy (prescription of diuretic and ≥2 other BP medications at ≥50% of maximum recommended hypertension doses). Among 468 877 hypertensives, 147 635 (31.5%) were uncontrolled; among uncontrolled hypertensives, 44 684 were prescribed ≥3 BP medications (30.3%), of whom 22 189 (15.0%) were prescribed optimal therapy. Clinical factors independently associated with optimal BP therapy included black race (odds ratio, 1.40 [95% confidence interval, 1.32–1.49]), chronic kidney disease (1.31 [1.25–1.38]), diabetes mellitus (1.30 [1.24–1.37]), and coronary heart disease risk equivalent status (1.29 [1.14–1.46]). Clinicians more often prescribe optimal therapy for aTRH when cardiovascular risk is greater and treatment goals lower. Approximately 1 in 7 of all uncontrolled hypertensives and 1 in 2 with uncontrolled aTRH are prescribed ≥3 BP medications in optimal regimens. Prescribing more optimal pharmacotherapy for uncontrolled hypertensives including aTRH, confirmed with out-of-office BP, could improve hypertension control.

Blood Pressure and Cholesterol Control in Hypertensive Hypercholesterolemic Patients National Health and Nutrition Examination Surveys 1988–2010

Background— Hypertension doubles coronary heart disease (CHD) risk. Treating hypertension only reduces CHD risk ≈25%. Treating hypercholesterolemia in hypertensive patients reduces residual CHD risk >35%. Methods and Results— To assess progress in concurrent hypertension and hypercholesterolemia control, National Health and Nutrition Examination Surveys 1988 to 1994, 1999 to 2004, and 2005 to 2010 were analyzed. Hypertension was defined by blood pressure ≥140/≥90 mm Hg, current medication treatment, and 2-told hypertension status; blood pressure <140/<90 defined control. Hypercholesterolemia was defined by ATP III criteria based on 10-year CHD risk, low-density lipoprotein cholesterol (LDL-C), and non–high-density lipoprotein cholesterol; values below diagnostic thresholds defined control. Across surveys, 60.7% to 64.3% of hypertensives were hypercholesterolemic. From 1988 to 1994 to 2005 to 2010, control of LDL-C rose (9.2% [95% confidence interval (CI), 6.6%–11.9%] to 45.4% [95% CI, 42.6%–48.3%]), concomitant hypertension and LDL-C (5.0% [95% CI, 3.3%–6.7%] to 30.7% [95% CI, 27.9%–33.4%]), and combined hypertension, LDL-C, and non–high-density lipoprotein cholesterol (1.8% [95% CI, 0.4%–3.2%] to 26.9% [95% CI, 24.4%–29.5%]). By multivariable logistic regression, factors associated with concomitant hypertension, LDL-C, and non–high-density lipoprotein cholesterol control (odds ratio [95% CI]) were statin (10.7 [8.1–14.3]) and antihypertensive (3.32 [2.45–4.50]) medications, age (0.77 [0.69–0.88]/10-year increase), ≥2 healthcare visits/yr (1.90 [1.26-2.87]), black race (0.59 [0.44–0.80]), Hispanic ethnicity (0.62 [0.43–0.90]), cardiovascular disease (0.44 [0.34–0.56]), and diabetes mellitus (0.54 [0.42–0.70]). Conclusions— Despite progress, opportunities for improving concomitant hypertension and hypercholesterolemia control persist. Prescribing antihypertensive and antihyperlipidemic medications to achieve treatment goals, especially for older, minority, diabetic, and cardiovascular disease patients, and accessing healthcare at least biannually could improve concurrent risk factor control and CHD prevention. # Clinical Perspective {#article-title-47}Background— Hypertension doubles coronary heart disease (CHD) risk. Treating hypertension only reduces CHD risk ≈25%. Treating hypercholesterolemia in hypertensive patients reduces residual CHD risk >35%. Methods and Results— To assess progress in concurrent hypertension and hypercholesterolemia control, National Health and Nutrition Examination Surveys 1988 to 1994, 1999 to 2004, and 2005 to 2010 were analyzed. Hypertension was defined by blood pressure ≥140/≥90 mm Hg, current medication treatment, and 2-told hypertension status; blood pressure <140/<90 defined control. Hypercholesterolemia was defined by ATP III criteria based on 10-year CHD risk, low-density lipoprotein cholesterol (LDL-C), and non–high-density lipoprotein cholesterol; values below diagnostic thresholds defined control. Across surveys, 60.7% to 64.3% of hypertensives were hypercholesterolemic. From 1988 to 1994 to 2005 to 2010, control of LDL-C rose (9.2% [95% confidence interval (CI), 6.6%–11.9%] to 45.4% [95% CI, 42.6%–48.3%]), concomitant hypertension and LDL-C (5.0% [95% CI, 3.3%–6.7%] to 30.7% [95% CI, 27.9%–33.4%]), and combined hypertension, LDL-C, and non–high-density lipoprotein cholesterol (1.8% [95% CI, 0.4%–3.2%] to 26.9% [95% CI, 24.4%–29.5%]). By multivariable logistic regression, factors associated with concomitant hypertension, LDL-C, and non–high-density lipoprotein cholesterol control (odds ratio [95% CI]) were statin (10.7 [8.1–14.3]) and antihypertensive (3.32 [2.45–4.50]) medications, age (0.77 [0.69–0.88]/10-year increase), ≥2 healthcare visits/yr (1.90 [1.26-2.87]), black race (0.59 [0.44–0.80]), Hispanic ethnicity (0.62 [0.43–0.90]), cardiovascular disease (0.44 [0.34–0.56]), and diabetes mellitus (0.54 [0.42–0.70]). Conclusions— Despite progress, opportunities for improving concomitant hypertension and hypercholesterolemia control persist. Prescribing antihypertensive and antihyperlipidemic medications to achieve treatment goals, especially for older, minority, diabetic, and cardiovascular disease patients, and accessing healthcare at least biannually could improve concurrent risk factor control and CHD prevention.

Hypertension in the United States, 1999 to 2012: progress toward Healthy People 2020 goals.

Background— To reduce the cardiovascular disease burden, Healthy People 2020 established US hypertension goals for adults to (1) decrease the prevalence to 26.9% and (2) raise treatment to 69.5% and control to 61.2%, which requires controlling 88.1% on treatment. Methods and Results— To assess the current status and progress toward these Healthy People 2020 goals, time trends in National Health and Nutrition Examination Surveys 1999 to 2012 data in 2-year blocks were assessed in adults ≥18 years of age age-adjusted to US 2010. From 1999 to 2000 to 2011 to 2012, prevalent hypertension was unchanged (30.1% versus 30.8%, P=0.32). Hypertension treatment (59.8% versus 74.7%, P<0.001) and proportion of treated adults controlled (53.3%–68.9%, P=0.0015) increased. Hypertension control to <140/<90 mm Hg rose every 2 years from 1999 to 2000 to 2009 to 2010 (32.2% versus 53.8%, P<0.001) before declining to 51.2% in 2011 to 2012. Modifiable factor(s) significant in multivariable logistic regression modeling include: (1) increasing body mass index with prevalent hypertension (odds ratio [OR], 1.44); (2) lack of health insurance (OR, 1.68) and <2 healthcare visits per year (OR, 4.24) with untreated hypertension; (3) healthcare insurance (OR, 1.69), ≥2 healthcare visits per year (OR, 3.23), and cholesterol treatment (OR, 1.90) with controlled hypertension. Conclusions— The National Health and Nutrition Examination Survey 1999 to 2012 analysis suggests that Healthy People 2020 goals for hypertension ([1] prevalence shows no progress, [2] treatment was exceeded, and [3] control) have flattened below target. Findings are consistent with evidence that (1) obesity prevention and treatment could reduce prevalent hypertension, and (2) healthcare insurance, ≥2 healthcare visits per year, and guideline-based cholesterol treatment could improve hypertension control.Background— To reduce the cardiovascular disease burden, Healthy People 2020 established US hypertension goals for adults to (1) decrease the prevalence to 26.9% and (2) raise treatment to 69.5% and control to 61.2%, which requires controlling 88.1% on treatment. Methods and Results— To assess the current status and progress toward these Healthy People 2020 goals, time trends in National Health and Nutrition Examination Surveys 1999 to 2012 data in 2-year blocks were assessed in adults ≥18 years of age age-adjusted to US 2010. From 1999 to 2000 to 2011 to 2012, prevalent hypertension was unchanged (30.1% versus 30.8%, P =0.32). Hypertension treatment (59.8% versus 74.7%, P <0.001) and proportion of treated adults controlled (53.3%–68.9%, P =0.0015) increased. Hypertension control to <140/<90 mm Hg rose every 2 years from 1999 to 2000 to 2009 to 2010 (32.2% versus 53.8%, P <0.001) before declining to 51.2% in 2011 to 2012. Modifiable factor(s) significant in multivariable logistic regression modeling include: (1) increasing body mass index with prevalent hypertension (odds ratio [OR], 1.44); (2) lack of health insurance (OR, 1.68) and <2 healthcare visits per year (OR, 4.24) with untreated hypertension; (3) healthcare insurance (OR, 1.69), ≥2 healthcare visits per year (OR, 3.23), and cholesterol treatment (OR, 1.90) with controlled hypertension. Conclusions— The National Health and Nutrition Examination Survey 1999 to 2012 analysis suggests that Healthy People 2020 goals for hypertension ([1] prevalence shows no progress, [2] treatment was exceeded, and [3] control) have flattened below target. Findings are consistent with evidence that (1) obesity prevention and treatment could reduce prevalent hypertension, and (2) healthcare insurance, ≥2 healthcare visits per year, and guideline-based cholesterol treatment could improve hypertension control. # CLINICAL PERSPECTIVE {#article-title-36}

Closing the Gap in Hypertension Control Between Younger and Older Adults National Health and Nutrition Examination Survey (NHANES) 1988 to 2010

Background —Joint National Committee goal blood pressure (BP) for all adults was <140/<90 mmHg or lower from 1984 to 2013. Adults ≥60 years (older) have mainly isolated systolic hypertension (ISH) with major trials attaining systolic BP <150 but not <140. The main objective was to assess changes in hypertension control to <140/<90 in younger (<60 years) and older adults and <150/<90 in the latter. Methods and Results —National Health and Nutrition Examination Surveys (NHANES) 1988-1994, 1999-2004, 2005-2010 were analyzed in adults ≥18 years. From 1988-1994 to 2005-2010, hypertension control to <140/<90 improved in older (31.6% to 53.1%, p<0.001) and younger (45.7% to 55.9%, p<0.001) patients. The age gap in control declined from 14.1% (p<0.01) in 1988-1994 to 2.8% (p=0.13) in 2005-2010. Better hypertension control reflected increased percentages of older (55.6% to 77.5%) and younger (34.6% to 54.7%) patients on treatment and treated older (45.7% to 64.9%) and younger patients (56.8% to 73.4%) controlled (all p<0.001). Control to <150/<90 rose from 48.8% to 69.9% in older adults. Antihypertensive medication number and percentages on ≥3 medications increased in both age groups but more in older patients (p<0.01). BP control was higher in both age groups with ≥2 healthcare visits/year and statin therapy. Conclusions —The age gap in hypertension control to <140/<90 was virtually eliminated in 2005-2010 as clinicians intensified therapy, especially in older patients where ISH predominates controlling 70% to <150/<90. More frequent healthcare and statin therapy may improve hypertension control in all adults.Background— Joint National Committee goal blood pressure for all adults was <140/<90 mm Hg or lower from 1984 to 2013. Adults aged ≥60 years (older) have mainly isolated systolic hypertension, with major trials attaining systolic blood pressure <150 but not <140 mm Hg. The main objective was to assess changes in hypertension control to <140/<90 mm Hg in younger (aged <60 years) and older adults and <150/<90 mm Hg in the latter. Methods and Results— National Health and Nutrition Examination Surveys (NHANES) 1988 to 1994, 1999 to 2004, and 2005 to 2010 were analyzed in adults aged ≥18 years. From 1988 to 1994 to 2005 to 2010, hypertension control to <140/<90 mm Hg improved in older (31.6% to 53.1%; P<0.001) and younger (45.7% to 55.9%; P<0.001) patients. The age gap in control declined from 14.1% (P<0.01) in 1988 to 1994 to 2.8% (P=0.13) in 2005 to 2010. Better hypertension control reflected increased percentages of older (55.6% to 77.5%) and younger (34.6% to 54.7%) patients on treatment and treated older (45.7% to 64.9%) and younger (56.8% to 73.4%) patients controlled (all P<0.001). Control to <150/<90 mm Hg rose from 48.8% to 69.9% in older adults. Antihypertensive medication number and percentages on ≥3 medications increased in both age groups but increased more in older patients (P<0.01). Blood pressure control was higher in both age groups with ≥2 healthcare visits per year and on statin therapy. Conclusions— The age gap in hypertension control to <140/<90 mm Hg was virtually eliminated in 2005 to 2010 as clinicians intensified therapy, especially in older patients in whom isolated systolic hypertension predominates, controlling 70% to <150/<90 mm Hg. More frequent healthcare visits and the use of statin therapy may improve hypertension control in all adults.

The Growing Gap in Hypertension Control Between Insured and Uninsured AdultsNovelty and Significance: National Health and Nutrition Examination Survey 1988 to 2010

Hypertension awareness, treatment and control are lower among uninsured than insured adults. Time trends in differences and underlying modifiable factors are important for informing strategies to improve health equity. National Health and Nutrition Examination Surveys 1988–1994, 1999–2004, 2005–2010 data in adults 18–64 years were analyzed to explore this opportunity. The proportion of adults with hypertension who were uninsured increased from 12.3% in 1988–1994 to 17.4% in 2005–2010. In 1988–1994, hypertension awareness, treatment and control to <140/<90 millimeters mercury (30.1% versus 26.5, p=0.27) were similar in insured and uninsured adults. By 2005–2010, the absolute gap in hypertension control between uninsured and insured adults of 21.9% (52.5% versus 30.6%, p<0.001]) was explained approximately equally by lower awareness (65.2% versus 80.7%), fewer aware adults treated (75.2% versus 88.5%,and fewer treated adults controlled (63.1% versus 73.5% [all p<0.001]). Publicly insured and uninsured adults had similar income. Yet, hypertension control was similar across time periods in publicly and privately insured adults, despite lower income and education in the former. In multivariable analysis, hypertension control in 2005–2010 was associated with visit frequency (odds ratio 3.4, 95% confidence interval [2.4–4.8]), statin therapy (1.8 [1.4–2.3]) and healthcare insurance (1.6 [1.2–2.2]) but not poverty index (1.04 [0.96–1.12]). Public or private insurance linked to more frequent healthcare, greater awareness and effective treatment of hypertension, and appropriate statin use could reverse a long-term trend of growing inequity in hypertension control between insured and uninsured adults.Hypertension awareness, treatment, and control are lower among uninsured than insured adults. Time trends in differences and underlying modifiable factors are important for informing strategies to improve health equity. National Health and Nutrition Examination Surveys 1988 to 1994, 1999 to 2004, and 2005 to 2010 data in adults aged 18 to 64 years were analyzed to explore this opportunity. The proportion of adults with hypertension who were uninsured increased from 12.3% in 1988 to 1994 to 17.4% in 2005 to 2010. In 1988 to 1994, hypertension awareness, treatment, and control to <140/<90 mm Hg (30.1% versus 26.5%; P=0.27) were similar in insured and uninsured adults. By 2005 to 2010, the absolute gap in hypertension control between uninsured and insured adults of 21.9% (52.5% versus 30.6%; P<0.001) was explained approximately equally by lower awareness (65.2% versus 80.7%), fewer aware adults treated (75.2% versus 88.5%), and fewer treated adults controlled (63.1% versus 73.5%; all P<0.001). Publicly insured and uninsured adults had similar income. Yet, hypertension control was similar across time periods in publicly and privately insured adults, despite lower income and education in the former. In multivariable analysis, hypertension control in 2005 to 2010 was associated with visit frequency (odds ratio, 3.4 [95% confidence interval, 2.4–4.8]), statin therapy (1.8 [1.4–2.3]), and healthcare insurance (1.6 [1.2–2.2]) but not poverty index (1.04 [0.96–1.12]). Public or private insurance linked to more frequent healthcare, greater awareness and effective treatment of hypertension, and appropriate statin use could reverse a long-term trend of growing inequity in hypertension control between insured and uninsured adults.

The Growing Gap in Hypertension Control Between Insured and Uninsured Adults: National Health and Nutrition Examination Survey 1988 to 2010

Hypertension awareness, treatment and control are lower among uninsured than insured adults. Time trends in differences and underlying modifiable factors are important for informing strategies to improve health equity. National Health and Nutrition Examination Surveys 1988–1994, 1999–2004, 2005–2010 data in adults 18–64 years were analyzed to explore this opportunity. The proportion of adults with hypertension who were uninsured increased from 12.3% in 1988–1994 to 17.4% in 2005–2010. In 1988–1994, hypertension awareness, treatment and control to <140/<90 millimeters mercury (30.1% versus 26.5, p=0.27) were similar in insured and uninsured adults. By 2005–2010, the absolute gap in hypertension control between uninsured and insured adults of 21.9% (52.5% versus 30.6%, p<0.001]) was explained approximately equally by lower awareness (65.2% versus 80.7%), fewer aware adults treated (75.2% versus 88.5%,and fewer treated adults controlled (63.1% versus 73.5% [all p<0.001]). Publicly insured and uninsured adults had similar income. Yet, hypertension control was similar across time periods in publicly and privately insured adults, despite lower income and education in the former. In multivariable analysis, hypertension control in 2005–2010 was associated with visit frequency (odds ratio 3.4, 95% confidence interval [2.4–4.8]), statin therapy (1.8 [1.4–2.3]) and healthcare insurance (1.6 [1.2–2.2]) but not poverty index (1.04 [0.96–1.12]). Public or private insurance linked to more frequent healthcare, greater awareness and effective treatment of hypertension, and appropriate statin use could reverse a long-term trend of growing inequity in hypertension control between insured and uninsured adults.Hypertension awareness, treatment, and control are lower among uninsured than insured adults. Time trends in differences and underlying modifiable factors are important for informing strategies to improve health equity. National Health and Nutrition Examination Surveys 1988 to 1994, 1999 to 2004, and 2005 to 2010 data in adults aged 18 to 64 years were analyzed to explore this opportunity. The proportion of adults with hypertension who were uninsured increased from 12.3% in 1988 to 1994 to 17.4% in 2005 to 2010. In 1988 to 1994, hypertension awareness, treatment, and control to <140/<90 mm Hg (30.1% versus 26.5%; P=0.27) were similar in insured and uninsured adults. By 2005 to 2010, the absolute gap in hypertension control between uninsured and insured adults of 21.9% (52.5% versus 30.6%; P<0.001) was explained approximately equally by lower awareness (65.2% versus 80.7%), fewer aware adults treated (75.2% versus 88.5%), and fewer treated adults controlled (63.1% versus 73.5%; all P<0.001). Publicly insured and uninsured adults had similar income. Yet, hypertension control was similar across time periods in publicly and privately insured adults, despite lower income and education in the former. In multivariable analysis, hypertension control in 2005 to 2010 was associated with visit frequency (odds ratio, 3.4 [95% confidence interval, 2.4–4.8]), statin therapy (1.8 [1.4–2.3]), and healthcare insurance (1.6 [1.2–2.2]) but not poverty index (1.04 [0.96–1.12]). Public or private insurance linked to more frequent healthcare, greater awareness and effective treatment of hypertension, and appropriate statin use could reverse a long-term trend of growing inequity in hypertension control between insured and uninsured adults.

2013 ACC/AHA Cholesterol Guideline and Implications for Healthy People 2020 Cardiovascular Disease Prevention Goals

Background Healthy People 2020 aim to reduce fatal atherosclerotic cardiovascular disease (ASCVD) by 20%, which translates into 310 000 fewer events annually assuming proportional reduction in fatal and nonfatal ASCVD. We estimated preventable ASCVD events by implementing the American College of Cardiology/American Heart Association (ACC/AHA) 2013 Cholesterol Guideline in all statin‐eligible adults. Absolute risk reduction (ARR) and number needed‐to‐treat (NNT) were calculated. Methods and Results National Health and Nutrition Examination Survey data for 2007–2012 were analyzed for adults aged 21 to 79 years and extrapolated to the US population. Literature‐guided assumptions were used including (1) low‐density lipoprotein cholesterol falls 33% with moderate‐intensity statins and 51% with high‐intensity statins; (2) for each 39 mg/dL decline in low‐density lipoprotein cholesterol, 10‐year ASCVD 10 risk would fall 21% when ASCVD 10 risk was ≥20% and 33% when ASCVD 10 risk was <20%; and (3) either all statin‐eligible untreated adults or all with ASCVD 10 risk ≥7.5% would receive statins. Of 175.9 million adults aged 21 to 79 years not taking statins, 44.8 million (25.5%) were statin eligible. Treating all statin‐eligible adults would prevent an estimated 243 589 ASCVD events annually (ARR 5.4%, 10‐year NNT 18). Treating all statin‐eligible adults with ASCVD 10 risk ≥7.5% reduces the number treated to 32.2 million (28.2% fewer), whereas ASCVD events prevented annually fall only 10.5% to 217 974 (6.8% ARR, NNT 15). Conclusions Implementing the ACC/AHA 2013 Cholesterol Guideline in all untreated, statin‐eligible adults could achieve ≈78% of the Healthy People 2020 ASCVD prevention goal. Most of the benefit is attained by individuals with 10‐year ASCVD risk ≥7.5%.

Role of aldosterone blockade in resistant hypertension.

Apparent treatment-resistant hypertension (aTRH), defined as uncontrolled blood pressure using 3 or more antihypertensive medications or controlled using 4 or more antihypertensive medications, affects approximately 30% of uncontrolled and 12% of controlled blood pressure (BP) patients. aTRH is used when pseudoresistance cannot be excluded (eg, BP measurement artifacts, mainly office resistance, suboptimal adherence, suboptimal treatment regimens, and true TRH). True TRH comprises approximately 30% to 50% of TRH. Patients with TRH have a high prevalence of obesity, insulin resistance, sleep apnea, and volume expansion. Aldosterone, a mineralocorticoid, is an important contributor to TRH, with primary aldosteronism present in approximately 20% of patients. Spironolactone, a mineralocorticoid-receptor antagonist, as a fourth-line agent, decreases BP 20 to 25/10 to 12 mm Hg in TRH patients with and without primary aldosteronism. The BP response to spironolactone is roughly double that of other classes of antihypertensive medications in TRH. Although approximately 70% of patients with uncontrolled TRH have estimated glomerular filtration rate of 50 or greater and a serum potassium level of 4.5 or less, which are associated with a low risk for hyperkalemia, only a small percentage receive a mineralocorticoid-receptor antagonist. This review examines the clinical epidemiology and pharmacotherapy of controlled and uncontrolled hypertension with an emphasis on aTRH, the role of aldosterone in blood pressure regulation, and the potential benefits of mineralocorticoid-receptor antagonist in uncontrolled TRH.

Trends in Prehypertension and Hypertension Risk Factors in US Adults

Prehypertension is associated with increased risk for hypertension and cardiovascular disease. Data are limited on the temporal changes in the prevalence of prehypertension and risk factors for hypertension and cardiovascular disease among US adults with prehypertension. We analyzed data from 30 958 US adults ≥20 years of age who participated in the National Health and Nutrition Examination Surveys between 1999 and 2012. Using the mean of 3 blood pressure (BP) measurements from a study examination, prehypertension was defined as systolic BP of 120 to 139 mm Hg and diastolic BP <90 mm Hg or diastolic BP of 80 to 89 mm Hg and systolic BP <140 mm Hg among participants not taking antihypertensive medication. Between 1999–2000 and 2011–2012, the percentage of US adults with prehypertension decreased from 31.2% to 28.2% (P trend=0.007). During this time period, the prevalence of several risk factors for cardiovascular disease and incident hypertension increased among US adults with prehypertension, including prediabetes (9.6% to 21.6%), diabetes mellitus (6.0% to 8.5%), overweight (33.5% to 37.3%), and obesity (30.6% to 35.2%). There was a nonstatistically significant increase in no weekly leisure-time physical activity (40.0% to 43.9%). Also, the prevalence of adhering to the Dietary Approaches to Stop Hypertension eating pattern decreased (18.4% to 11.9%). In contrast, there was a nonstatistically significant decline in current smoking (25.9% to 23.2%). In conclusion, the prevalence of prehypertension has decreased modestly since 1999–2000. Population-level approaches directed at adults with prehypertension are needed to improve risk factors to prevent hypertension and cardiovascular disease.

Systolic Blood Pressure Intervention Trial (SPRINT) and Target Systolic Blood Pressure in Future Hypertension Guidelines

The Systolic Blood Pressure (SBP, mm Hg) Intervention Trial (SPRINT) showed that targeting SBP <120 mm Hg (intensive treatment, mean SBP: 121.5 mm Hg) versus <140 (standard treatment, mean SBP: 134.6 mm Hg) reduced cardiovascular events 25%. SPRINT has 2 implicit assumptions that could impact future US hypertension guidelines: (1) standard therapy controlled SBP similarly to that in adults with treated hypertension and (2) intensive therapy produced a lower mean SBP than in adults with treated hypertension and SBP <140 mm Hg. To examine these assumptions, US National Health and Nutrition Examination Survey 2009 to 2012 data were analyzed on 3 groups of adults with treated hypertension: group 1 consisted of SPRINT-like participants aged ≥50 years; group 2 consisted of participants all aged ≥18 years; and group 3 consisted of participants aged ≥18 years excluding group 1 but otherwise similar to SPRINT-like participants except high cardiovascular risk. Mean SBPs in groups 1, 2, and 3 were 133.0, 130.1, and 124.6, with 66.2%, 72.2%, and 81.9%, respectively, controlled to SBP <140; 68.3%, 74.8%, and 83.4% of the controlled subset had SBP <130. Mean SBPs in those controlled to <140 were 123.3, 120.9, and 118.9, respectively. Among US adults with treated hypertension, (1) the SPRINT-like group had higher mean SBP than comparison groups, yet lower than SPRINT standard treatment group and (2) among groups 1 to 3 with SBP <140, SBP values were within <3 mm Hg of SPRINT intensive treatment. SPRINT results suggest that treatment should be continued and not reduced when treated SBP is <130, especially for the SPRINT-like subset. Furthermore, increasing the percentage of treated adults with SBP <140 could approximate SPRINT intensive treatment SBP without lowering treatment goals.