More deaths from cardiovascular causes are attributed to elevated blood pressure than to any other risk factor, in the US. In the past 50 years, the mean systolic blood pressure has declined by approximately 10% and the mean diastolic blood pressure has declined by approximately 13% in people over 40 years of age in the US. This is partly because of greater awareness of the risk and more widespread treatment of hypertension. Despite this, the number of people with hypertension is increasing. It is estimated that 44% of the 64 million adults in the US with hypertension did not have the condition controlled in 2014. Therefore, there is enormous potential for improving this population’s health by expanding treatment and improving control.

More than a decade ago, the 2003 hypertension guidelines of the Seventh Joint National Committee focused on controlling elevated systolic blood pressure in all adults with hypertension and recommended a similar blood-pressure goal regardless of age, with the exception of more aggressive treatment to a lower target in patients with diabetes or chronic kidney disease. However, the 2014 guidelines of the Eighth Joint National Committee recommended three important changes to the 2003 guidelines: focusing on diastolic (rather than systolic) blood pressure for adults under the age of 60 and setting more conservative blood-pressure goals for adults ≥ 60 years of age (150/90mmHg) and for patients with diabetes or chronic kidney disease (140/90mmHg). 

Compared with the recommendations in the previous guidelines, implementation of the 2014 guidelines would make approximately 1% of young adults and 8% of older adults ineligible to receive hypertension-lowering treatment. However, an estimated 28 million adults still would have uncontrolled hypertension according to the relaxed standards.

A recent study¹ estimates that even with the newer, less aggressive guidelines, full implementation would result in approximately 56,000 fewer cardiovascular events and 13,000 fewer deaths from cardiovascular causes annually, which would result in overall cost savings. The projections showed that the treatment of patients with existing cardiovascular disease (CVD) or stage 2 hypertension would save lives and costs for men aged 35 to 74 years and for women aged 45 to 74 years. The treatment of men and women with existing CVD, and men with stage 2 hypertension but without CVD, would still save costs even if strategies to increase medication adherence doubled treatment costs. The treatment of stage 1 hypertension was cost effective (defined as <$50,000 per QALY) for all men and for women aged 45 to 74 years, whereas treating women aged 35 to 44 years with stage 1 hypertension but without CVD had intermediate or low cost-effectiveness.

In Ireland, less than half of the population (those with medical cards) is entitled to free GP care and drug treatment for hypertension. In a condition that is asymptomatic, cost of treatment is a significant deterrent to compliance. It is sadly not rare to be told by a patient with a myocardial infarction that “I had high blood pressure in the past and it got better with treatment so I stopped”. 

Hypertension is no longer much talked about, possibly because there have been no recent innovations in drug therapy for the pharmaceutical industry to promote. It is important not to forget about this silent killer, and not to accept less than optimal control of blood pressure.

Reference

1. Moran AE et al. Cost-effectiveness of hypertension therapy according to 2014 Guidelines. N Engl J Med 2015; 372: 447-455