HHS Public Access

Author manuscript
Hypertension. Author manuscript; available in PMC 2019 September 01.
Author Manuscript

Published in final edited form as:

Hypertension. 2018 September ; 72(3): 602–609. doi:10.1161/HYPERTENSIONAHA.118.11609.

Prevalence of hypertension and cardiovascular risk according to

blood pressure thresholds used for diagnosis
Julio A. Lamprea-Montealegre, MD MPH PhD1, Leila R. Zelnick, PhD2, Yoshio N. Hall, MD
MS3, Nisha Bansal, MD MS4, and Ian H. de Boer, MD MS5
1KidneyResearch Institute, Division of Cardiology, Department of Medicine, University of
Washington, Seattle
Author Manuscript

2KidneyResearch Institute, Division of Nephrology, Department of Medicine, University of

Washington, Seattle
3KidneyResearch Institute, Division of Nephrology, Department of Medicine, University of
Washington, Seattle
4KidneyResearch Institute, Division of Nephrology, Department of Medicine, University of
Washington, Seattle
5KidneyResearch Institute, Division of Nephrology, Department of Medicine and Department of
Epidemiology, University of Washington, Seattle

Abstract
Author Manuscript

We sought to estimate the prevalence of hypertension and characteristics of hypertensive adults in

the United States according to blood pressure thresholds used for diagnosis and estimate their
associated CVD risk. Analyses included adults 20 years of age or older in the 2013-2014 National
Health and Nutrition Examination Survey (NHANES) (N=5,389), and enrolled participants in the
Systolic Blood Pressure Intervention Trial (SPRINT) (N=9,361) and the Action to Control
Cardiovascular Risk in Diabetes-BP Trial (ACCORD-BP) (N=4,733) trials. In NHANES,
prevalence estimates incorporated the probability of observing elevated blood pressure on two
separate occasions. Using the new BP thresholds of 130/80 mm Hg or greater, approximately 24
million new American adults would be diagnosed as having hypertension and 4.3 million would be
recommended to start antihypertensive medications. These individuals would have a lower mean
atherosclerotic CVD risk (17%) than participants in SPRINT and ACCORD-BP (22% and 27%)
and would be less likely to have prevalent cardiovascular disease (9% versus 17% and 34%). In
Author Manuscript

SPRINT and ACCORD-BP, only a minority (9% and 13%) of participants were not on
antihypertensive medications at baseline, and, rates of incident CVD in these participants were
substantially lower compared to those on baseline BP medications. We conclude that adopting the

Corresponding author: Julio A. Lamprea-Montealegre, Cardiology Department, University of Washington School of Medicine, Box
356422, 1959 NE Pacific Street, Seattle, WA 98195, [email protected], P: (206)-685-1397, F: (206)-685-9394.
Authorship: Drs. Lamprea-Montealegre and Zelnick contributed equally and are co-first authors in this study.
Conflicts of Interest Disclosure:
Dr. de Boer reported receiving grant funding from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK),
National Heart, Lung, and Blood Institute (NHLBI), research support from Medtronic and Abbott, and consulting for Boehringer-
Ingelheim and Ironwood. Dr. Hall reported serving on the board of Trustees of the American Kidney Fund. No other disclosures were
reported.
 Lamprea-Montealegre et al. Page 2

ACC/AHA guidelines would lead to a substantial increase in the prevalence of hypertension and in
Author Manuscript

the number of American adults recommended to start antihypertensive medications. These

individuals would have a substantially lower cardiovascular risk than most participants previously
studied in two large BP trials.

Keywords
Hypertension; cardiovascular disease; epidemiology; guidelines; diagnosis

Introduction
Hypertension is an independent, modifiable risk factor for the development of cardiovascular
disease and the leading cause of disability worldwide1,2. Guidelines have traditionally
Author Manuscript

defined hypertension as the current use of an antihypertensive medication and/or a systolic

BP (SBP) ≥140 mm Hg or a diastolic BP (DBP) ≥90 mmHg, based on at least two BP
readings obtained on two or more occasions3,4. Recently, the American College of
Cardiology and American Heart Association (ACC/AHA) BP guidelines recommended
changing the BP threshold used to diagnose hypertension to ≥ 130/80 mm Hg5.

It is estimated that under these new lower BP thresholds, 31 million US adults with SBP
130-139 mm Hg or DBP 80-89 mm Hg not on BP medications will be labeled as having
hypertension6. Of these, the ACC/AHA guidelines recommend starting BP therapy on
individuals with a 10-year atherosclerotic cardiovascular risk (ASCVD) greater than 10%. It
is estimated that 4.2 million US adults would meet this recommendation6. These estimates,
however, have been based on BP readings taken in one occasion; an important consideration
since most BP guidelines recommend establishing a diagnosis of hypertension only after BP
Author Manuscript

is measured on at least two occasions. It is critical to properly characterize the individuals

that would be newly recommended to start a BP medication since recent research has shown
a net benefit from intensive BP therapy only among individuals with a 10-year ASCVD risk
greater than 18%7.

The Systolic Blood Pressure Intervention Trial (SPRINT) and the Action to Control
Cardiovascular Risk in Diabetes-BP Trial (ACCORD-BP) are the largest clinical trials
evaluating intensive BP targets among individuals with SBP >130 mm Hg at high CVD
risk8,9. Even though the newly recommended thresholds for hypertension were largely
informed by results from SPRINT, most patients in this trial (and in ACCORD-BP) were on
BP medications at baseline. Given that the CVD risk profile of patients on long-standing BP
medications may be different than that of patients not on medications despite similar BP
Author Manuscript

values, it is important to determine whether individuals that would be newly recommended

to start BP therapy were well represented in these trials, and therefore, establish if there is
evidence to support the recommendation for BP treatment initiation in these patients.

We sought to estimate how adopting these newly recommended BP thresholds would impact
the prevalence of hypertension among US adults accounting for persistent hypertension
(elevated BP on more than two occasions). In addition, we sought to characterize the
population that would be newly recommended for initiation of antihypertensive medications

Hypertension. Author manuscript; available in PMC 2019 September 01.

 Lamprea-Montealegre et al. Page 3

and compare them to the demographic and clinical characteristics of participants enrolled in
Author Manuscript

the SPRINT and ACCORD-BP trials.

Methods
Data source
Individual level data from SPRINT and ACCORD-BP were obtained from the National
Heart, Lung, and Blood Institute (NHLBI) biologic specimen and data repositories
information coordinating center (BioLINCC). To request access to the BioLINCC data
repository, a completed application form and research proposal should be submitted to
NHLBI. Data can be accessed through the BioLINCC web site at https://
biolincc.nhlbi.nih.gov/home/. NHANES data can be accessed through the Centers for
Disease Control and Prevention (CDC) National Center for Health Statistics website at
https://www.cdc.gov/nchs/nhanes/index.htm. The present study was deemed exempt from
Author Manuscript

review by the Institutional Review Board at the University of Washington.

Study Populations
The National Health and Nutrition Examination Survey (NHANES)10 is a program of
studies conducted by the National Center for Health Statistics to evaluate the health of non-
institutionalized adults and children in the United States. The NHANES sample is selected
through a complex multistage design with oversampling for persons of black race, Hispanic
ethnicity, or both.

The current study includes 5,380 participants of the 2013-2014 NHANES who were aged 20
years or older, who underwent a health examination at an NHANES mobile examination
center (MEC) with available data for prescription medication use and at least two BP
Author Manuscript

readings.

SPRINT enrolled 9,361 adults 50 years of age or older with a SBP of at least 130 mm Hg
and an increased CVD risk8. High CVD risk was defined as history of clinical or subclinical
CVD, chronic kidney disease with an estimated glomerular filtration rate of 20 to less than
60 ml/min/1.73 m2, a 10-year CVD risk on the basis of the Framingham risk score of 15%
or greater, or an age of 75 years or older. Patients with diabetes mellitus or prior stroke were
excluded. ACCORD-BP enrolled 4,733 participants 40 years of age or older with type 2
diabetes mellitus (T2DM) and a glycated hemoglobin level of 7.5% or greater, a SBP of 130
to 180 mm Hg, and history of CVD9. Participants with a body-mass index of 45 kg/m2 or
greater, a serum creatinine of more than 1.5 mg/dl, and other serious illnesses were
excluded.
Author Manuscript

Blood pressure measurement

In NHANES, blood pressure was measured by a physician certified in blood pressure
measurement using the standardized protocol of the AHA during a single MEC visit11,12.
The first BP measurement was recorded after a 5-minute period of rest with two additional
readings obtained 30 seconds apart using the same arm. A fourth reading was recorded in
case one or more of the readings were unobtainable.

Hypertension. Author manuscript; available in PMC 2019 September 01.

 Lamprea-Montealegre et al. Page 4

SPRINT and ACCORD-BP used automated devices to measure BP and used very similar
Author Manuscript

classes and numbers of antihypertensive agents. Although SPRINT measured BP in the

absence of an observer for the majority of participants (as opposed to ACCORD-BP),
similar results for the effect of the intensive BP intervention have been found when analyses
have been performed separately in observed or unobserved participants13.

Hypertension definition in NHANES

Prevalent hypertension was defined as current use of an antihypertensive medication or mean
systolic blood pressure (SBP) or diastolic blood pressure (DBP) higher than the diagnostic
threshold accounting for the probability of having elevated blood pressure on two occasions
(persistent hypertension). We used two different BP thresholds to diagnose hypertension: the
traditional threshold of ≥140/90 mm Hg and the newly recommended threshold of ≥130/80
mm Hg.
Author Manuscript

Prevalent hypertension estimates incorporate the probability of having persistent

hypertension because most guidelines recommend diagnosing hypertension only if elevated
BP is present on at least two separate days3–5. We considered any participant treated with an
antihypertensive medication to have persistent hypertension. For participants not treated
with an antihypertensive medication but with mean BP above diagnostic threshold, we
incorporated into our statistical analyses the estimated probability that mean SBP or DBP
would be elevated when next measured, following an approach we used previously to
estimate the prevalence of persistent chronic kidney disease14. We based our estimates that
BP would be persistently elevated on data collected during NHANES III (1988-1994),
during which 1,853 participants underwent repeat BP measurements two weeks apart
(Supplemental material).
Author Manuscript

Cardiovascular disease endpoints in SPRINT and ACCORD-BP

SPRINT and ACCORD-BP evaluated effect of intensive compared to standard BP treatment
targets (<120 versus <140 mm Hg SBP) on a primary composite CVD end-point of non-fatal
myocardial infarction or stroke, or death from cardiovascular causes. SPRINT also included
unstable angina and acute heart failure as part of its composite endpoint8,9. We conducted
separate analyses with the original primary pre-specified composite CVD endpoint for each
trial.

Other Clinical Characteristics

In NHANES, we defined diabetes mellitus as use of a glucose lowering medication or
hemoglobin A1C% ≥6.5%14 and prevalent cardiovascular disease (CVD) as a self-reported
Author Manuscript

history of congestive heart failure, coronary artery disease, or stroke. Estimated glomerular
filtration rate (eGFR) was calculated from serum creatinine using the CKD-EPI formula15,
and estimated atherosclerotic CVD (ASCVD) risk was calculated using the 2013 ACC/AHA
ASCVD pooled cohort equation16.

In SPRINT and ACCORD-BP, we used the CKD-EPI formula to estimate the glomerular
filtration rate and estimated the ASCVD risk with the 2013 ACC/AHA pooled cohort

Hypertension. Author manuscript; available in PMC 2019 September 01.

 Lamprea-Montealegre et al. Page 5

equation. In ACCORD-BP, all included patients had a history of T2DM and a baseline
Author Manuscript

glycated hemoglobin of 7.5% or greater.

Statistical methods
In NHANES, analyses incorporated sampling weights to account for non-response bias and
the sampling design. We used a bootstrap approach with 500 replicates to account for the
variability in the estimate of the probability of persistent hypertension9. We estimated the
prevalence of hypertension as the prevalence of hypertension in the bootstrap sample
multiplied by the bootstrap probability of persistence; the final estimate and 95% CI were
the mean and 2.5/97.5th percentiles across bootstrap replicates, respectively (Supplement).

Incident CVD rates were calculated separately in SPRINT and ACCORD-BP as the number
of events in the primary composite endpoint divided by the total time at risk stratifying by
BP value and prior use of BP medication. Confidence intervals were derived with a bootstrap
Author Manuscript

approach using 500 replicates.

Analysis were performed using STATA version 11.0 (StataCorp) and R version 3.4.0 (R
foundation for Statistical Computing).

Results
Prevalence of Hypertension
The estimated prevalence of hypertension among US adults was 44.0% (95% CI, 42.2%,
45.7%) using newly recommended BP thresholds as compared to 34.2% (95% CI, 32.5%,
35.8%) using traditional thresholds. This represents an estimated absolute increase in
hypertension prevalence of 9.8% (95% CI, 8.7%, 11.1%) and a relative increase of 28.6%
Author Manuscript

(95% CI, 25%, 33.1%) (Table 1).

The absolute increase in hypertension prevalence was largest for adults aged 40-59 years,
men, those who were obese (Quetelet index ≥ 30 kg/m2) or free of significant comorbidities
such as diabetes or CVD, and in those with eGFR ≥60 mL/min/1.73m2 (Table 1 and Figure
1)

Characteristics of individuals classified as hypertensive under newly recommended BP

thresholds
Compared to US adults classified as hypertensive using traditional BP thresholds (≥ 140/90
mm Hg), participants re-classified as hypertensive (BP ≥ 130/80 and <140/90 mm Hg) were
younger; less likely to have diabetes mellitus, CVD, or an estimated glomerular filtration
Author Manuscript

rate < 60 ml/min/1.73 m2; and had a lower estimated 10-year risk of ASCVD (Table 2).

Compared to SPRINT and ACCORD-BP, individuals that would be reclassified as having

hypertension and be recommended for initiation of BP therapy based on 10-year ASCVD
risk greater than 10%, were younger and more likely to be male; less likely to have a history
of CVD, or an estimated glomerular filtration rate <60 ml/min/m2; and had a lower
estimated 10-year ASCVD risk (Table 3).

Hypertension. Author manuscript; available in PMC 2019 September 01.

 Lamprea-Montealegre et al. Page 6

Endpoints in SPRINT and ACCORD-BP

Author Manuscript

The cumulative incidence of the primary composite cardiovascular endpoint in SPRINT and
ACCORD-BP were 6% and 9% during a median follow-up time of 3.2 years and 4.7 years,
respectively. Of participants not on BP medications at baseline and with a SBP ≥ 130 or
DBP ≥ 80 mm Hg, and a SBP <140 and DBP<90 mm Hg, there were 10 events (2% of total)
and 14 events (3% of total), in SPRINT and ACCORD-BP, respectively.

In each trial, incident rates of the primary endpoint in participants not on antihypertensive
medications at baseline were substantially lower than rates observed for participants on
baseline BP medications (Table 4).

Discussion
Implementation of the new ACC/AHA guidelines for hypertension diagnosis would lead to
Author Manuscript

an estimated prevalence of hypertension of 44% among US adults, representing an absolute

increase of nearly 10%. Newly reclassified hypertensive individuals would be younger and
have a lower prevalence of major comorbid conditions compared to adults traditionally
diagnosed with hypertension. Furthermore, individuals that would be recommended to start
BP therapy have a substantial lower CVD risk profile than most participants enrolled in the
SPRINT and ACCORD-BP trials. In each of these trials, participants that were not on
antihypertensive medications at baseline had a substantially lower CVD risk than participant
on baseline antihypertensive medications.

We estimate that applying the newly recommended BP thresholds to hypertension diagnosis

would reclassify an estimated 24 million adults with SBP 130-139 mmHg or DBP 80-89
who are not currently treated for hypertension, and based on a 10-year ASCVD risk of
Author Manuscript

≥10%, would recommend starting BP therapy on approximately 4.5 million American

adults. These estimates are lower than prior reports that have estimated the population
impact of adopting the ACC/AHA guidelines in US adults. Muntner et al, estimated that 31
million American adults would be reclassified as having hypertension6. The reason for the
discrepancy is that in our analyses we account for the probability of the persistence of
hypertension on our prevalence estimates, an approach recommended by most BP
guidelines.

The new guidelines recommend treating hypertension to a target BP of <130/80 mmHg

based largely on results of the SPRINT trial, which demonstrated that targeting SBP <120
mmHg reduced CVD events among participants at high CVD risk5. However, treatment
targets are distinct from, and need not be identical to, thresholds used for diagnosis which
we evaluate in this study. For example, hemoglobin A1c ≥6.5% is used to diagnose diabetes,
Author Manuscript

while hemoglobin A1c <7% is a common treatment target14. This consideration is critical to
interpret the results of SPRINT and ACCORD-BP who were designed to evaluate the
effectiveness of intensive treatment targets (but not of different diagnostic thresholds) in
participants who were for the most part on baseline antihypertensive medications.

American adults that would be newly recommended to start antihypertensive medications

have a lower CVD risk than participants in SPRINT and ACCORD-BP. This is supported by

Hypertension. Author manuscript; available in PMC 2019 September 01.

 Lamprea-Montealegre et al. Page 7

our findings of lower CVD risk-factor profile in NHANES participants compared to those in
Author Manuscript

SPRINT and ACCORD-BP. Furthermore, CVD event rates in participants in these trials that
were not on baseline antihypertensive medications, and, thus, that would most closely
resemble the population recommended to start antihypertensive medications, were markedly
lower than those of participants on baseline antihypertensive medications. These
observations are important since prior research has shown a net benefit to risk balance of
intensive BP reduction that is dependent on CVD risk, with individuals at highest CVD risk
deriving most benefit7,17.

There is insufficient evidence to support the recommendation of starting antihypertensive

medications in the newly reclassified population. As we show, only a minority of CVD
events in in SPRINT and ACCORD-BP occurred among participants in the lower BP
threshold category who were not on baseline antihypertensive medications. In the HOPE-3
trial of adults with intermediate CVD risk and no history of CVD, participants with baseline
Author Manuscript

BP <140/90 mmHg had no significant benefit from treatment with candesartan plus
hydrochlorothiazide, compared with placebo, on a composite primary CVD endpoint18. As
opposed to SPRINT and ACCORD-BP, only 22% of HOPE-3 participants were taking BP
medications. Although data from HOPE-3 may apply more closely to the population that
would be recommended to start BP therapy compared to SPRINT and ACCORD-BP, no
prior clinical trial has primarily evaluated the effect of BP therapy in this population.

Our study is limited in that NHANES 2013-2014 did not have repeated BP measurements to
accurately classify persistent hypertension at the individual level. It is possible that our
estimates of persistence may be imprecise due to secular trends in BP treatment and control.
In addition, NHANES relied on self-report of CVD which may underestimate the prevalence
of CVD. Moreover, the cross-sectional study design in NHANES precludes assessing
Author Manuscript

associations of hypertension diagnoses with CVD events. Finally, owing to the small number
of events in SPRINT and ACCORD-BP, we were unable to provide reliable estimates for the
effect of intensive BP therapy in the newly reclassified population recommended for BP
therapy.

In conclusion, the newly recommended thresholds for blood pressure diagnosis would lead
to a substantial increase in the prevalence of hypertension with the largest increase among
adults at a low cardiovascular risk. Individuals that would be recommended to start BP
therapy were not well represented and had a markedly lower CVD risk profile than
participants in SPRINT and ACCORD-BP.

Supplementary Material
Author Manuscript

Refer to Web version on PubMed Central for supplementary material.

Acknowledgments
This research was supported by an unrestricted gift from the Northwest Kidney Centers to the Kidney Research
Institute.

Hypertension. Author manuscript; available in PMC 2019 September 01.

 Lamprea-Montealegre et al. Page 8

References
Author Manuscript

1. Rosendorff C, Lackland DT, Allison M, et al. Treatment of hypertension in patients with coronary
artery disease: a scientific statement from the American Heart Association, American College of
Cardiology, and American Society of Hypertension. Circulation. 2015; 131(19):e435–e470.
[PubMed: 25829340]
2. GBD 2016 Risk Factors Collaborators. Global, regional, and national comparative risk assessment
of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks,
1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;
390(10100):1345–1422. [PubMed: 28919119]
3. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;
42(6):1206–1252. [PubMed: 14656957]
4. de Boer IH, Bangalore S, Benetos A, et al. Diabetes and Hypertension: A Position Statement by the
American Diabetes Association. Diabetes Care. 2017; 40(9):1273–1284. [PubMed: 28830958]
5. Whelton PK, Karey RM, Aronow WS, et al. ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/
Author Manuscript

ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High
Blood Pressure in Adults. J Am Coll Cardiol. 2017; 2018:71e127–248.
6. Muntner P, Carey RM, Gidding SM, et al. Potential U.S. Population Impact of the 2017 American
College of Cardiology/American Heart Association Blood Pressure Guideline. Circulation. 2018;
137(2):109–118. [PubMed: 29133599]
7. Phillips RA, Xu Jiaqiong Xu, Peterson LF, et al. Impact of Cardiovascular Risk on the Relative
Benefit and Harm of Intensive Treatment of Hypertension. J Am Coll Cardiol. 2018; 17:1601–10.
8. SPRINT Research Group. Wright JT, Williamson JD, Whelton PK, Snyder JK, Sink KM, et al. A
Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med
Massachusetts Medical Society. 2015 Nov 26; 373(22):2103–16.
9. ACCORD Study Group. Cushman WC, Evans GW, Byington RP, Goff DC, Grimm RH, et al.
Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010 Apr 29;
362(17):1575–85. [PubMed: 20228401]
10. US Centers for Disease Control and Prevention; National Center for Health Statistics. National
Health and Nutrition Examination Survey 1988-1994, and 2013-2014 documentation files. http://
Author Manuscript

www.cdc.gov/nchs/nhanes.htm. Accessed November 2017

11. Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in
humans and experimental animals: Part 1: blood pressure measurement in humans: a statement for
professionals from the Subcommittee of Professional and Public Education of the American Heart
Association Council on High Blood Pressure Research. Hypertension. 2005; 45(1):142–161.
[PubMed: 15611362]
12. US Centers for Disease Control and Prevention; National Center for Health Statistics. National
Health and Nutrition Examination Survey 2013-2014 examination and laboratory procedures files.
https://wwwn.cdc.gov/nchs/nhanes/ContinuousNhanes/Manuals.aspx?BeginYear=2013. Accessed
November 2017
13. Johnson KC, Whelton PK, Cushman WC, Cutler JA, Evans GW, Snyder JK, et al. Blood Pressure
Measurement in SPRINT (Systolic Blood Pressure Intervention Trial). Hypertension. 2018
HYPERTENSIONAHA.117.10479.
14. Afkarian M, Zelnick LR, Hall YN, et al. Clinical Manifestations of Kidney Disease Among US
Author Manuscript

Adults with Diabetes, 1988-2014. JAMA. 2016; 316(6):602–610. [PubMed: 27532915]

15. Inker LA, Schmid CH, Tighiouart H, Eckfeldt JH, Feldman HI, Greene T, et al. Estimating
glomerular filtration rate from serum creatinine and cystatin C. N Engl J Med. 2012; 367:20–9.
[PubMed: 22762315]
16. Goff DC, 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. Circulation. 2014; 129(25 Suppl 2):S49–S73. [PubMed:
24222018]

Hypertension. Author manuscript; available in PMC 2019 September 01.

 Lamprea-Montealegre et al. Page 9

17. The Blood Pressure Lowering Treatment Trialists’ Collaboration. Blood-pressure lowering
Treatment based on cardiovascular risk: a meta-analysis of individual patient data. Lancet. 2014;
Author Manuscript

384(9943):591–598. [PubMed: 25131978]

18. Lonn EM, Bosch J, López-Jaramillo P, et al. Blood-Pressure Lowering in Intermediate-Risk
Persons without Cardiovascular Disease. N Engl J Med. 2016; 374(21):2009–2020. [PubMed:
27041480]
Author Manuscript
Author Manuscript
Author Manuscript

Hypertension. Author manuscript; available in PMC 2019 September 01.

 Lamprea-Montealegre et al. Page 10

Perspectives
Author Manuscript

There is insufficient evidence to recommend initiation of BP therapy among US adults

newly labeled as hypertensives using the ACC/AHA recommended thresholds. Future
research should establish if lowering diagnostic thresholds for hypertension is associated
with a reduction in cardiovascular disease burden.
Author Manuscript
Author Manuscript
Author Manuscript

Hypertension. Author manuscript; available in PMC 2019 September 01.

 Lamprea-Montealegre et al. Page 11

Novelty and Significance

Author Manuscript

What is new?

- We estimate the prevalence of hypertension in US adults under the new

ACC/AHA diagnostic blood pressure thresholds accounting for the
probability of observing an elevated blood pressure on two occasions.

- We characterize the adult US population that would be recommended to start

antihypertensive medications.

- We estimate the cardiovascular disease risk of adults that would be

recommended to start antihypertensive medications in two large
contemporary blood pressure trials.

What is relevant?
Author Manuscript

- Proper characterization and estimation of cardiovascular risk of adults that

would be recommended to start antihypertensive medications under the new
guidelines has significant clinical and public health implications.

Summary
- The newly recommended thresholds for hypertension diagnosis would lead to
a substantial increase in the prevalence of hypertension. There is insufficient
evidence to recommend initiation of BP therapy among US adults newly
classified as hypertensives.
Author Manuscript
Author Manuscript

Hypertension. Author manuscript; available in PMC 2019 September 01.

 Lamprea-Montealegre et al. Page 12
Author Manuscript
Author Manuscript
Author Manuscript

Figure 1. Prevalence of hypertension in US adults with traditional and new criteria for diagnosis
by age and clinical characteristics
Traditional criteria for hypertension diagnosis: SBP ≥140 mmHg, DBP≥90 mm Hg, and/or
current use of antihypertensive medication. New criteria for hypertension diagnosis:
SBP≥130 mmHg, DBP≥80 mm Hg, and/or current use of antihypertensive medication
Error bars indicate 95% confidence intervals
Author Manuscript

Hypertension. Author manuscript; available in PMC 2019 September 01.

 Lamprea-Montealegre et al. Page 13

Table 1

Prevalence of hypertension among US adults with traditional and new criteria for the diagnosis of
Author Manuscript

hypertension in NHANES 2013-2014

Characteristic Prevalence with Prevalence with new Absolute difference in Relative percent
* criteria† prevalence difference in prevalence
traditional criteria (95% CI) (95% CI)
(95% CI) (95% CI)

Overall 34.2 (32.5, 35.8) 44.0 (42.2, 45.7) 9.8 (8.7, 11.1) 28.6 (25.0, 33.1)

Age
20-39 8.7 (7.3, 10.0) 17.1 (15.4, 18.9) 8.4 (7.3, 9.8) 97.1 (76.5, 122.7)

40-59 34.7 (31.9, 37.5) 47.6 (44.7, 50.7) 12.9 (11.0, 15.0) 37.3 (31.4, 45.5)

≥60 72.4 (69.8, 75.5) 79.7 (77.2, 82.1) 7.2 (5.5, 9.0) 10.0 (7.5, 12.8)

Gender
Male 35.0 (32.6, 37.5) 46.7 (44.1, 49.4) 11.7 (10.1, 13.4) 33.2 (28.4, 39.6)
Author Manuscript

Female 33.5 (31.1, 35.4) 41.5 (39.3, 43.5) 8.1 (6.9, 9.2) 24.2 (20.3, 28.7)

Race/Ethnicity
White, non-Hispanic 36.8 (34.5, 39.2) 46.2 (44.0, 48.7) 9.4 (8.0, 10.9) 25.5 (21.0, 30.5)

Black, non-Hispanic 41.1 (38.0, 44.0) 52.3 (49.4, 55.4) 11.1 (9.4, 13.2) 27.1 (21.9, 32.8)

Asian, non-Hispanic 25.9 (22.0, 29.5) 34.3 (30.3, 38.2) 8.4 (6.5, 10.7) 32.7 (24.3, 43.3)

Hispanic 21.5 (19.6, 23.8) 31.9 (29.4, 34.6) 10.4 (8.7, 12.2) 48.2 (38.7, 58.5)

Diabetes
No 28.7 (27.0, 30.5) 38.8 (37.0, 40.9) 10.1 (8.9, 11.5) 35.2 (30.3, 41.2)
Yes 75.6 (72.0, 79.1) 82.2 (79.1, 85.0) 6.5 (4.7, 8.8) 8.7 (6.0, 12.0)

Prevalent CVD
No 29.9 (28.1, 31.6) 40.2 (38.4, 42.1) 10.4 (9.2, 11.7) 34.6 (30.3, 40.3)

Yes 82.0 (77.3, 86.5) 85.4 (81.1, 89.2) 3.4 (1.9, 5.4) 4.2 (2.3, 6.8)
Author Manuscript

ASCVD Risk
< 10% 20.4 (18.6, 22.1) 30.5 (28.6, 32.7) 10.2 (8.9, 11.6) 49.9 (42.0, 59.2)

≥ 10% 76.7 (74.1, 79.4) 84.4 (82.2, 86.4) 7.6 (5.6, 9.6) 9.9 (7.1, 12.8)

BMI (kg/m2)

< 25 21.6 (19.2, 24.1) 29.0 (26.4, 31.6) 7.3 (6.0, 8.8) 34.0 (26.8, 43.1)

25 - < 30 33.0 (30.4, 36.0) 42.8 (40.0, 45.8) 9.7 (8.0, 11.4) 29.3 (23.3, 35.7)

≥ 30 44.4 (41.7, 47.2) 56.3 (53.7, 59.1) 11.9 (10.4, 13.8) 26.7 (22.7, 32.4)

eGFR < 60 mL/min/1.73m2

≥ 60 30.0 (28.2, 31.7) 40.2 (38.5, 42.2) 10.3 (9.1, 11.6) 34.4 (29.7, 39.8)

< 60 84.9 (80.8, 88.6) 87.3 (83.5, 90.3) 2.3 (0.8, 4.2) 2.7 (1.0, 5.1)

Urine ACR (mg/g)

Author Manuscript

< 30 30.9 (29.1, 32.6) 40.7 (39.0, 42.6) 9.8 (8.7, 11.1) 31.6 (27.4, 37.2)

≥ 30 59.2 (54.4, 63.4) 68.8 (63.9, 72.8) 9.5 (7.3, 12.0) 16.2 (11.5, 21.0)

Cell contents are proportions (%) (95% CI).

Abbreviations: CVD, cardiovascular disease; ASCVD, atherosclerotic cardiovascular disease; BMI, body mass index; eGFR, estimated glomerular
filtration rate; ACR, albumin to creatinine ratio.

Hypertension. Author manuscript; available in PMC 2019 September 01.

 Lamprea-Montealegre et al. Page 14

All prevalence estimates account for the persistence of hypertension (supplement).

*
Defined as SBP ≥140 mmHg, DBP≥90 mm Hg, and/or current use of antihypertensive medication.
†
Defined as SBP≥130 mmHg, DBP≥80 mm Hg, and/or current use of antihypertensive medication.
Author Manuscript
Author Manuscript
Author Manuscript
Author Manuscript

Hypertension. Author manuscript; available in PMC 2019 September 01.

 Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Table 2

Demographic and clinical characteristics of NHANES 2013-2014 population

Characteristic * Newly classified with hypertension† Hypertension based on traditional criteria‡

No hypertension
(N = 2,617) (N=618) (N = 2,145)

N Weighted mean or percent (95% CI) N Weighted mean or percent (95% CI) N Weighted mean or percent (95% CI)

Demographic variables
Age (years) 38.9 (38.0, 39.8) 46.4 (44.5, 48.3) 60.0 (59.2, 60.9)
Lamprea-Montealegre et al.

Women 1,455 55 (52, 57) 255 43 (37, 49) 1,085 50 (47, 53)

Race/ethnicity

White, non-Hispanic 1,097 63 (56, 71) 249 63 (55, 71) 966 71 (64, 77)

Black, non-Hispanic 413 10 (6, 13) 135 13 (9, 17) 561 14 (10, 18)

Asian, non-Hispanic 358 6 (4, 8) 63 5 (3, 6) 190 4 (3, 5)

Hispanic 655 18 (12, 24) 148 16 (11, 21) 388 10 (5, 14)

Medical history
Diabetes 112 3.4 (2.6, 4.1) 59 8 (5, 11) 611 25 (23, 27)

CVD 60 2 (1, 3) 19 3 (1, 4) 438 19 (17, 21)

Atherosclerotic CVD risk (%), mean 2.6 (2.3, 2.9) 5.5 (4.7, 6.2) 16.5 (15.6, 17.4)

ASCVD> 10% 167 6 (4, 7) 118 18 (14, 23) 1,191 55 (51, 59)

Medications
Antihypertensive medications 0 0 0 0 1,723 80 (77, 84)
Lipid-lowering medications 143 6 (5, 8) 53 10 (6, 14) 931 45 (41, 48)

Statins 127 6 (4, 7) 48 9 (5, 12) 867 41 (37, 45)

Hypertension. Author manuscript; available in PMC 2019 September 01.

Fibrates 15 0.5 (0.1, 0.9) 4 1.5 (0, 3.2 74 4.0 (2.5, 5.4)

Aspirin 1 0.02 (0, 0.07) 2 0.4 (0, 1.0) 48 1.5 (0.9, 2.0)

Physical examination

BMI (kg/m2), mean 27.5 (27.1, 27.9) 30.3 (29.5, 31.2) 31.0 (30.6, 31.4)

Systolic BP 112.2 (111.7, 112.6) 128.8 (127.8, 129.7)§ 133.4 (131.8, 135.0)║

Diastolic BP 66.7 (65.9, 67.5) 77.7 (76.7, 78.8)§ 71.6 (70.5, 72.7)║

Laboratory data
Page 15
 Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Characteristic * Newly classified with hypertension† Hypertension based on traditional criteria‡

No hypertension
(N = 2,617) (N=618) (N = 2,145)

N Weighted mean or percent (95% CI) N Weighted mean or percent (95% CI) N Weighted mean or percent (95% CI)

eGFR (mL/min/1.73 m2), mean 101 (99, 103) 96 (94, 98) 81 (80, 83)

eGFR < 60 46 1.7 (1.0, 2.3) 10 1.7 (0.5, 3.0) 392 18 (16, 20)

Cell contents are N, mean (95% CI), or proportion (%) (95% CI).

Abbreviations: CVD, cardiovascular disease; ASCVD, atherosclerotic cardiovascular disease; BMI, body mass index; eGFR, estimated glomerular filtration rate.
Lamprea-Montealegre et al.

*
No hypertension was defined as SBP <130 mmHg, DBP<80 mmHg, and no treatment with antihypertensive medication.
†
Newly classified with hypertension was defined as SBP≥130 mmHg or DBP≥80 mmHg and, SBP<140 mmHg and DBP<90 mmHg, and no treatment with antihypertensive medication.
‡
Hypertension based on traditional criteria was defined as SBP≥140 mmHg, DBP≥90 mm Hg, and/or current use of an antihypertensive medication.
§
In this group, 39% were classified as hypertensive based on SBP only, 43% based on DBP only, and 18% based on SBP and DBP.
║
In this group, 13% were classified as hypertensive based on SBP only, 2% on DBP only, 4% based on SBP and DBP, and 80% based on use of antihypertensive medications.

Hypertension. Author manuscript; available in PMC 2019 September 01.

Page 16
 Lamprea-Montealegre et al. Page 17

Table 3

Demographic and clinical characteristics of US adults newly recommended to start antihypertensive

Author Manuscript

medications and baseline characteristics of SPRINT and ACCORD-BP participants.

Characteristic NHANES SPRINT ACCORD

Newly classified with hypertension and (N = 9361) (N = 4733)
10-year ASCVD risk >10% (N = 118)

Weighted mean (SD) or N (weighted Mean (SD) or N (percent) Mean (SD) or N (percent)
percent)

Demographic variables
Age (years) 63.2 (12.3) 67.9 (9.4) 62.7 (6.7)

Women 32 (31) 3332 (36) 2258 (48)

Race/ethnicity

White, non-Hispanic 49 (72) 5399 (58) 2781 (59)

Black, non-Hispanic 24 (11) 2802 (30) 1127 (24)

Author Manuscript

Hispanic 34 (12) 984 (11) 330 (7)

Other 11 (6) 176 (2) 495 (10)

Medical history
Diabetes 24 (17) 0 (0) 4733 (100)

CVD 10 (9) 1562 (17) 1593 (34)

Atherosclerotic CVD risk (%), mean 16.9 (7.7) 22.0 (14.5) 27.2 (14.5)

ASCVD > 10% 118 (100) 7602 (81) 4226 (89)

Medications
Antihypertensive medications 0 (0) 8479 (91) 4132 (87)

Lipid-lowering medications 19 (18) NA 3235 (68)

Statins 18 (18) 4054 (43) 3063 (65)

Author Manuscript

Fibrates 0 (0) NA 311 (7)

Aspirin 4756 (51) 2472 (52)

Physical examination

BMI (kg/m2), mean 28.5 (7.2) 29.9 (5.8) 32.1 (5.5)

Systolic BP 133.1 (4.8) 139.7 (15.6) 144.2 (10.5)

Diastolic BP 72.6 (12.3) 78.1 (11.9) 78.3 (9.6)

Laboratory data

eGFR (mL/min/1.73 m2), mean 82.2 (17.8) 71.7 (20.6) 91.6 (28.8)

eGFR < 60 7 (6) 2650 (28) 403 (9)

Cell contents are N, mean (95% CI), or proportion (%) (95% CI). Abbreviations: CVD, cardiovascular disease; ASCVD, atherosclerotic
cardiovascular disease; BP, blood pressure; BMI, body mass index; eGFR, estimated glomerular filtration rate.
Author Manuscript

Hypertension. Author manuscript; available in PMC 2019 September 01.

 Lamprea-Montealegre et al. Page 18

Table 4

Primary composite CVD endpoints in SPRINT and ACCORD-BP

Author Manuscript

Study N at risk* N events Proportion of IR per 1000 person-

total events* years
(95% bootstrapped CI)

SPRINT

SBP≥130 or DBP≥80 and SBP<140 and DBP<90, not on BP 247 10 2% 12.9 (5.3,22.0)
medications at baseline

SBP ≥ 140 or DBP ≥ 90, not on BP medications at baseline 561 21 4% 12.2 (7.5, 17.9)

SBP≥130 or DBP≥80 and SBP<140 and DBP<90, on BP 2599 133 24% 16.2 (13.5, 19.0)
medications at baseline
SBP ≥ 140 or DBP ≥ 90, on BP medications at baseline 4092 285 51% 22.4 (19.9, 25.0)

ACCORD-BP

SBP≥130 or DBP≥80 and SBP<140 and DBP<90, not on BP 227 14 3% 12.8 (6.8, 20.2)
meds at baseline
Author Manuscript

SBP≥140 or DBP≥90, not on BP meds at baseline 373 25 6% 13.9 (8.8, 19.5)

SBP≥130 or DBP≥80 and SBP<140 and DBP<90, on BP meds 1584 147 33% 20.0 (16.9, 23.5)
at baseline

SBP≥140 or DBP≥90, on BP meds at baseline 2549 259 58% 21.8 (19.3, 24.5)

Composite primary outcome for ACCORD is nonfatal MI, nonfatal stroke, or CVD death; composite primary outcome for SPRINT is MI, HF,
stroke, angina, or CVD death.

Abbreviations: BP, blood pressure; SBP, systolic blood pressure; DBP, diastolic blood pressure; IR, incident rate.
*
An additional 113 events occurred in 1,749 participants with a SBP <130 and a DBP <80 mm Hg at randomization. Only 74 participants in this
category were not on medications at baseline.
Author Manuscript
Author Manuscript

Hypertension. Author manuscript; available in PMC 2019 September 01.