Potential need for expanded pharmacologic treatment and lifestyle modification services under the 2017 ACC/AHA Hypertension Guideline

Matthew D Ritchey; Cathleen Gillespie; Gregory Wozniak; Christina M Shay; Angela M Thompson‐Paul; Fleetwood Loustalot; Yuling Hong

doi:10.1111/jch.13364

. 2018 Sep 8;20(10):1377–1391. doi: 10.1111/jch.13364

Potential need for expanded pharmacologic treatment and lifestyle modification services under the 2017 ACC/AHA Hypertension Guideline

Matthew D Ritchey ^1,^✉, Cathleen Gillespie ¹, Gregory Wozniak ², Christina M Shay ³, Angela M Thompson‐Paul ¹, Fleetwood Loustalot ¹, Yuling Hong ¹

PMCID: PMC8030763 PMID: 30194806

Abstract

Application of the 2017 ACC/AHA Hypertension Guideline expands the number of US adults requiring blood pressure (BP) management. The authors use 2011‐2014 NHANES data to describe the population groups most affected by the new guideline, compared with the previous JNC‐7 guideline, and describe the previous interaction with the health care sector among those adults recommended new or intensified pharmacologic treatment and/or lifestyle modification. The 2017 Hypertension Guideline reclassifies 32.3 million US adults as newly hypertensive and recommends BP‐related treatment of 133.7 million adults, including 57.8 million with uncontrolled BP recommended to initiate or intensify pharmacologic treatment and 50.5 million newly recommended lifestyle modification alone. An estimated 13.1 million (22.7%) adults recommended to initiate or intensify pharmacologic treatment, and 20.6 million (40.8%) adults newly recommended lifestyle modification alone report not having established health care linkages. Among the adults newly recommended lifestyle modification alone, the odds of reclassification from no recommended intervention, under JNC‐7, to recommended lifestyle modification alone were lower for adults with established linkages to care (aOR: 0.78 [95% CI: 0.67‐0.91]) compared to those without, decreased with increasing age, were greater for men (1.72 [1.52‐1.94]) compared to women and were greater for obese adults (1.23 [1.00‐1.53]) compared with normal or underweight adults. Application of the 2017 Hypertension Guideline increases the number and alters the distribution of US adults in need of initiating or intensifying BP treatment. This includes identifying millions of US adults who previously had limited interaction with health care and are now recommended new or intensified pharmacologic treatment and/or lifestyle modification.

Keywords: American Medical Association, Clinical management of high blood pressure, hypertension general, lifestyle modification/hypertension, or American Heart Association

1. INTRODUCTION

Sustained high blood pressure (BP) is a leading risk factor for developing heart disease, stroke, and renal disease.1, 2, 3 The positive association between BP and cardiovascular disease (CVD) risk has been well established.1, 4 Classification of BP levels into categories supports clinical decision making, public health surveillance, and public and private programmatic activities.

The 2017 American College of Cardiology and American Heart Association (ACC/AHA) Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure (2017 Hypertension Guideline), which was released in November 2017, established new BP categories (normal BP: systolic BP [SBP] <120 and diastolic BP [DBP] <80 mm Hg; elevated BP: SBP 120‐129 and DBP <80 mm Hg; Stage 1 hypertension: SBP 130‐139 or DBP 80‐89 mm Hg; and Stage 2 hypertension: SBP ≥140 or DBP ≥90 mm Hg) and provided updated recommendations for hypertension diagnosis and the use of pharmacologic treatment and lifestyle modification for BP management.5 A paper by Muntner et al 6 summarized the effects of applying the new guideline on the estimated prevalence of hypertension, recommended pharmacologic treatment, and BP control among those on pharmacologic treatment compared to applying the guideline used previously for national surveillance,7, 8 the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC‐7).9 They demonstrated that application of the new guideline among US adults aged ≥20 years results in a sizable increase (31.1 million) in the number classified as now having hypertension and a relatively small increase (4.2 million) in the number recommended pharmacologic treatment. Furthermore, they estimated that 7.9 million adults who were currently on pharmacologic treatment and considered to have their BP controlled under JNC‐7 would likely need to intensify their treatment to meet the thresholds for BP control established under the 2017 Hypertension Guideline.

This study builds on the work of Muntner,6 by more fully describing the subgroups most affected by reclassification of their hypertension, BP treatment, and BP control status with application of the new guideline compared to JNC‐7 using National Health and Nutrition Examination Survey (NHANES) data. Furthermore, we describe the prior access and utilization of health care services among those in need of initiating or intensifying BP management under the new guideline, including those adults with elevated BP or Stage 1 hypertension newly recommended lifestyle modification alone without pharmacologic treatment. These findings will inform the clinical‐ and community‐based actions necessary to manage the likely increased need for BP management services under the new guideline, especially among certain subgroups. Moreover, our methodology, which has been updated compared to that used by Muntner to better align with 2017 Hypertension Guideline criteria, can serve as the basis for surveillance of BP‐related outcomes in the United States, including tracking the progress made among subgroups with known disparities, using nationally representative population‐based surveys.10

2. METHODS

NHANES is a complex, multistage probability sample of the US civilian, noninstitutionalized population.11 To obtain statistically stable estimates, we analyzed data from two 2‐year NHANES cycles (2011‐2014) in which 11 539 participants aged ≥18 years were interviewed and examined. We excluded pregnant women (n = 122) and participants who did not have ≥1 complete nonzero SBP and DBP measurements, information on self‐reported current use of BP‐lowering medication, or values for other covariates of interest (n = 1386), yielding a final analytic sample of 10 031 participants (Table S1). All analyses were conducted using the Mobile Examination Center (MEC) sampling weights and statistical software (SAS version 9.4 and SUDAAN, Release 11; RTI International, Research Triangle Park, NC, USA) to adjust variance estimates for the multistage, clustered sample design. The data used are publicly available, and further Institutional Review Board approval was not required for their use in secondary analyses. The differences identified in the methodology used in this study compared with Muntner et al 6 are summarized in Table S2.

2.1. Hypertension definitions

A maximum of three BP readings were measured for each participant in the MEC under a standard protocol12; the mean of the available readings represented participants' SBP and DBP. For participants with a single BP reading that measurement was used in place of an average. Applying JNC‐7, we defined hypertension as SBP ≥140 mm Hg or DBP ≥90 mm Hg, or self‐reported current use of BP‐lowering medication, defined as an answer of “Yes” to both: “Because of your high BP/hypertension, have you ever been told to take prescribed medicine?” and “Are you currently taking medication to lower your BP?” The 2017 Hypertension Guideline was applied by lowering thresholds for SBP to ≥130 mm Hg and DBP to ≥80 mm Hg.

2.2. Recommended pharmacologic treatment and lifestyle modification definitions

To identify participants who were recommended both pharmacologic treatment and lifestyle modification to manage their hypertension according to JNC‐7, we included participants with hypertension, as well as participants with mean BP 130‐139/80‐89 mm Hg and who had diabetes mellitus (diabetes) or chronic kidney disease (CKD). Diabetes was determined by participant self‐report, measured hemoglobin A1c ≥6.5%, or fasting plasma glucose ≥126 mg/dL.13 CKD was defined as an estimated glomerular filtration rate <60 mL/Min/1.73 m² or urine albumin‐to‐creatinine ratio ≥300 mg/g.14 To align with the 2017 Hypertension Guideline, we defined participants as being recommended pharmacologic treatment if they were already on BP medication therapy, had Stage 2 hypertension, or had Stage 1 hypertension and met ≥1 of these criteria for existing or high risk of developing CVD: a self‐reported history of clinical CVD (coronary heart disease, acute myocardial infarction, stable or unstable angina, congestive heart failure, or stroke)15; have diabetes or CKD; aged ≥65 years; or have a 10‐year Atherosclerotic CVD (ASCVD) Risk Score ≥10%, based on the pooled cohort equations from the American College of Cardiology/American Heart Association Guideline on the Assessment of Cardiovascular Risk.15, 16

2.3. Recommended lifestyle modification without pharmacologic treatment definition

Two groups were identified as being recommended lifestyle modification without pharmacologic treatment (lifestyle modification alone) with application of the 2017 Hypertension Guideline. The first group included those participants with elevated BP. The second group included those participants with Stage 1 hypertension, but who did not meet the criteria for pharmacologic treatment. No similar categorization for recommended lifestyle modification alone exists in JNC‐7, so this classification was not applied in those analyses.

2.4. Blood pressure control definitions

We defined BP control according to each guideline: under JNC‐7, BP control was defined as BP <130/80 mm Hg among those with diabetes or CKD who had initiated pharmacologic treatment or <140/90 mm Hg among all other adults; under the 2017 Hypertension Guidelines, BP control was defined as BP <130/80 mm Hg. We estimated control among all hypertensive adults and control among adults recommended pharmacologic therapy, according to each guideline.

2.5. Comparing estimates from application of the JNC‐7 guideline and 2017 Hypertension Guidelines

We estimated the prevalence for the measures above according to each guidelines’ criteria. To estimate population counts, we multiplied the estimated prevalence (as proportions) by the average 2011‐2012 and 2013‐2014 National Center for Health Statistics’ 2‐year national population counts, which are compiled from the US Census Bureau's American Community Survey.17 We characterized the degree of reclassification resulting from application of the new versus old guideline and assessed for variation in reclassification rates across subgroups, by calculating odds ratios (aORs) adjusting for the potential confounders of sex, age group, and race/ethnicity. Subgroups assessed included stratifying participants by sex; age group; race ethnicity; body mass index (BMI) categories (among adults aged ≥20 years: underweight or normal [BMI <25 kg/m²], overweight [25 ≤ BMI <30 kg/m²], or obese [BMI ≥30 kg/m²]; among adults aged 18‐19 years: underweight or normal [BMI <85th sex age‐specific percentiles]; overweight [85th ≤ BMI <95th percentile]; obese [BMI ≥95th percentile])18; diabetes, and CKD status; history of clinical CVD; 10‐year ASCVD risk category (<10% or ≥10%); and health care access and use characteristics, including having health insurance (having any, defined as Medicare, private, or other public; or having none); having a usual source of care (“Yes” to "Is there a place that you usually go when you are sick or need advice about your health?"); the number of health care visits in the past year (per participant's response to: "During the last 12 months how many times have you seen a doctor or other health professional about your health at a doctor's office, a clinic, hospital emergency department, at home or some other place? Do not include times you were hospitalized overnight."); and having established linkages to care, defined as being insured, having a usual source of care, and having had ≥1 visits during the past year.

3. RESULTS

3.1. Hypertension prevalence

Application of the 2017 Hypertension Guideline to data collected during 2011‐2014 classifies 44.4% (95% confidence interval [CI]: 42.4‐46.5) of US adults (104.6 million) as having hypertension (Table 1). This represents an increase of 13.7 percentage points, or 32.3 million adults, compared to applying JNC‐7, which classifies 30.7% (29.0‐32.5) of US adults as having hypertension. Odds of reclassification were lower for adults with established linkages to care (aOR: 0.76 [95% CI: 0.63‐0.91]), with approximately 39.4% of adults newly reclassified as hypertensive (12.5 million) reporting having limited established linkages to care. In addition, odds of reclassification were as follows: greater for men (1.61 [1.35‐1.91]) compared to women; greater for adults aged 45‐64 years (1.26 [1.07‐1.48]) and lower for adults aged ≥65 years (0.78 [0.61‐0.99]) compared to adults aged 18‐44 years; greater for overweight (1.44 [1.13‐1.85]) and obese (1.50 [1.18‐1.90]) adults compared with normal or underweight adults; and lower for adults with diabetes (0.75 [0.60‐0.93]) or prior history of clinical CVD (0.58 [0.41‐0.81]) compared to those without. Odds of reclassification were not significantly different across race ethnicity groups (P > 0.05).

Table 1.

Odds of reclassification of hypertension status among adults aged ≥18 years with application of the 2017 Hypertension Guideline compared to JNC‐7—National Health and Nutrition Examination Survey, 2011‐2014^a

	Sample	Population	JNC‐7^b ^, ^c		2017 Hypertension Guideline^b ^, ^d		Difference
	n	N^e	% (95% CI)	N	% (95% CI)	N	%^f	N	aOR^g (95% CI)
Total	10 031	235.4	30.7 (29.0‐32.5)	72.3	44.4 (42.4‐46.5)	104.6	13.7	32.3
Men	4966	113.2	30.4 (28.3‐32.6)	34.4	47.0 (44.3‐49.6)	53.2	16.6	18.8	1.61 (1.35‐1.91)
Women	5065	122.1	31.0 (29.1‐32.9)	37.9	42.0 (39.7‐44.3)	51.3	11.0	13.4	1.00
Age group (y)
18‐44	4631	111.6	9.9 (8.8‐11.1)	11.0	23.1 (21.1‐25.3)	25.8	13.3	14.8	1.00
45‐64	3310	82.0	40.2 (37.8‐42.7)	33.0	56.2 (53.9‐58.5)	46.1	16.0	13.1	1.26 (1.07‐1.48)
45‐54	1654	43.6	29.4 (26.9‐32.1)	12.8	46.9 (44.2‐49.7)	20.5	17.5	7.6	1.41 (1.12‐1.78)
55‐64	1656	38.4	52.1 (48.5‐55.6)	20.0	66.3 (63.1‐69.4)	25.5	14.2	5.5	1.09 (0.91‐1.31)
≥65	2090	41.7	67.4 (65.1‐69.7)	28.1	77.9 (76.0‐79.7)	32.5	10.4	4.4	0.78 (0.61‐0.99)
65‐74	1202	23.6	62.6 (58.9‐66.0)	14.8	75.0 (72.7‐77.2)	17.7	12.5	2.9	0.94 (0.68‐1.30)
≥75	888	18.1	74.8 (71.8‐77.6)	13.5	82.1 (79.0‐84.9)	14.9	7.4	1.3	0.53 (0.42‐0.68)
Race ethnicity
NH White	4030	155.8	32.3 (30.1‐34.6)	50.3	46.2 (43.4‐49.0)	71.9	13.9	21.6	1.00
NH Black	2261	27.2	39.4 (37.3‐41.5)	10.7	53.4 (51.1‐55.7)	14.5	14.0	3.8	1.02 (0.83‐1.26)
NH Asian	1243	12.0	23.6 (20.6‐26.9)	2.8	35.3 (31.7‐39.1)	4.2	11.7	1.4	0.83 (0.67‐1.03)
Hispanic	2199	34.7	20.2 (17.8‐22.9)	7.0	33.5 (30.9‐36.3)	11.6	13.3	4.6	0.95 (0.78‐1.14)
Other	298	5.7	26.4 (19.6‐34.5)	1.5	41.6 (34.6‐48.8)	2.3	15.2	0.9	1.11 (0.69‐1.78)
BMI category^h
Normal/Underweight	3254	73.5	18.6 (16.2‐21.2)	13.6	29.0 (26.6‐31.6)	21.3	10.5	7.7	1.00
Overweight	3170	77.7	29.8 (28.1‐31.5)	23.1	45.0 (42.6‐47.4)	34.9	15.2	11.8	1.44 (1.13‐1.85)
Obese	3607	84.2	42.1 (39.8‐44.5)	35.5	57.4 (54.7‐60.0)	48.3	15.2	12.8	1.50 (1.18‐1.90)
Diabetes mellitusⁱ
Yes	1566	27.9	66.0 (62.9‐69.0)	18.4	77.2 (74.0‐80.1)	21.5	11.2	3.1	0.75 (0.60‐0.93)
No	8465	207.5	26.0 (24.3‐27.7)	53.9	40.0 (38.0‐42.1)	83.1	14.1	29.2	1.00
Chronic kidney disease^j
Yes	1758	34.7	61.3 (57.9‐64.5)	21.2	72.7 (69.5‐75.7)	25.2	11.5	4.0	0.87 (0.69‐1.12)
No	8273	200.7	25.4 (23.7‐27.2)	51.0	39.6 (37.5‐41.7)	79.4	14.1	28.3	1.00
History of clinical CVD^k
Yes	1051	21.3	67.0 (63.4‐70.5)	14.3	75.6 (72.2‐78.8)	16.2	8.6	1.8	0.58 (0.41‐0.81)
No	8980	214.0	27.1 (25.3‐28.9)	58.0	41.3 (39.2‐43.5)	88.4	14.2	30.5	1.00
ASCVD risk^l
≥10%	2265	43.3	71.0 (67.7‐74.1)	30.7	82.2 (79.6‐84.4)	35.5	11.1	4.8	0.54 (0.42‐0.69)
<10%	3389	90.4	28.8 (26.8‐30.9)	26.0	46.2 (44.0‐48.4)	41.8	17.4	15.7	1.00
Health care access and use
Health insurance^m
Any	7757	190.7	34.0 (32.0‐36.0)	64.8	47.0 (44.7‐49.4)	89.7	13.1	24.9	0.78 (0.63‐0.96)
Private	5190	145.1	30.3 (28.1‐32.6)	44.0	44.0 (41.3‐46.7)	63.8	13.7	19.9	0.80 (0.65‐0.98)
Medicare	1182	20.1	65.8 (60.6‐70.6)	13.3	75.1 (71.9‐78.0)	15.1	9.3	1.9	0.58 (0.36‐0.93)
Other public	1385	25.4	29.7 (26.7‐32.8)	7.5	42.2 (39.2‐45.2)	10.7	12.5	3.2	0.73 (0.52‐1.03)
None	2274	44.7	16.8 (14.9‐18.9)	7.5	33.4 (31.1‐35.8)	14.9	16.6	7.4	1.00
Usual source of careⁿ
Yes	8372	198.4	34.2 (32.5‐35.9)	67.8	47.2 (45.1‐49.3)	93.7	13.0	25.9	0.74 (0.61‐0.91)
No	1659	37.0	12.1 (9.7‐14.9)	4.5	29.5 (26.8‐32.5)	10.9	17.5	6.5	1.00
Health care visits past year^o
0	1641	35.8	14.5 (12.7‐16.5)	5.2	32.5 (29.5‐35.6)	11.7	18.0	6.4	1.00
1	1888	43.7	17.0 (14.9‐19.3)	7.4	32.9 (30.3‐35.6)	14.4	15.9	7.0	0.90 (0.71‐1.14)
2+	6502	155.8	38.3 (36.1‐40.6)	59.6	50.4 (47.9‐52.9)	78.6	12.1	18.9	0.68 (0.53‐0.87)
Established linkages to care^p
Yes	6524	159.0	37.6 (35.7‐39.6)	59.8	50.1 (47.9‐52.4)	79.7	12.5	19.9	0.76 (0.63‐0.91)
No	3507	76.3	16.3 (14.7‐18.1)	12.4	32.6 (30.3‐35.0)	24.9	16.3	12.5	1.00

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2017 Hypertension Guideline: 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure; aOR: adjusted odds ratio; ASCVD, atherosclerotic cardiovascular disease; BMI: body mass index; CI: confidence interval; CVD, cardiovascular disease; JNC‐7: Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; NH: non‐Hispanic.

Hypertension is defined as a high average BP (based on up to 3 measurements) or self‐reported BP‐lowering medication use. BP‐lowering medication use is defined by answers to the questions: "Because of your high blood pressure/hypertension, have you ever been told to take prescribed medicine?" and "Are you now taking prescribed medicine?"

JCN‐7 defines hypertension as BP ≥140/90 mm Hg.

2017 Hypertension Guideline defines hypertension as BP ≥130/80 mm Hg.

Population in millions, calculated by multiplying the estimated hypertension prevalence (as proportions) by the average 2011‐2012 and 2013‐2014 National Center for Health Statistics’ 2‐year national population counts, which are compiled from the US Census Bureau's American Community Survey (https://wwwn.cdc.gov/nchs/nhanes/ResponseRates.aspx).

Difference in hypertension prevalence under JNC‐7 and the 2017 Hypertension Guideline.

Odds for being newly diagnosed as hypertensive under the 2017 Hypertension Guideline compare to JNC‐7; adjusted for sex, age group, and race/ethnicity.

Defined based on BMI = weight (kg)/height (m)². Among adults’ age ≥20 years: normal/underweight defined as BMI <25.0; overweight defined as BMI 25.0‐29.9; and obese defined as BMI ≥30.0. Among adults aged 18‐19 years: normal/underweight defined as BMI <85th sex‐ and height‐specific percentile; overweight defined as BMI 85th ‐<95th sex‐ and height‐specific percentile; and obese defined as BMI ≥95th sex‐ and height‐specific percentile. BMI percentiles based on: https://www.cdc.gov/growthcharts/html_charts/bmiagerev.htm.

ⁱ

Defined as fasting plasma glucose ≥126 mg/dL, glycohemoglobin (HbA1c) ≥6.5%, or self‐report (an answer of "yes" to the question "Have you ever been told by a doctor or health professional that you have diabetes or sugar diabetes?").

Defined as urinary albumin/creatinine ratio >30 mg/g or estimated glomerular filtration rate <60 mL/min per 1.73 m².

Defined from self‐report: stable or unstable angina, congestive heart failure, acute myocardial infarction, or stroke.

ASCVD risk is calculated among adults age 40‐79 years, based on the pooled cohort equations from the American College of Cardiology/American Heart Association Guideline on the Assessment of Cardiovascular Risk.16

Defined as an answer of "yes" to the question "Are you covered by health insurance or some other kind of health care plan?" Participants reporting only a single‐service plan were defined as not insured. Other public insurance includes Medigap, Medicaid, SCHIP, military health plan, Indian Health Service, state‐sponsored health plan, or other government insurance.

ⁿ

Defined as an answer of "yes" or "there is more than one place" to the question "Is there a place that you usually go when you are sick or you need advice about your health?”

Based on answers to the question "During the past 12 months, how many times have you seen a doctor or other health care professional about your health at a doctor's office, a clinic or some other place?"

Defined as having health insurance, having a usual source of health care, and ≥1 health care visit in the past year.

3.2. Recommended pharmacologic treatment and lifestyle modification prevalence

Applying the new guideline criteria versus those of JNC‐7 resulted in a 2.1 percentage point increase in the prevalence of recommended pharmacologic treatment and lifestyle modification in the US adult population (from 33.3% [95% CI: 31.5‐35.2] to 35.4% [33.4‐37.4]), which reclassified 4.9 million adults (Table 2). Odds for reclassification of recommended pharmacologic treatment did not differ by reported heath care access and use status; however, around 22.4% (1.1 million) of adults newly recommended pharmacologic therapy reported having limited established linkages to care (Figure 1). Odds of reclassification did vary by sex (aOR: 2.20 [95% CI: 1.47‐3.27] for men compared to women) and age (aOR of 8.69 [3.58‐21.06] among adults aged 45‐64 years and 29.24 [13.17‐64.93] among adults aged ≥65 years, compared to adults aged 18‐44 years). There was no change in the proportion of persons with CKD or diabetes recommended pharmacologic treatment since criteria did not change between guidelines. Among adults recommended pharmacologic treatment, under the 2017 Hypertension Guideline, 34.8% are currently untreated (Figure 2). Of those untreated, 37.8% have Stage 1 hypertension, of which 38.9% were aged ≥65 years, 28.5% were diabetic, 36.3% had CKD, 16.8% had a history of clinical CVD, and 44.6% had an ASCVD risk ≥10%; and 62.2% have Stage 2 hypertension.

Table 2.

Odds of reclassification of recommended pharmacologic treatment among adults aged ≥18 years with application of the 2017 Hypertension Guideline compared to JNC‐7—National Health and Nutrition Examination Survey, 2011‐2014^a

	Population	JNC‐7^b ^, ^c		2017 Hypertension Guideline^b ^, ^d		Difference
	N^e	% (95% CI)	N	% (95% CI)	N	%^f	N	aOR^g (95% CI)
Total	235.4	33.3 (31.5‐35.2)	78.3	35.4 (33.4‐37.4)	83.2	2.1	4.9
Men	113.2	33.5 (31.1‐35.9)	37.9	36.2 (33.9‐38.7)	41.0	2.7	3.1	2.20 (1.47‐3.27)
Women	122.1	33.1 (31.2‐35.1)	40.4	34.5 (32.5‐36.6)	42.2	1.4	1.7	1.00
Age group (y)
18‐44	111.6	11.8 (10.5‐13.2)	13.1	12.0 (10.7‐13.4)	13.4	0.3	0.3	1.00
45‐64	82.0	43.2 (40.9‐45.6)	35.4	45.4 (42.9‐47.9)	37.2	2.2	1.8	8.69 (3.58‐21.06)
45‐54	43.6	32.8 (30.1‐35.5)	14.3	33.7 (31.0‐36.4)	14.7	0.9	0.4	3.52 (1.27‐9.75)
55‐64	38.4	54.7 (51.3‐58.0)	21.0	58.2 (54.6‐61.7)	22.4	3.6	1.4	14.37 (5.71‐36.18)
≥65	41.7	71.0 (68.8‐73.1)	29.6	77.9 (76.0‐79.7)	32.5	6.9	2.9	29.24 (13.17‐64.93)
65‐74	23.6	66.1 (62.9‐69.1)	15.6	75.0 (72.7‐77.2)	17.7	9.0	2.1	38.97 (17.12‐88.69)
≥75	18.1	78.4 (74.8‐81.7)	14.2	82.1 (79.0‐84.9)	14.9	3.7	0.7	15.31 (6.25‐37.47)
Race ethnicity
NH White	155.8	34.7 (32.3‐37.2)	54.0	37.2 (34.6‐39.9)	58.0	2.5	3.9	1.00
NH Black	27.2	42.1 (40.0‐44.2)	11.4	43.4 (41.3‐45.5)	11.8	1.3	0.3	0.67 (0.42‐1.05)
NH Asian	12.0	25.9 (22.7‐29.3)	3.1	27.2 (24.0‐30.6)	3.3	1.3	0.2	0.72 (0.43‐1.20)
Hispanic	34.7	23.9 (21.4‐26.6)	8.3	25.0 (22.5‐27.6)	8.7	1.1	0.4	0.75 (0.47‐1.18)
Other	5.7	28.1 (21.2‐36.2)	1.6	29.3 (22.4‐37.3)	1.7	1.2	0.1	0.69 (0.18‐2.65)
BMI category^h
Normal/Underweight	73.5	20.3 (17.7‐23.1)	14.9	22.0 (19.2‐25.1)	16.2	1.7	1.3	1.00
Overweight	77.7	32.0 (30.2‐33.9)	24.9	34.7 (32.8‐36.7)	26.9	2.7	2.1	1.15 (0.67‐1.96)
Obese	84.2	45.8 (43.3‐48.3)	38.6	47.6 (45.1‐50.2)	40.1	1.8	1.5	0.88 (0.51‐1.54)
Diabetes mellitusⁱ
Yes	27.9	77.2 (74.0‐80.1)	21.5	77.2 (74.0‐80.1)	21.5	0.0	0.0
No	207.5	27.4 (25.6‐29.2)	56.8	29.7 (27.9‐31.7)	61.7	2.4	4.9	–
Chronic kidney disease^j
Yes	34.7	72.7 (69.5‐75.7)	25.2	72.7 (69.5‐75.7)	25.2	0.0	0.0
No	200.7	26.5 (24.7‐28.3)	53.1	28.9 (27.1‐30.8)	58.0	2.4	4.9	–
History of clinical CVD^k
Yes	21.3	70.8 (67.4‐74.0)	15.1	75.6 (72.2‐78.8)	16.2	4.9	1.0	1.02 (0.54‐1.91)
No	214.0	29.5 (27.7‐31.4)	63.2	31.3 (29.4‐33.4)	67.1	1.8	3.9	1.00
ASCVD risk^l
≥10%	43.3	75.3 (72.3‐78.0)	32.6	82.2 (79.6‐84.4)	35.5	6.9	3.0	2.05 (0.91‐4.62)
<10%	90.4	31.3 (29.2‐33.4)	28.3	32.7 (30.8‐34.7)	29.6	1.5	1.3	1.00
Health care access and use
Health insurance^m
Any	190.7	36.4 (34.3‐38.5)	69.3	38.6 (36.4‐40.9)	73.6	2.2	4.3	0.59 (0.30‐1.18)
Private	145.1	32.6 (30.2‐35.1)	47.3	34.7 (32.1‐37.4)	50.4	2.1	3.0	0.57 (0.28‐1.18)
Medicare	20.1	69.1 (64.5‐73.3)	13.9	73.5 (69.7‐77.1)	14.8	4.5	0.9	0.42 (0.20‐0.88)
Other public	25.4	31.9 (29.0‐35.0)	8.1	33.3 (30.4‐36.3)	8.4	1.4	0.4	0.87 (0.36‐2.11)
None	44.7	20.1 (18.2‐22.2)	9.0	21.5 (19.3‐23.8)	9.6	1.4	0.6	1.00
Usual source of careⁿ
Yes	198.4	36.7 (34.9‐38.5)	72.8	38.9 (36.9‐40.9)	77.1	2.2	4.3	0.56 (0.26‐1.2)
No	37.0	15.0 (12.1‐18.3)	5.5	16.5 (13.7‐19.9)	6.1	1.6	0.6	1.00
Health care visits past year^o
0	35.8	17.1 (15.1‐19.3)	6.1	18.4 (16.5‐20.4)	6.6	1.3	0.5	1.00
1	43.7	19.6 (17.2‐22.1)	8.5	21.9 (19.5‐24.5)	9.6	2.4	1.0	1.54 (0.68‐3.49)
≥2	155.8	40.8 (38.5‐43.2)	63.6	43.0 (40.6‐45.5)	67.1	2.2	3.4	0.79 (0.39‐1.60)
Established linkages to care^p
Yes	159.0	40.0 (38.0‐42.1)	63.6	42.4 (40.2‐44.6)	67.4	2.4	3.8	0.61 (0.35‐1.07)
No	76.3	19.3 (17.3‐21.4)	14.7	20.8 (18.8‐22.9)	15.8	1.5	1.1	1.00

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2017 Hypertension Guideline, 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure; aOR, adjusted odds ratio; ASCVD, atherosclerotic cardiovascular disease; CI, confidence interval; CVD, cardiovascular disease; JNC‐7, Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; NH, non‐Hispanic.

–, Odds ratios undefined.

JCN‐7 defines hypertension as BP ≥140/90 mm Hg. Pharmacologic treatment is recommended for those with hypertension or those with diabetes or chronic kidney disease and BP ≥130/80 mm Hg.

2017 Hypertension Guideline defines hypertension as BP ≥130/80 mm Hg. Pharmacologic treatment is recommended for adults: already taking BP medication, with Stage 1 hypertension (systolic BP 130‐139 or diastolic BP 80‐89 mm Hg and who meet ≥1 criteria: aged ≥65 years, have diabetes or chronic kidney disease, have history of clinical CVD, or have a 10‐year ASCVD risk of ≥10%, or with Stage 2 hypertension (BP ≥140/90 mm Hg).

Population in millions, calculated by multiplying the estimated prevalence of recommended pharmacologic treatment (as proportions) by the average 2011‐2012 and 2013‐2014 National Center for Health Statistics’ 2‐year national population counts, which are compiled from the US Census Bureau's American Community Survey (https://wwwn.cdc.gov/nchs/nhanes/ResponseRates.aspx ).

Difference in recommended pharmacologic treatment prevalence under JNC‐7 and the 2017 Hypertension Guideline.

Odds for being newly recommended pharmacologic treatment under the 2017 Hypertension Guideline compare to JNC‐7, adjusted for sex, age group, and race/ethnicity.

Defined based on BMI = weight (kg)/height (m)². Among adults aged ≥20 years: normal/underweight defined as BMI <25.0; overweight defined as BMI 25.0‐29.9; and obese defined as BMI ≥30.0. Among adults aged 18‐19 years: normal/underweight defined as BMI <85th sex‐ and height‐specific percentile; overweight defined as BMI 85th ‐<95th sex‐ and height‐specific percentile; and obese defined as BMI ≥95th sex‐ and height‐specific percentile. BMI percentiles based on: https://www.cdc.gov/growthcharts/html_charts/bmiagerev.htm.

ⁱ

Defined as urinary albumin/creatinine ratio >30 mg/g or estimated glomerular filtration rate <60 mL/min per 1.73 m².

Defined from self‐report: stable or unstable angina, congestive heart failure, acute myocardial infarction, or stroke.

ⁿ

Defined as an answer of "yes" or "there is more than one place" to the question "Is there a place that you usually go when you are sick or you need advice about your health?"

Defined as having health insurance, having a usual source of health care, and ≥1 health care visit in the past year.

Number of US Adults Recommended Pharmacologic Treatment and/or Lifestyle Modification to Manage their Blood Pressure, By Recommended Treatment Type and Established Linkages to Care Status^a, National Health and Nutrition Examination Survey, 2011‐2014 (N = 133.7 million). BP: blood pressure. (a) Hatched sections represent the percentage of the specified population who reported having limited established linkages to care, defined as being uninsured, not having a usual source of care, or having had no health care visits during the past year. (b) Controlled BP defined as treated SBP <130 mm Hg and DBP <80 mm Hg

Prevalence of treatment status and blood pressure category^a, by recommended treatment status type—2017 Hypertension Guideline, National Health and Nutrition Examination Survey, 2011‐2014. ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease. ^aBlood pressure categories include normal BP: untreated systolic BP (SBP) <120 mm Hg and diastolic BP (DBP) <80 mm Hg; elevated BP: untreated SBP 120‐129 mm Hg and DBP <80 mm Hg; controlled BP: treated SBP <130 mm Hg and DBP <80 mm Hg; uncontrolled Stage 1 hypertension: treated or untreated SBP 130‐139 mm Hg or DBP 80‐89 mm Hg; and uncontrolled Stage 2 hypertension: treated or untreated SBP ≥140 mm Hg or DBP ≥90 mm Hg

3.3. Recommended lifestyle modification without pharmacologic treatment prevalence

Applying the new guideline, an estimated 21.5% (95% CI: 20.1‐22.9) of US adults, or 50.5 million people, are recommended lifestyle modification alone to manage their BP (Table 3). Of those, 29.2 million (57.7%) are classified as having elevated BP, which represents 12.4% (11.3‐13.6) of US adults (Table 3 and Figure 2). Among the adults newly recommended lifestyle modification alone, 20.6 million (40.8%) reported not having established linkages to care (Figure 1), with the odds of reclassification from no recommended intervention, under JNC‐7, to recommended lifestyle modification alone being lower for adults with established linkages to care (aOR: 0.78 [95% CI: 0.67‐0.91]) compared to those without. Moreover, the odds for reclassification decreased with increasing age and was greater for men (1.72 [1.52‐1.94]) compared to women and greater for obese adults (1.23 [1.00‐1.53]) compared with normal or underweight adults.

Table 3.

Odds of reclassification of recommended lifestyle modification alone without pharmacologic treatment among adults aged ≥18 years with application of the 2017 Hypertension Guideline—National Health and Nutrition Examination Survey, 2011‐2014^a

	N^b	Elevated BP or stage 1 hypertension and lifestyle modification alone recommended^c ^, ^d			Elevated BP and lifestyle modification alone recommended^c ^, ^d
	N^b	% (95% CI)	N	aOR^e (95% CI)	% (95% CI)	N	aOR^e (95% CI)
Total	235.4	21.5 (20.1‐22.9)	50.5		12.4 (11.3‐13.6)	29.2
Men	113.2	26.2 (24.5‐27.9)	29.6	1.72 (1.52‐1.94)	15.4 (14.1‐16.9)	17.4	1.73 (1.47‐2.03)
Women	122.1	16.9 (15.3‐18.7)	20.6	1.00	9.4 (8.1‐10.9)	11.5	1.00
Age group (y)
18‐44	111.6	24.5 (22.6‐26.5)	27.3	1.00	13.4 (12.0‐14.9)	15.0	1.00
45‐64	82.0	23.8 (21.2‐26.6)	19.5	0.97 (0.80‐1.17)	13.0 (10.9‐15.3)	10.7	0.98 (0.79‐1.22)
45‐54	43.6	27.7 (24.0‐31.8)	12.1	1.20 (0.94‐1.53)	14.4 (11.5‐17.9)	6.3	1.11 (0.83‐1.49)
55‐64	38.4	19.5 (16.0‐23.5)	7.5	0.74 (0.58‐0.95)	11.4 (8.7‐14.8)	4.4	0.84 (0.61‐1.15)
≥65	41.7	8.6 (7.2‐10.3)	3.6	0.29 (0.24‐0.36)	8.6 (7.2‐10.3)	3.6	0.63 (0.49‐0.80)
65‐74	23.6	9.7 (7.8‐12.1)	2.3	0.33 (0.25‐0.43)	9.7 (7.8‐12.1)	2.3	0.71 (0.53‐0.96)
≥75	18.1	6.9 (5.2‐9.2)	1.3	0.23 (0.17‐0.31)	6.9 (5.2‐9.2)	1.2	0.50 (0.37‐0.68)
Race ethnicity
NH White	155.8	21.4 (19.5‐23.4)	33.3	1.00	12.4 (10.9‐14.1)	19.3	1.00
NH Black	27.2	21.7 (19.7‐23.7)	5.9	0.96 (0.81‐1.14)	11.6 (10.4‐13.0)	3.2	0.92 (0.75‐1.13)
NH Asian	12.0	19.3 (16.9‐21.9)	2.3	0.83 (0.67‐1.02)	11.2 (9.1‐13.6)	1.3	0.87 (0.68‐1.12)
Hispanic	34.7	21.6 (19.8‐23.5)	7.5	0.89 (0.77‐1.04)	13.0 (11.4‐14.7)	4.5	0.99 (0.80‐1.23)
Other	5.7	26.6 (18.9‐36.1)	1.5	1.22 (0.77‐1.95)	14.4 (8.9‐22.5)	0.8	1.13 (0.63‐2.01)
BMI category^f
Normal/underweight	73.5	19.2 (16.6‐22.2)	14.1	1.00	12.2 (10.6‐14.1)	9.0	1.00
Overweight	77.7	22.5 (20.2‐24.9)	17.5	1.19 (0.96‐1.49)	12.2 (10.6‐14.0)	9.5	0.94 (0.78‐1.13)
Obese	84.2	22.5 (20.5‐24.6)	18.9	1.23 (1.00‐1.53)	12.7 (11.0‐14.7)	10.7	1.04 (0.81‐1.32)
Diabetes mellitus^g
Yes	27.9	8.0 (6.3‐10.1)	2.2	0.32 (0.24‐0.43)	8.0 (6.3‐10.1)	2.2	0.61 (0.45‐0.83)
No	207.5	23.3 (21.7‐25.0)	48.3	1.00	13.0 (11.7‐14.4)	27.0	1.00
Chronic kidney disease^h
Yes	34.7	6.8 (5.1‐9.1)	2.4	0.31 (0.22‐0.43)	6.8 (5.1‐9.1)	2.4	0.54 (0.38‐0.77)
No	200.7	24.0 (22.4‐25.7)	48.2	1.00	13.4 (12.1‐14.7)	26.9	1.00
History of clinical CVDⁱ
Yes	21.3	5.9 (4.2‐8.2)	1.3	0.28 (0.19‐0.41)	5.9 (4.2‐8.2)	1.3	0.46 (0.31‐0.68)
No	214.0	23.0 (21.5‐24.6)	49.3	1.00	13.0 (11.8‐14.4)	27.8	1.00
ASCVD risk^j
≥10%	43.3	7.5 (6.2‐9.1)	3.3	0.22 (0.17‐0.27)	7.5 (6.2‐9.1)	3.2	0.42 (0.34‐0.53)
<10%	90.4	27.7 (25.4‐30.1)	25.0	1.00	14.2 (12.3‐16.4)	12.8	1.00
Health care access and use
Health insurance^k
Any	190.7	20.2 (18.8‐21.7)	38.6	0.82 (0.71‐0.94)	11.8 (10.7‐13.0)	22.5	0.84 (0.67‐1.05)
Private	145.1	21.7 (19.9‐23.7)	31.6	0.86 (0.75‐0.99)	12.5 (11.1‐13.9)	18.1	0.87 (0.71‐1.08)
Medicare	20.1	10.2 (7.9‐13.0)	2.1	0.66 (0.44‐1.00)	8.6 (6.6‐11.3)	1.7	0.74 (0.46‐1.20)
Other public	25.4	19.4 (17.0‐22.2)	4.9	0.69 (0.56‐0.84)	10.6 (9.1‐12.3)	2.7	0.72 (0.53‐0.98)
None	44.7	26.8 (24.5‐29.3)	12.0	1.00	14.9 (12.6‐17.6)	6.7	1.00
Usual source of care^l
Yes	198.4	20.2 (18.8‐21.7)	40.1	0.79 (0.68‐0.93)	11.9 (10.7‐13.1)	23.6	0.87 (0.74‐1.03)
No	37.0	28.2 (25.3‐31.2)	10.4	1.00	15.2 (13.4‐17.1)	5.6	1.00
Health care visits past year^m
0	35.8	31.1 (28.4‐33.8)	11.1	1.00	16.9 (14.3‐20.0)	6.1	1.00
1	43.7	27.4 (24.3‐30.7)	12.0	0.90 (0.74‐1.09)	16.4 (13.6‐19.6)	7.2	1.03 (0.81‐1.30)
≥2	155.8	17.6 (16.0‐19.3)	27.4	0.59 (0.50‐0.69)	10.2 (9.2‐11.4)	15.9	0.64 (0.51‐0.82)
Established linkages to careⁿ
Yes	159.0	18.9 (17.3‐20.6)	30.0	0.78 (0.67‐0.91)	11.1 (10.0‐12.3)	17.6	0.80 (0.66‐0.96)
No	76.3	26.9 (24.8‐29.1)	20.6	1.00	15.1 (13.2‐17.2)	11.5	1.00

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Includes examined adults aged ≥18 years with ≥1 complete nonzero systolic and diastolic blood pressure (BP) measurement and complete data to establish hypertension and treatment eligibility status. Pregnant women were excluded. BP defined by average of up to 3 measurements. No similar categorization for recommended lifestyle modification alone exists in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

Population in millions, calculated by multiplying the estimated prevalence of recommended lifestyle modification (as proportions) by the average 2011‐2012 and 2013‐2014 National Center for Health Statistics’ 2‐year national population counts, which are compiled from the US Census Bureau's American Community Survey (https://wwwn.cdc.gov/nchs/nhanes/ResponseRates.aspx).

Elevated BP is defined as systolic BP 120‐129 mm Hg and diastolic BP <80 mm Hg. Stage 1 hypertension is defined as systolic BP 130‐139 or DBP 80‐89 mm Hg.

Lifestyle modification is recommended for adults with elevated BP or Stage 1 hypertension and: no history of clinical CVD; aged <65 years; no diabetes or chronic kidney disease, and 10‐year ASCVD risk <10%.

AOR for being newly recommended lifestyle modification; adjusted for sex, age group, and race ethnicity using logistic regression.

Defined based BMI = weight (kg)/height (m)². Among adults aged ≥20 years: normal/underweight defined as BMI <25.0; overweight defined as BMI 25.0‐29.9; and obese defined as BMI ≥30.0. Among adults aged 18‐19 years: normal/underweight defined as BMI <85th sex‐ and height‐specific percentile; overweight defined as BMI 85th ‐<95th sex‐ and height‐specific percentile; and obese defined as BMI ≥95th sex‐ and height‐specific percentile. BMI percentiles based on: https://www.cdc.gov/growthcharts/html_charts/bmiagerev.htm.

Defined as urinary albumin/creatinine ratio >30 mg/g or estimated glomerular filtration rate <60 mL/min per 1.73 m².

ⁱ

Defined from self‐report: stable or unstable angina, congestive heart failure, acute myocardial infarction, or stroke.

ASCVD risk is calculated among adults aged 40‐79 years, based on the pooled cohort equations from the American College of Cardiology/American Heart Association Guideline on the Assessment of Cardiovascular Risk.16

Defined as an answer of "yes" or "there is more than one place" to the question "Is there a place that you usually go when you are sick or you need advice about your health?"

ⁿ

Defined as having health insurance, having a usual source of health care, and ≥1 health care visit in the past year.

3.4. Blood pressure control prevalence

Under the 2017 Hypertension Guideline, the prevalence of BP control among adults with hypertension decreased 21.1 percentage points (from 45.3% [42.0‐48.7] to 24.3% [21.9‐26.8]) when compared to JNC‐7 (Table 4). Odds of reclassification from having controlled to uncontrolled BP were higher among adults with established linkages to care (aOR: 1.91 [95% CI: 1.18‐3.08]) compared to those without and higher among overweight (2.07 [1.31‐3.28]) and obese (1.74 [1.24‐2.45]) adults compared to normal weight or underweight adults. Among adults recommended pharmacologic treatment with application of the new guideline, the prevalence of BP control decreased from 41.8% (95% CI: 38.6‐45.1) to 30.5% (27.6‐33.6) (Table S3); variation by subgroup in odds for reclassification within this population was similar to that seen among all hypertensive adults. Among the 57.8 million US adults with uncontrolled BP and recommended pharmacologic treatment, 22.7% (13.1 million) reported not having established linkages to care (Figure 1).

Table 4.

Odds of reclassification of blood pressure control status among hypertensive adults aged ≥18 years with application of the 2017 Hypertension Guideline compared to JNC‐7—National Health and Nutrition Examination Survey, 2011‐2014^a

	JNC‐7^b ^, ^c			2017 Hypertension Guideline^b ^, ^d
	N^e	BP Controlled		N^e	BP controlled		Difference^g
	N^e	% (95% CI)	N^f	N^e	% (95% CI)	N^f	%	N	aOR^h (95% CI)
Total	72.3	45.3 (42.0‐48.7)	32.8	104.6	24.3 (21.9‐26.8)	25.4	−21.1	−7.4
Men	34.4	43.1 (39.6‐46.7)	14.8	53.2	21.8 (19.7‐24.2)	11.6	−21.3	−3.2	0.75 (0.55‐1.00)
Women	37.9	47.4 (43.4‐51.5)	18.0	51.3	26.9 (23.6‐30.6)	13.8	−20.5	−4.2	1.00
Age group (y)
18‐44	11.0	40.1 (33.8‐46.8)	4.4	25.8	11.8 (9.3‐14.7)	3.0	−28.4	−1.4	1.00
45‐64	33.0	51.4 (46.5‐56.3)	17.0	46.1	28.1 (25.1‐31.4)	12.9	−23.3	−4.0	1.61 (1.05‐2.46)
45‐54	12.8	51.9 (46.2‐57.5)	6.7	20.5	25.3 (21.3‐29.7)	5.2	−26.6	−1.5	1.32 (0.81‐2.15)
55‐64	20.0	51.1 (44.7‐57.6)	10.2	25.5	30.3 (26.5‐34.4)	7.7	−20.8	−2.5	1.84 (1.12‐3.03)
≥65	28.1	40.0 (36.5‐43.5)	11.2	32.5	28.7 (25.0‐32.6)	9.3	−11.3	−1.9	1.04 (0.69‐1.58)
65‐74	14.8	45.9 (41.2‐50.7)	6.8	17.7	31.7 (26.8‐37.0)	5.6	−14.2	−1.2	1.18 (0.70‐1.99)
≥75	13.5	32.5 (27.1‐38.3)	4.4	14.9	24.5 (20.1‐29.6)	3.7	−7.9	−0.7	0.86 (0.57‐1.29)
Race ethnicity
NH White	50.3	48.3 (43.9‐52.8)	24.3	71.9	26.7 (23.8‐29.8)	19.2	−21.6	−5.1	1.00
NH Black	10.7	38.6 (34.3‐43.0)	4.1	14.5	20.3 (17.0‐24.1)	3.0	−18.2	−1.2	1.12 (0.84‐1.50)
NH Asian	2.8	33.7 (28.4‐39.3)	1.0	4.2	16.0 (12.2‐20.8)	0.7	−17.6	−0.3	0.92 (0.63‐1.34)
Hispanic	7.0	39.4 (35.0‐43.9)	2.8	11.6	18.1 (15.1‐21.6)	2.1	−21.3	−0.7	0.79 (0.60‐1.05)
Other	1.5	39.5 (24.4‐56.8)	0.6	2.3	18.7 (9.0‐34.9)	0.4	−20.7	−0.1	0.97 (0.34‐2.72)
BMI categoryⁱ
Normal/Underweight	13.6	32.9 (26.3‐40.3)	4.5	21.3	16.8 (12.8‐21.7)	3.6	−16.1	−0.9	1.00
Overweight	23.1	50.2 (45.7‐54.8)	11.6	34.9	24.9 (21.8‐28.4)	8.7	−25.3	−2.9	2.07 (1.31‐3.28)
Obese	35.5	46.9 (43.3‐50.6)	16.7	48.3	27.1 (24.5‐30.0)	13.1	−19.8	−3.5	1.74 (1.24‐2.45)
Diabetes mellitus^j
Yes	18.4	37.1 (32.1‐42.4)	6.8	21.5	31.7 (27.3‐36.5)	6.8	−5.4	0.0	–
No	53.9	48.2 (44.3‐52.1)	25.9	83.1	22.4 (19.8‐25.1)	18.6	−25.8	−7.4
Chronic kidney disease^k
Yes	21.2	33.3 (30‐36.8)	7.1	25.2	28.0 (25.0‐31.3)	7.1	−5.2	0.0	–
No	51.0	50.4 (46‐54.7)	25.7	79.4	23.1 (20.2‐26.2)	18.3	−27.3	−7.4
History of clinical CVD^l
Yes	14.3	48.3 (42.0‐54.6)	6.9	16.2	36.6 (31.5‐42.1)	5.9	−11.7	−1.0	0.89 (0.53‐1.47)
No	58.0	44.6 (40.9‐48.4)	25.9	88.4	22.0 (19.7‐24.6)	19.5	−22.6	−6.4	1.00
ASCVD risk^m
≥10%	30.7	36.9 (33.3‐40.7)	11.3	35.5	25.7 (22.7‐29.0)	9.1	−11.2	−2.2	0.66 (0.42‐1.03)
<10%	26.0	62.0 (57.1‐66.7)	16.1	41.8	29.2 (26.0‐32.5)	12.2	−32.8	−4.0	1.00
Health care access and use
Health insuranceⁿ
Any	64.8	46.5 (43.3‐49.8)	30.1	89.7	26.5 (23.9‐29.2)	23.7	−20.1	−6.4	1.07 (0.62‐1.84)
Private	44.0	47.9 (43.8‐52.0)	21.0	63.8	25.3 (22.4‐28.5)	16.2	−22.5	−4.9	1.12 (0.64‐1.98)
Medicare	13.3	39.7 (35.0‐44.7)	5.3	15.1	29.9 (25.0‐35.2)	4.5	−9.9	−0.7	0.77 (0.37‐1.62)
Other public	7.5	50.7 (43.5‐57.8)	3.8	10.7	28.5 (22.7‐35.0)	3.0	−22.2	−0.8	0.99 (0.55‐1.78)
None	7.5	35.1 (26.8‐44.4)	2.6	14.9	11.2 (8.2‐15.1)	1.7	−23.9	−1.0	1.00
Usual source of care
Yes	67.8	47.4 (43.9‐51.0)	32.1	93.7	26.5 (23.8‐29.4)	24.9	−20.9	−7.3	11 . 29 (4.89‐26.07)
No	4.5	13.9 (8.0‐23.0)	0.6	10.9	5.0 (2.6‐9.2)	0.5	−8.9	−0.1	1.00
Health care visits past year^o
0	5.2	12.5 (6.6‐22.3)	0.7	11.7	5.1 (2.5‐10.0)	0.6	−7.4	−0.1	1.00
1	7.4	30.5 (24.4‐37.4)	2.3	14.4	10.2 (7.4‐13.8)	1.5	−20.3	−0.8	11 . 86 (1.82‐77.30)
≥2	59.6	50.1 (46.7‐53.4)	29.9	78.6	29.7 (26.7‐32.9)	23.3	−20.3	−6.5	18 . 82 (3.16‐112.24)
Established linkages to care^p
Yes	59.8	48.5 (45.0‐51.9)	29.0	79.7	28.5 (25.7‐31.5)	22.7	−20.0	−6.3	1.91 (1.18‐3.08)
No	12.4	30.2 (24.1‐37.1)	3.8	24.9	10.8 (8.3‐14.0)	2.7	−19.4	−1.1	1.00

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2017 Hypertension Guideline: 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure; aOR: adjusted odds ratio; ASCVD: atherosclerotic cardiovascular disease; BMI: body mass index; CI: confidence interval; CVD: cardiovascular disease; JNC‐7: Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; NH: non‐Hispanic.

Estimates in italics are unstable with relative standard errors >30%.

–, Odds ratios undefined.

Hypertension is defined as a high average blood pressure (BP) (based on up to 3 measurements) or self‐reported BP‐lowering medication use. BP‐lowering medication use is defined by answers to the questions: "Because of your high blood pressure/hypertension, have you ever been told to take prescribed medicine?" and "Are you now taking prescribed medicine?"

JCN‐7 defines hypertension as BP ≥140/90 mm Hg. BP control is defined as <130/80 mm Hg among those with diabetes or chronic kidney disease who had initiated pharmacologic treatment or <140/90 mm Hg among all other adults.

2017 Hypertension Guideline defines hypertension as BP ≥130/80 mm Hg. BP control is defined as BP <130/80 mm Hg.

Population with hypertension (N in millions), calculated by multiplying the estimated hypertension prevalence (as proportions) by the average 2011‐2012 and 2013‐2014 National Center for Health Statistics’ 2‐year national population counts, which are compiled from the US Census Bureau's American Community Survey (https://wwwn.cdc.gov/nchs/nhanes/ResponseRates.aspx ).

Population with controlled hypertension (N in millions), calculated by multiplying the estimated prevalence of controlled hypertension (as proportions) by the average 2011‐2012 and 2013‐2014 National Center for Health Statistics’ 2‐year national population counts, which are compiled from the US Census Bureau's American Community Survey (https://wwwn.cdc.gov/nchs/nhanes/ResponseRates.aspx ).

Difference in BP control prevalence under JNC‐7 and the 2017 Hypertension Guideline.

Odds for having controlled BP under JNC‐7 but not under the 2017 Hypertension Guideline ("newly" uncontrolled); adjusted for sex, age group, and race/ethnicity.

ⁱ

Defined based on BMI = weight (kg)/height (m)². Among adults aged ≥20 years: normal/underweight defined as BMI <25.0; overweight defined as BMI 25.0‐29.9; and Obese defined as BMI ≥30.0. Among adults aged 18‐19 years: Normal/Underweight defined as BMI <85th sex‐ and height‐specific percentile; overweight defined as BMI 85th ‐<95th sex‐ and height‐specific percentile; and obese defined as BMI ≥95th sex‐ and height‐specific percentile. BMI percentiles based on: https://www.cdc.gov/growthcharts/html_charts/bmiagerev.htm.

Defined as urinary albumin/creatinine ratio >30 mg/g or estimated glomerular filtration rate <60 mL/min per 1.73 m².

Defined from self‐report: stable or unstable angina, congestive heart failure, acute myocardial infarction, or stroke.

ⁿ

Defined as an answer of "yes" or "there is more than one place" to the question "Is there a place that you usually go when you are sick or you need advice about your health?"

Defined as having health insurance, having a usual source of health care, and ≥1 health care visit in the past year.

4. DISCUSSION

Despite updates to the methodology used, this study supports the findings by Muntner et al 6 as we found that application of the 2017 Hypertension Guideline results in a large increase (32.3 million) in the number of US adults aged ≥18 years considered hypertensive and a relatively small increase (4.9 million) in the number newly recommend pharmacologic treatment. Furthermore, this study demonstrates that application of the new guideline results in over half (~57%) of adults being recommended some form of BP treatment, including either pharmacologic treatment in addition to lifestyle modification or lifestyle modification alone. Among the 133.7 million adults recommended treatment, 108.3 million need to initiate or intensify BP treatment to align with the new recommendations, of which almost one‐third (33.7 million) do not have prior established linkages to health care. Additional clinical and public health resources are likely required to establish linkages to health care and manage the increased number of US adults recommended these services.

The lower BP thresholds included in the 2017 Hypertension Guideline were established based on recent evidence demonstrating that BP targets lower than previously recommended might confer cardiovascular benefits.2, 19, 20, 21, 22, 23 While there may be some risk in labeling millions of additional US adults as having elevated BP or hypertension on their perceived health status,24 the resulting unintended harms could be minimized. This could be accomplished if the new recommendations are implemented within an environment where patients are encouraged to partner with health care professionals to promote the earlier identification and coordinate the ongoing management of their condition. However, potential barriers to receiving this type of partnership‐driven care need to be overcome to maximize the benefits from intervening earlier in the course of the disease. For example, among adults newly recommended lifestyle modification alone, around 40.8% (20.6 million) do not have established linkages to care. Additional engagement with the health care sector among this group is likely needed to support the ongoing tracking and management of their BP (eg, recommended reassessment every 3‐6 months5, 9), as well as improve their referral to and utilization of lifestyle modification interventions, including using a DASH dietary pattern to reduce sodium intake25, 26, 27 and increase potassium intake,28 decreasing body weight,29 increasing physical activity levels,30, 31 and keeping alcohol consumption to recommended levels.26, 32 Furthermore, because upwards of 80% of adults newly recommended to initiate or intensify BP management are insured, health plans could support these interventions by offering innovative payment models for clinicians and broadened coverage for evidence‐based interventions conducted outside the clinical setting (eg, self‐measured blood pressure measurement and lifestyle modification programs). Finally, implementation of broad, population‐focused interventions that create healthier environments are needed to support lifestyle modifications, including interventions that improve the built environment to promote increased physical activity33; reduce sodium in commercially processed and restaurant foods34, 35; and increase the availability of healthy foods in schools, workplaces, and the community.36

Application of the 2017 Hypertension Guideline disproportionally affects some groups more than others in being reclassified as having hypertension or being recommended to initiate or intensify their BP treatment. This includes adults aged 18‐64 years and men, two groups who historically have limited access to or low utilization of health care services for hypertension management.37 In addition, 3.6 million of the 4.9 million (73.5%) US adults who are newly recommended pharmacologic treatment and 36.4 million of the 50.5 million (72.1%) of those newly recommended lifestyle modification alone are overweight or obese. The US Preventive Services Task Force recommends that health care professionals offer or refer patients who are overweight or obese and have additional CVD risk factors to intensive, multicomponent behavioral interventions.38 However, the coverage of, availability of, and accessibility to these services have historically been limited.39, 40 Therefore, access to, capacity in and linkage between clinical and community settings, including commercial weight loss programs, need to expand to provide patients greater opportunity to utilize these services.

Finally, shortages in primary health care professionals41 will likely require expanding use of system approaches, collaborative relationships among health care professionals, and clinical‐community linkages to serve the greater number of adults needing new or intensified BP management and other related services. For example, team‐based models of care utilizing a diverse health care team—including nurses, nutritionists, and pharmacists—have been shown to be a cost‐effective strategy in BP management.42, 43 Effective team‐based care often requires the integration of standardized hypertension treatment approaches (eg, protocols) to support communication between team members and help guide decision making, including the intensification of pharmacologic treatment.44 In addition, population health management tools, when integrated into care processes, can be used to track adherence to pharmacologic treatment and lifestyle modification and progress in BP control and inform clinical decision making.45, 46 However, we should not assume that health care systems can be solely responsible for managing all of the increased demands resulting from the application of the new guideline. It is important that additional considerations be made regarding the availability and accessibility of community‐based resources to the populations in need of them, including those groups shown in this study to be at greatest risk for reclassification of their hypertension and recommended BP treatment status. The use of population health management tools can support the referral of these patients to resources outside of the primary care setting for BP management and other services, including referral to community partners such as community health workers,47 fitness and nutritional counseling groups,48 and pharmacist‐based interventions, such as medication therapy management programs.49

This study's strength is that it uses data collected systematically among a cohort of representative US adults to describe the effects of the 2017 Hypertension Guideline. However, there are several limitations. First, NHANES participants have their BP measured up to 3 times during a single visit to the MEC; hence, hypertension classification in NHANES deviates from the clinical definition, which relies on 2 or more BP readings on 2 or more separate visits. However, the methodology used to acquire accurate BP readings among NHANES participants12 (eg, determination of appropriate cuff size, 5‐minute rest period between measurements) aligns with those recommended within both guidelines5, 9 and <1% of participants in the analytic sample used in this study had fewer than 2 complete systolic and diastolic BP readings. Next, these data do not include self‐measured or ambulatory blood pressure measurements, which are now included in US recommendations for hypertension diagnosis.5, 50 The use of these BP measures is expected to improve diagnostic accuracy in the presence of white‐coat hypertension or masked hypertension, but their current use clinically for these purposes has been sparse.5 Third, we apply the new guideline to data that were collected prior to its release. Fourth, no official definition for established health care linkages exists; however, the definition used in this study is likely conservative as it does not meet the recommended visit frequency for BP management.5, 9 Fifth, other researchers may interpret guideline criteria differently within the available NHANES data, which could generate different results; however, the relative differences will likely be small as demonstrated by the comparisons in the overall estimates presented here and those by Muntner.6 Finally, we only categorize adults based on the criteria included in the guidelines and are unable to take into account comorbidities, expected lifespan, patient preferences, and potential modifications to how CVD risk is calculated and interpreted that could affect treatment decisions.

This study reveals that application of the 2017 Hypertension Guideline results in millions of additional US adults being recommended to initiate or intensify pharmacologic treatment and/or lifestyle modification to manage their BP, many, of whom, do not have established linkages to health care. These findings can be used to inform translation of the new guideline into clinical practice and public health programs to secure the additional health care and community resources likely necessary to meet the increased demand for services, especially among certain subgroups such as younger adults, men, and overweight or obese individuals. Furthermore, the updated methodology presented here can be used for public health surveillance of hypertension prevalence and BP management‐related estimates in the United States and tracking progress made among subgroups with known disparities.

CONFLICT OF INTEREST

No conflict of interests to disclose.

Supporting information

Click here for additional data file.^{(44KB, docx)}

Ritchey MD, Gillespie C, Wozniak G, et al. Potential need for expanded pharmacologic treatment and lifestyle modification services under the 2017 ACC/AHA Hypertension Guideline. J Clin Hypertens. 2018;20:1377–1391. 10.1111/jch.13364

The findings and conclusions in this report are those of the authors and do not necessarily represent the official positions of the Centers for Disease Control and Prevention, American Medical Association, or American Heart Association

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Click here for additional data file.^{(44KB, docx)}

[jch13364-bib-0001] 1. Rapsomaniki E, Timmis A, George J, Blood, et al. pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life‐years lost, and age‐specific associations in 1.25 million people. Lancet. 2014;383:1899‐1911. [DOI] [PMC free article] [PubMed] [Google Scholar]

[jch13364-bib-0002] 2. Xie X, Atkins E, Lv J, et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta‐analysis. Lancet. 2016;387:435‐443. [DOI] [PubMed] [Google Scholar]

[jch13364-bib-0003] 3. Tedla FM, Brar A, Browne R, Brown C. Hypertension in chronic kidney disease: navigating the evidence. Int J Hypertens. 2011;2011:132405. [DOI] [PMC free article] [PubMed] [Google Scholar]

[jch13364-bib-0004] 4. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age‐specific relevance of usual blood pressure to vascular mortality: a meta‐analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903‐1913. [DOI] [PubMed] [Google Scholar]

[jch13364-bib-0005] 5. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/ NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Am Coll Cardiol. 2017;71;e116‐e135. [DOI] [PubMed] [Google Scholar]

[jch13364-bib-0006] 6. Muntner P, Carey RM, Giddling S, et al. Potential U.S. population impact of the 2017 American College of Cardiology/American Heart Association High Blood Pressure Guideline. Circulation. 2017;137:109‐118. [DOI] [PMC free article] [PubMed] [Google Scholar]

[jch13364-bib-0007] 7. Ritchey MD, Wall HK, Gillespie C, George MG, Jamal A. Million hearts: prevalence of leading cardiovascular disease risk factors–United States, 2005‐2012. MMWR Morb Mortal Wkly Rep. 2014;63:462‐467. [PMC free article] [PubMed] [Google Scholar]

[jch13364-bib-0008] 8. Healthy People 2020 . Washington DC. US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. https://www.healthypeople.gov/node/4555/data_details. Accessed November 2, 2017.

[jch13364-bib-0009] 9. Chobanian AV, Bakris G, Black H, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560‐2572. [DOI] [PubMed] [Google Scholar]

[jch13364-bib-0010] 10. Crim MT, Yoon SS, Ortiz E, et al. National surveillance definitions for hypertension prevalence and control among adults. Circulation. 2012;5:343‐351. [DOI] [PMC free article] [PubMed] [Google Scholar]

[jch13364-bib-0011] 11. Centers for Disease Control and Prevention . National Health and Nutrition Examination Survey: surveys and data collection systems (2010 data). http://www.cdc.gov/nchs/nhanes.htm. Accessed October 31, 2017.

[jch13364-bib-0012] 12. National Center for Health Statistics . National health and nutrition examination survey, physician examination procedures manual. 2013. https://wwwn.cdc.gov/nchs/data/nhanes/2013-2014/manuals/Phys_Exam_Manual_2013.pdf. Accessed November 8, 2017.

[jch13364-bib-0013] 13. Menke A, Casagrande S, Geiss L, Cowie CC. Prevalence of and trends in diabetes among adults in the united states, 1988–2012. JAMA. 2015;314:1021‐1029. [DOI] [PubMed] [Google Scholar]

[jch13364-bib-0014] 14. Castro AF, Coresh J. CKD surveillance using laboratory data from the population‐based National Health and Nutrition Examination Survey (NHANES). Am J Kidney Dis. 2009;53:S46‐S55. [DOI] [PMC free article] [PubMed] [Google Scholar]

[jch13364-bib-0015] 15. Mercado C, DeSimone AK, Odom E, Gillespie C, Ayala C, Loustalot F. Prevalence of cholesterol treatment eligibility and medication use among adults‐United States, 2005–2012. MMWR Morb Mortal Wkly Rep. 2015;64:1305‐1311. [DOI] [PubMed] [Google Scholar]

[jch13364-bib-0016] 16. Goff DC Jr, Lloyd‐Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:2935‐2959. [DOI] [PMC free article] [PubMed] [Google Scholar]

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PERMALINK

Potential need for expanded pharmacologic treatment and lifestyle modification services under the 2017 ACC/AHA Hypertension Guideline

Matthew D Ritchey, PT DPT OCS MPH

Cathleen Gillespie, MS

Gregory Wozniak, PhD

Christina M Shay, PhD

Angela M Thompson‐Paul, PhD MSPH

Fleetwood Loustalot, PhD FNP

Yuling Hong, MD PhD

Abstract

1. INTRODUCTION

2. METHODS

2.1. Hypertension definitions

2.2. Recommended pharmacologic treatment and lifestyle modification definitions

2.3. Recommended lifestyle modification without pharmacologic treatment definition

2.4. Blood pressure control definitions

2.5. Comparing estimates from application of the JNC‐7 guideline and 2017 Hypertension Guidelines

3. RESULTS

3.1. Hypertension prevalence

Table 1.

3.2. Recommended pharmacologic treatment and lifestyle modification prevalence

Table 2.

Figure 1.

Figure 2.

3.3. Recommended lifestyle modification without pharmacologic treatment prevalence

Table 3.

3.4. Blood pressure control prevalence

Table 4.

4. DISCUSSION

CONFLICT OF INTEREST

Supporting information

REFERENCES

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

Cite

Add to Collections

PERMALINK

Potential need for expanded pharmacologic treatment and lifestyle modification services under the 2017 ACC/AHA Hypertension Guideline

Matthew D Ritchey, PT DPT OCS MPH

Cathleen Gillespie, MS

Gregory Wozniak, PhD

Christina M Shay, PhD

Angela M Thompson‐Paul, PhD MSPH

Fleetwood Loustalot, PhD FNP

Yuling Hong, MD PhD

Abstract

1. INTRODUCTION

2. METHODS

2.1. Hypertension definitions

2.2. Recommended pharmacologic treatment and lifestyle modification definitions

2.3. Recommended lifestyle modification without pharmacologic treatment definition

2.4. Blood pressure control definitions

2.5. Comparing estimates from application of the JNC‐7 guideline and 2017 Hypertension Guidelines

3. RESULTS

3.1. Hypertension prevalence

Table 1.

3.2. Recommended pharmacologic treatment and lifestyle modification prevalence

Table 2.

Figure 1.

Figure 2.

3.3. Recommended lifestyle modification without pharmacologic treatment prevalence

Table 3.

3.4. Blood pressure control prevalence

Table 4.

4. DISCUSSION

CONFLICT OF INTEREST

Supporting information

REFERENCES

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

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