Thomas J. Wang and Ramachandran S. Vasan
Epidemiology of Uncontrolled Hypertension in the United States
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Epidemiology of Uncontrolled Hypertension in the
Thomas J. Wang, MD; Ramachandran S. Vasan, MD
servational studies indicate that this risk is continuous,
without evidence of a threshold, down to blood pressures as
low as 115/75 mm Hg.1Randomized controlled trials have
convincingly shown that treatment of hypertension reduces
the risk of stroke, coronary heart disease, congestive heart
failure, and mortality.2,3Because hypertension currently af-
fects 1 in 4 American adults (?65 million people in 1999 to
2000)4and may affect ?90% of individuals during their
lifetimes,5adequate control of blood pressure is of enormous
public health importance. However, recent studies indicate
that as many as two thirds of those with hypertension in the
United States are either untreated or undertreated.6Studies
based on national data and community cohorts have shed
light on the reasons underlying this poor control, but several
questions remain unanswered. In this article, we review
contemporary data on the epidemiology of uncontrolled
hypertension in the United States by (1) defining what
constitutes “controlled hypertension”; (2) describing the cur-
rent magnitude of the problem, including temporal trends; (3)
summarizing the public health consequences of uncontrolled
hypertension; (4) examining the clinical correlates of uncon-
trolled hypertension and appraising the patient- and
physician-related factors related to poor control of blood
pressure; and (5) identifying future research directions, in-
cluding potential interventions to address this problem. In this
article, “uncontrolled hypertension” signifies blood pressure
that is inadequately treated rather than blood pressure that is
resistant to treatment, as might be observed with secondary
causes of hypertension such as renal artery stenosis.
ypertension is a powerful risk factor for fatal and
nonfatal cardiovascular disease events. Data from ob-
Definition: What Is Optimal Blood
The definition of high blood pressure has changed over time
and differs between guidelines proposed by expert bodies.
Variation in the definition of hypertension influences the
number of people classified as having uncontrolled hyperten-
sion7and may contribute to uncertainty among clinicians
(Table 1).8The 1977 report of the Joint National Committee
on the Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure (JNC) regarded a blood pressure ?160/
95 mm Hg as elevated, although treatment recommendations
were based primarily on the diastolic blood pressure.9The
1980 JNC report defined hypertension based on a diastolic
blood pressure threshold alone (90 mm Hg).10In 1984, this
definition was changed again, to a blood pressure ?140/
90 mm Hg.11In JNC VI (1997), a lower threshold of
130/85 mm Hg was recommended for individuals with dia-
betes mellitus.12JNC VII lowered this target for individuals
with diabetes or chronic kidney disease, to 130/80 mm Hg,3
bringing this threshold in agreement with recommendations
of the American Diabetes Association and the National
Kidney Foundation.13,14However, the National Committee
for Quality Assurance (NCQA), an organization that issues
periodic “report cards” for managed care organizations,
continues to use a cut point of 140/90 mm Hg in both diabetic
and nondiabetic patients.15
Individuals with evidence of target organ damage such as
left ventricular hypertrophy or who have experienced clinical
sequelae such as heart failure are at particularly high risk of
cardiovascular events, and use of lower blood pressure
thresholds for these individuals was endorsed by JNC VI.12
The European Society of Hypertension/European Society of
Cardiology guidelines also recommend that treatment thresh-
olds account for baseline cardiovascular risk,16similar to the
approach based on absolute risk contained in the National
Cholesterol Education Program (NCEP) guidelines.17How-
ever, in an effort to simplify treatment guidelines, the JNC
VII report recommends use of an alternate blood pressure
threshold only for patients with diabetes or chronic kidney
Magnitude of the Problem
Data on the prevalence of controlled and uncontrolled hyper-
tension are available from national cross-sectional surveys,
epidemiological investigations, community studies, health
maintenance organizations, and reports of physician office
practices (Table 2).6,18–42
From the Framingham Heart Study, Framingham, Mass (T.J.W., R.S.V.); Cardiology Division (T.J.W.), Massachusetts General Hospital, Harvard
Medical School, Boston, Mass; and Sections of Cardiology and Preventive Medicine (R.S.V.), Boston Medical Center, Boston University School of
Medicine, Boston, Mass.
Guest Editor for this article was Donna K. Arnett.
Correspondence to Ramachandran S. Vasan, MD, Framingham Heart Study, 73 Mt Wayte Ave, Suite 2, Framingham, MA 01702. E-mail
© 2005 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.orgDOI: 10.1161/CIRCULATIONAHA.104.490599
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KEY WORDS: epidemiology ? hypertension ? risk factors
September 13, 2005
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