The prevalence and treatment of hypertension in Veterans Health Administration, assessing the impact of the updated clinical guidelines : Journal of Hypertension

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The prevalence and treatment of hypertension in Veterans Health Administration, assessing the impact of the updated clinical guidelines

Yamada, Masaakia,b; Wachsmuth, Jasonb; Sambharia, Meenakshib; Griffin, Benjamin R.a,b; Swee, Melissa L.b; Reisinger, Heather Schachta,b,c; Lund, Brian C.a; Girotra, Saket R.d; Sarrazin, Mary V.a,b; Jalal, Diana I.a,b

Author Information

aCenter for Access & Delivery Research and Evaluation, Iowa City VAMC

bThe University of Iowa Roy J. and Lucille A Carver, College of Medicine

cInstitute for Clinical and Translational Science, Iowa City, Iowa

dDivision of Cardiovascular Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA

Correspondence to Diana I. Jalal, MD, 200 Hawkins Dr, Division of Nephrology, E300C GH, Iowa City, IA 52242, USA. E-mail: [email protected]

Abbreviations: ACC, American College of Cardiology; AHA, American Heart Association; BP, blood pressure; CKD, chronic kidney disease; CVD, cardiovascular disease; DoD, Department of Defense; HTN CPG, Hypertension Clinical Practice Guideline; SPRINT, Systolic Blood PRessure INtervention Trial; VHA, Veterans Health Administration

Received 15 April, 2022

Revised 27 January, 2023

Accepted 20 February, 2023

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Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.

Journal of Hypertension 41(6):p 995-1002, June 2023. | DOI: 10.1097/HJH.0000000000003424

Abstract

INTRODUCTION

Hypertension (HTN) is the leading risk factor for cardiovascular disease (CVD) worldwide [1]. The landmark study, Systolic Blood PRessure INtervention Trial (SPRINT), demonstrated a compelling reduction in the risk of death and cardiovascular events with the targeting of lower blood pressure (BP) goals (SBP <120 mmHg) than previously recommended in individuals at high risk of CVD with SBP at least 130 mmHg [2]. Over the last few years, there has been a move to redefine lower BP cutoffs for the diagnosis of hypertension and to recommend targeting lower BP goals in patients with a diagnosis of hypertension. For example, the American College of Cardiology (ACC)/American Heart Association (AHA) undertook a systematic review [3] leading to the redefinition of hypertension as a BP at least 130/80 mmHg and the recommendation to lower BP goals to less than 130/80 mmHg for individuals at increased cardiovascular risk [4].

Several studies have shown that redefining hypertension increases the burden of hypertension significantly in several populations [5–11]. However, no study to date, has evaluated the impact of redefining hypertension among Veterans, a patient population with markedly increased risk of CVD and an already high prevalence of hypertension [12]. In March 2020, Veterans Health Administration (VHA), which represents one of the largest healthcare systems in the US, embraced a more stringent definition of hypertension for the SBP cutoff. Specifically, VHA and the Department of Defense (DoD) in conjunction with the Hypertension Clinical Practice Guideline (HTN CPG) working group have supported defining hypertension as SBP at least 130 mmHg and/or DBP at least 90 mmHg [13]. In addition, the working group recommended lowering the SBP goal to less than 130 mmHg for all patients with hypertension including those with diabetes. The potential implications of the more stringent guidelines on the prevalence and management of hypertension among Veterans are unknown. Here, we sought to evaluate the impact of the VHA/DoD and the ACC/AHA guidelines on the prevalence of hypertension in VHA and, among Veterans with known hypertension, we evaluated the implications of lowering the SBP treatment goal. In addition, we evaluated whether BP control improved over time.

METHODS

Data source and study population

The data source for this study was the US Veterans Health Administration (VHA) database, which houses inpatient and outpatient medical records for all healthcare encounters within VHA. We performed a retrospective cohort study of Veterans who received care at the VA between 1 January 2016 and 31 December 2017. To be included in the analysis, Veterans were required to have had at least two outpatient measurements of BP during the period 1 January 2016 and 31 December 2017. This time-period was selected considering the ACC/AHA guideline was released in 2017. Patients were excluded if they had a history of dementia, metastatic cancer, severe liver disease, end-stage kidney disease, or were on palliative status or receiving midodrine. The ICD-10-CM diagnostic codes for the exclusion criteria are shown in Supplemental Table 1, https://links.lww.com/HJH/C167. To evaluate BP control over time, for each patient, a baseline period for assessing mean BP and hypertension was defined as the 12 months following the first BP measurement after 1 January 2016. Patients were followed up to 31 December 2021.

Blood pressure measurements

We included BP values during the baseline period if they were recorded during outpatient visits. These office BP values were obtained conventionally. We excluded nonphysiologic values as well as erroneous entries (i.e. SBP less than 40 mmHg or greater than 300 mmHg; DBP less than 10; and SBP less than DBP) [14,15]. If multiple readings were recorded for a single date, then we used the lowest systolic and lowest DBP [14,16]. To evaluate BP control over time (after the baseline period), we required at least one BP reading per year for the years of follow-up. For this portion of this analysis, in addition to the aforementioned exclusion criteria, we excluded Veterans who died prior to the follow-up period or those with SBP less than 100 mmHg at baseline (n = 62 052, 1.3%). If more than one BP reading was available per year, then average BP was utilized.

Definition of prevalent hypertension

Prevalent hypertension was evaluated to include known (diagnosed) hypertension and unknown (newly identified hypertension). Diagnosed hypertension was defined as either two or more separate outpatient visits with an ICD-10 CM diagnostic code related to hypertension during the study baseline period (Supplemental Table 2, https://links.lww.com/HJH/C167) [17], or receipt of any first-line therapy for hypertension management based on the VHA and ACC/AHA guidelines [4,13]. A detailed list of the included medications is shown in Supplemental Table 3, https://links.lww.com/HJH/C167. Newly identified hypertension was defined as at least two or more occurrences of elevated outpatient BP measurements (in accordance with the different guidelines) during the baseline period, with no ICD-10-CM Code for hypertension and no receipt of oral antihypertensive medications during the cohort period. Newly identified hypertension was evaluated based on the 2020 VHA/DoD HTN CPG defined as SBP at least 130 mmHg and/or DBP at least 90 mmHg, based on the 2017 ACC/AHA criteria defined as SBP at least 130 mmHg and/or DBP at least 80 mmHg [4], or based on the less stringent criteria of the Joint National Committee (JNC) 7 [18] and the European Society of Hypertension (ESH) 2021 [19] as SBP at least 140 mmHg and/or DBP at least 90 mmHg.

Definition of controlled versus uncontrolled hypertension

Among Veterans with known (diagnosed) hypertension, we evaluated the following categories: Uncontrolled per the VHA/DoD HTN CPG guideline defined as SBP at least 130 mmHg and/or DBP at least 90 mmHg, additionally uncontrolled based on the ACC/AHA criteria including those with DBP 80–89 mmHg, and controlled hypertension based on the ACC/AHA criteria defined as SBP less than 130 mmHg and DBP less than 80 mmHg [4].

Covariates

The baseline data included for the covariates were obtained at the time of first BP measurements. The following baseline variables were included in the analysis: age (years), sex (male, female), race (white, black, other), BMI that was calculated by height and weight measurements (kg/m2), and baseline comorbidity defined by the Agency for Healthcare Research and Quality Elixhauser comorbidity index [20].

Statistical analysis

First, we calculated the overall prevalence of hypertension including both diagnosed and newly identified hypertension and assessed the difference in the hypertension prevalence using the VHA/DoD criteria, the ACC/AHA criteria, and the JNC 7 and ESH criteria. We evaluated the demographics and clinical characteristics of the Veterans with newly identified hypertension according to three categories: SBP at least 140 or DBP at least 90 mmHg (JNC 7 and ESH), SBP at least 130 mmHg or DBP at least 90 mmHg (VHA/DoD), and DBP at least 80 mmHg (isolated diastolic hypertension according to the ACC/AHA criteria). We also examined the differences in individual components of hypertension diagnosis (ICD-10 CM, oral antihypertensive drugs, and actual BP values) according to the different cutoffs. Second, in those with known hypertension, we compared the baseline demographics and clinical characteristics for Veterans categorized as: controlled hypertension per the ACC/AHA guideline (SBP <130 mmHg and DBP <80 mmHg), uncontrolled hypertension per the VHA/DoD guideline (SBP ≥130 mmHg or DBP ≥90 mmHg), and those who are additional uncontrolled based on the ACC/AHA (DBP 80–89 mmHg).

Lastly, to better understand how the more stringent guidelines have impacted BP control over time, we evaluated BP over 5 years of follow-up among the Veterans with newly identified hypertension or known hypertension who are designated uncontrolled per the updated VHA/DoD or the ACC/AHA guidelines and who have at least one risk factor for CVD [2]. Only Veterans with complete BP data over the 5-year follow-up period were included. We report the mean (SD) of BP and the n (%) of Veterans with controlled BP over 5 years after the baseline period. Then we describe the n (%) with SBP in the following categories less than 130, 130–139, and at least 140 mmHg and DBP categories less than 80, 80–89, and at least 90 mmHg for years 1 through 5. A two-sided P value of 0.05 was considered to be statistically significant, and 95% CIs were presented for all relative risks. Analyses were conducted with SAS software version 9.4 (SAS Institute, Cary, North Carolina, USA).

RESULTS

Overall prevalence of hypertension among veterans

We identified 5 224 462 patients with two or more valid BP measurements during 2016–2017, of which 385 911 were removed because of the presence of exclusion criteria. Of the 4 838 551 Veterans remaining for analysis, 3 438 363 (71%) Veterans were found to have prevalent hypertension based on ICD-10-CM codes, oral antihypertensive drug prescription, SBP at least 140, or DBP at least 90 mmHg (JNC 7 and ESH 2021) (Fig. 1). Of these hypertensive Veterans, 88% (n = 3 027 300) were captured either by ICD-10-CM codes or drug prescription (i.e. known/diagnosed hypertension) while the remaining 12% (n = 411 063) were identified based on their outpatient BP readings (SBP ≥140 or DBP ≥90 mmHg). When the VHA/DoD criteria were applied (SBP ≥130 mmHg or DBP ≥90 mmHg), an additional 492 106 Veterans were found to have hypertension and the prevalence of hypertension increased to 3 930 469 (81%). When applying the ACC/AHA diastolic cutoff (DBP ≥80 mmHg), another additional 268 732 Veterans were found to have hypertension with an overall prevalence of 87% (n = 4 199 201). These data are shown in Fig. 1.

F1
FIGURE 1:
The change in the prevalence of hypertension based on each blood pressure cutoff. This depicts the change in the overall prevalence of hypertension based on the blood pressure (BP) cutoffs. The prevalence of hypertension was noted to increase from 71% with a definition of at least 140/90 mmHg (JNC 7 and ESC/ESH 2021 guidelines) to 81% with a definition of ≥at least 130/90 mmHg per the updated VHA/DoD guideline. Of note, applying the ACC/AHA definition of ≥130/80 mmHg increased the prevalence of hypertension to 87%. ACC/AHA, American College of Cardiology/American Heart Association; DoD, Department of Defense.

Next, we evaluated the patient factors of the 492 106 and the 268 732 Veterans with newly identified hypertension based on the VHA/DoD and ACC/AHA. These are shown in Table 1 in contrast to the 3 438 363 Veterans who were found to have prevalent hypertension based on ICD-10-CM codes, oral antihypertensive drug prescription, or BP cutoff based on the JNC 7/ESH criteria. The Veterans with newly identified hypertension based on the VHA/DoD and ACC/AHA criteria were younger and had a significantly lower burden of comorbid conditions than the Veterans diagnosed per the JNC 7/ESH 2021 criteria. Of the 492 106 Veterans with newly identified hypertension based on the VHA/DoD guideline, 186 577 (38%) were found to have at least one of the following CVD risk factors: age at least 65 years, history of diabetes, coronary artery disease, ischemic stroke, or advanced chronic kidney disease [4]. Among the additional 268 732 Veterans with newly identified isolated diastolic hypertension based on the ACC/AHA guidelines, 49 038 Veterans (18%) had at least one of the aforementioned CVD risk factors.

TABLE 1 - Clinical characteristics of Veterans with hypertension based on the more stringent criteria
Characteristic Per JNC/ESH criteriaa (n = 3 438 363) Newly identified per VHA/DoD criteria (n = 492 106) Newly identified IDH per ACC/AHA criteriab (n = 268 732) P value
Age (mean ± SD) 64.6 ± 13.7 54.5 ± 17.1 46.9 ± 14.4 <0.0001
Male gender [n (%)] 3 231 709 (94) 439 553 (89) 220 857 (82) <0.0001
Race [n (%)]
 White 2 363 299 (69) 336 827 (68) 174 469 (65) <0.0001
 Black 623 924 (18) 76 972 (16) 47 182 (18) <0.0001
 Other 278 831 (8) 52 535 (11) 33 779 (13) <0.0001
Mean BMI (kg/m2) ± SD 30.7 ± 6.1 29.4 ± 5.5 29.2 ± 5.3 <0.0001
Comorbidities [n (%)]
 Smoking history 442 070 (13) 56 604 (12) 29 938 (11) <0.0001
 Diabetes mellitus 1 093 956 (32) 45 565 (9) 13 838 (5) <0.0001
 Advanced CKDc 212 700 (6) 6211 (1) 1729 (0.6) <0.0001
 Congestive heart failure 143 355 (4) 1993 (0.4) 526 (0.2) <0.0001
 Cardiomyopathy 54 297 (2) 776 (0.2) 348 (0.1) <0.0001
 Coronary artery disease 610 898 (18) 19 872 (4) 4447 (2) <0.0001
 Atrial fibrillation 235 879 (7) 8388 (2) 2711 (1) <0.0001
 Cardiac device use 70 709 (2) 2078 (0.4) 601 (0.2) <0.0001
 Peripheral artery disease 207 778 (6) 8601 (2) 2189 (0.8) <0.0001
 Ischemic stroke 144 680 (4) 5588 (1) 1590 (0.6) <0.0001
 Chronic lung disease 519 836 (15) 49 191 (10) 21 392 (8) <0.0001
 Pulmonary arterial hypertension 32 392 (0.9) 1868 (0.4) 753 (0.3) <0.0001
 Sleep apnea 493 048 (14) 47 738 (10) 24 730 (9) <0.0001
CKD, chronic kidney disease; IDH, isolated diastolic hypertension; JNH, Joint National Committee; DoD, Department of Defense; VHA, Veterans Health Administration.
aPrevalent hypertension based on the previous definition including ICD-10-CM codes, oral antihypertensive drug prescription, or BP cutoff at least 140/90 mmHg in accordance with JNC 7 and ESC/ESH guidelines.
bVeterans with isolated diastolic hypertension in accordance with the ACC/AHA guidelines.
cAdvanced CKD without dialysis.

Prevalence of uncontrolled hypertension among veterans with known hypertension

Next, we evaluated BP control among Veterans with known hypertension by using mean SBP during the baseline period. Of the 2 768 826 Veterans with known hypertension, 949 875 (34%) were found to have controlled hypertension defined per the VHA/DoD guideline as mean SBP less than 130 mmHg and DBP less than 90 mmHg and 1 818 951 (66%) were found to have uncontrolled hypertension defined as mean SBP at least 130 mmHg or DBP at least 90 mmHg. When applying the ACC/AHA 2017 guideline, an additional 166 995 (6%) were found to have uncontrolled BP based on DBP at least 80 mmHg. Patient characteristics are shown in Table 2 for the following categories: controlled hypertension per the ACC/AHA guideline (SBP <130 mmHg and DBP <80 mmHg), uncontrolled hypertension per the VHA/DoD guideline (SBP ≥130 mmHg or DBP ≥90 mmHg), those who are additional uncontrolled based on the ACC/AHA (DBP 80–89 mmHg). Those with uncontrolled hypertension defined per the VHA/DoD guidelines were older, more likely to be of black race, and had higher BMI. In addition, they had higher rates of diabetes, congestive heart failure, coronary artery disease, chronic obstructive lung disease, and sleep apnea. Of note, the additional Veterans identified to have uncontrolled DBP based on the ACC/AHA guideline (n = 166 995) were generally younger and had lower rates of comorbidities including diabetes mellitus coronary artery disease, and congestive heart failure. Among the 1 818 951 with uncontrolled hypertension based on the VHA/DoD guideline, we identified n = 1 370 545 (75%) Veterans who had at least one risk factor for CVD. Among the additional 166 995 Veterans with uncontrolled DBP based on the ACC/AHA guideline, approximately 82 770 (50%) had at least one risk factor for CVD.

TABLE 2 - Characteristics of Veterans with known hypertension
Baseline characteristics Class Overall (n = 2 768 826) Controlleda (ACC/AHA) (n = 782 880) Uncontrolled (VHA/DoD) (n = 1 818 951) Additional uncontrolled (ACC/AHA) (n = 166 995) P value
Age category (years) [n (%)] <40 124 689 (5) 40 100 (5) 65 512 (4) 19 077 (11) <0.001
40–49 198 504 (7) 45 030 (6) 122 440 (7) 31 034 (19)
50–59 435 289 (16) 104 775 (13) 284 179 (16) 46 335 (28)
60–69 1 053 092 (38) 292 441 (37) 708 841 (30) 51 810 (3)
70–79 603 108 (22) 184 413 (24) 404 053 (22) 14 642 (9)
≥80 354 144 (13) 116 121 (15) 233 926 (13) 4097 (3)
Male gender [n (%)] 2 615 045 (94) 733 619 (94) 1 730 309 (95) 151 117 (91) <0.001
Race category [n (%)] White 1 900 919 (69) 568 311 (73) 1 229 177 (68) 103 431 (62) <0.001
Black 507 309 (18) 110 634 (14) 356 855 (20) 39 820 (24)
Other 222 398 (8) 62 899 (8) 143 176 (8) 16 323 (10)
Mean BMI (kg/m2), SD 30.8 ± 6.1 30.3 ± 6.1 31.0 ± 6.1 31.0 ± 5.6 <0.001
Comorbidity [n (%)]
 Smoking history 363 176 (13) 107 164 (14) 230 088 (13) 25 924 (16) <0.0001
 Diabetes mellitus 982 565 (36) 292 007 (37) 651 804 (36) 38 754 (23) <0.0001
 Advanced CKDb 193 449 (7) 58 235 (7) 129 383 (7) 5831 (4) <0.0001
 Congestive heart failure 132 804 (5) 61 236 (8) 66 872 (4) 4696 (3) <0.0001
 Cardiomyopathy 51 261 (2) 26 186 (3) 22 272 (1) 2803 (2) <0.0001
 Coronary artery disease 554 291 (20) 207 714 (27) 328 892 (18) 17 685 (11) <0.0001
 Atrial fibrillation 212 921 (8) 87 210 (11) 115 706 (6) 10 005 (6) <0.0001
 Cardiac device use 64 801 (2) 31 488 (4) 30 798 (2) 2515 (2) <0.0001
 Peripheral artery disease 186 465 (7) 61 202 (8) 119 869 (7) 5394 (3) <0.0001
 Ischemic stroke 129 186 (5) 40 101 (5) 84 857 (5) 4228 (3) 0.59
 Chronic lung disease 441 675 (16) 147 048 (19) 272 744 (15) 21 883 (13) <0.0001
 Pulmonary arterial hypertension 28 839 (1) 11 322 (1) 16 026 (1) 1491 (1) <0.0001
 Sleep apnea 429 284 (16) 126 670 (16) 273 185 (15) 29 429 (18) <0.0001
aControlled hypertension is defined as SBP less than 130 and DBP less than 90 mmHg per the VHA/DoD guideline.
bAdvanced CKD without dialysis.

Blood pressure control among veterans with newly identified hypertension who have at least one risk factor for cardiovascular disease

Among those Veterans at high risk of CVD, we found that neither mean SBP nor DBP improved over a 5-year follow-up period after baseline (Table 3). When we defined controlled hypertension as SBP less than 130 mmHg and DBP less than 90 mmHg, we observed a decline in the overall n (%) of Veterans with controlled hypertension from 16 513 (51%) in year 1 to 15 952 (50%), 15 669 (49%), 13 350 (41%), and 14 343 (45%) in years 2, 3, 4, and 5, respectively (P value for trend <0.0001). Additionally, the percent of Veterans with SBP in each of the following categories was evaluated over time: less than 130, 130–139 mmHg, and at least 140 mmHg. The number (%) of Veterans with SBP less than 130 mmHg decreased significantly and the number (%) of Veterans with SBP at least 140 mmHg increased significantly over time (Table 4). A similar trend was observed for the DBP categories less than 80, 80–89 mmHg, and at least 90 mmHg in this group and among the Veterans with newly identified hypertension based on the ACC/AHA criteria for DBP who had at least one CVD risk factor (Table 5).

TABLE 3 - Blood pressure valuesa over time for the Veterans with hypertension and at least one additional cardiovascular disease risk factor who have newly identified hypertension or known hypertension who are now uncontrolled based on the Veterans Health Administration/Department of Defense guideline
Year 1 Year 2 Year 3 Year 4 Year 5 P value for trend
Veterans with newly identified hypertension and ≥1 CVD risk factor SBP 130.1 (10.2) 130.9 (11.7) 131.2 (12.1) 133.5 (14.2) 132.5 (15.4) <0.0001
DBP 75.5 (7.1) 75.5 (7.3) 75.3 (7.2) 76.0 (8.0) 75.3 (8.5) <0.0001
Veterans with known hypertension, newly uncontrolled and ≥1 CVD risk factor SBP 141.9 (13.1) 141.3 (13.5) 140.8 (13.9) 142.5 (16.3) 141.4 (17.9) <0.0001
DBP 77.7 (8.4) 77.0 (8.2) 76.5 (8.1) 76.9 (8.9) 76.2 (9.5) <0.0001
aBP shown as mean (SD) for each year.

TABLE 4 - Blood pressure control among Veterans with newly identified hypertension based on the Veterans Health Administration/Department of Defense guideline
SBP categories (mmHg) DBP categories (mmHg)
Year <130 130–139 ≥140 <80 80–89 ≥90
Year 1 16 530 (51) 11 309 (35) 4382 (14) 23 504 (75) 8045 (24) 672 (2)
Year 2 15 963 (49) 9968 (31) 6290 (20) 23 615 (75) 7821 (23) 785 (2)
Year 3 15 679 (49) 9741 (30) 6801 (21) 23 955 (76) 7487 (22) 779 (2)
Year 4 13 380 (41) 9506 (30) 9335 (29) 22 106 (71) 8825 (26) 1290 (3)
Year 5 14 376 (45) 8890 (28) 8955 (28) 22 582 (72) 8244 (24) 1395 (4)
Overall P value <0.0001 <0.0001

TABLE 5 - Blood pressure control among Veterans with newly identified isolated diastolic hypertension based on the ACC/AHA guideline
DBP categories (mmHg)
Year <80 80–89 ≥90
Year 1 5101 (67) 2375 (30) 181 (2)
Year 2 5205 (69) 2226 (29) 226 (3)
Year 3 5357 (71) 2069 (26) 231 (3)
Year 4 4772 (63) 2508 (32) 377 (4)
Year 5 4776 (63) 2451 (32) 430 (5)
Overall P value <0.0001

Blood pressure control among veterans with known hypertension, who are uncontrolled with at least one risk factor for cardiovascular disease

As shown in Table 3, mean BP decreased significantly over time (P value for trend analysis, <0.0001) although the change in BP values was not clinically significant (less than 1 mmHg). Among the Veterans with uncontrolled hypertension defined as SBP at least 130 mmHg or DBP at least 90 mmHg and at least one CVD risk factor, we observed an increase in the overall n (%) of Veterans with controlled hypertension (defined as <130/90 mmHg) from 65 645 (16.4%) in year 1 to 75 953 (19%), 83 499 (21%), 84 022 (21%), and 102 455 (26%) in years 2–5, respectively (P value <0.0001). When we evaluated the n (%) of Veterans with SBP in each of the following categories: <130, 130–139 mmHg, and at least 130 mmHg, SBP control improved over time although the n (%) of Veterans with uncontrolled SBP remained large. The number of Veterans with SBP less than 130 mmHg increased significantly to 102 743 (25%) in year 5 from 65 806 (16%) in year 1. The number of Veterans with SBP 130–139 mmHg and at least 140 mmHg decreased from n = 122 884 (30%) in year 1 to n = 97 992 (24%) in year 5 and from n = 212 040 (54%) in year 1 to n = 199 995 (51%) in year 5, respectively. Similarly, the n (%) of Veterans with DBP less than 80 mmHg increased significantly whereas the n (%) of Veterans with DBP 80–89 and at least 90 mmHg declined over time. These findings are detailed in Table 6. It is noted that among the Veterans with uncontrolled hypertension defined as DBP at least 80 mmHg per the ACC/AHA guideline, the n (%) of Veterans with DBP less than 80 mmHg increased to 11 096 (46%) in year 5 from 9128 (38%) in year 1. Although the n (%) of Veterans with DBP 80–89 mmHg decreased significantly, the n (%) of Veterans with DBP at least 90 mmHg increased to 3110 (12%) in year 5 from 1964 (8%) in year 1 (Table 7).

TABLE 6 - Blood pressure control among Veterans with uncontrolled blood pressure based on the Veterans Health Administration/Department of Defense guideline
Systolic BP categories (mmHg) Diastolic BP categories (mmHg)
Year <130 130–139 ≥140 <80 80–89 90
Year 1 65 806 (16) 122 884 (30) 212 040 (54) 245 302 (63) 126 789 (30) 28 639 (6)
Year 2 76 043 (19) 119 788 (30) 204 899 (52) 259 932 (67) 117 195 (28) 23 603 (5)
Year 3 83 571 (21) 117 088 (29) 200 071 (51) 272 105 (70) 108 767 (26) 19 858 (4)
Year 4 84 242 (21) 100 285 (25) 216 203 (55) 259 075 (67) 112 633 (27) 29 022 (6)
Year 5 102 743 (25) 97 992 (24) 199 995 (51) 265 582 (68) 105 311 (25) 29 837 (7)
Overall P value ∗ <0.0001 <0.0001

TABLE 7 - Blood pressure control among Veterans additionally uncontrolled based on the American College of Cardiology/American Heart Association criteria for DBP
DBP categories (mmHg)
Year <80 80–89 ≥90
Year 1 9128 (38) 13 605 (55) 1964 (8)
Year 2 10 142 (42) 12 564 (50) 1991 (8)
Year 3 10 859 (45) 11 952 (48) 1886 (7)
Year 4 10 046 (42) 11 655 (47) 2996 (11)
Year 5 4776 (63) 2451 (32) 3110 (12)
Overall P value <0.0001

DISCUSSION

Here, we report the impact of redefining hypertension diagnosis cutoffs and BP treatment goals in VHA, one of the largest integrated healthcare systems in the United States. These data are important considering that Veterans have high rates of hypertension prevalence and are at increased risk of CVD [12]. The overall prevalence of hypertension increased by 14% when we applied the BP cutoff less than 130/90 mmHg versus less than 140/90 mmHg. This is just shy of half million additional veterans being labeled as hypertensive patients, many of whom (38%) would require active BP management including the initiation of pharmacotherapy. Among Veterans with a known diagnosis of hypertension, only 34% were found to have well controlled hypertension based on the recent VHA/DoD HTN CPG (i.e. mean SBP <130 mmHg and DBP <90 mmHg). Among those with uncontrolled hypertension based on the VHA/DoD guideline, a considerable number of Veterans [n = 1 370 545 (75%)] have at least one risk factor for CVD necessitating intensification of BP management. Among the Veterans with newly identified hypertension eligible for intensification of therapy BP control did not improve over 5 years of follow-up. Although the number of Veterans who achieved SBP and DBP goals improved among those with known/diagnosed and uncontrolled hypertension, the vast majorities of Veterans in this group remained uncontrolled over 5 years. Our data highlight the impact of BP redefinition on the prevalence and management of hypertension within VHA.

The optimal BP threshold for the diagnosis of hypertension and the goal BP in those with hypertension have been in constant flux in the last decade. The JNC 7 and the ESH 2021 guidelines had adopted 140/90 mmHg as a cutoff for the diagnosis of hypertension and as a general treatment target [18,19]. In 2017, the ACC/AHA guideline updated the recommended cutoff for the diagnosis of hypertension to less than 130/80 mmHg and set the therapy target as the same [4]. The most recent CPG by the VHA/DoD group opted for a BP cutoff of 130/90 mmHg to define and treat hypertension. Of note, while VHA/DoD and the ACC/AHA guidelines have set lower BP goals generally, it is acknowledged that the individuals at increased risk of CVD are the most likely to benefit.

Several studies have evaluated the potential impact of redefining the BP diagnosis threshold on the prevalence of hypertension in various populations [5–11]. Even prior to applying the lower BP cutoffs, we observed a higher prevalence of hypertension among Veterans relative to the reports in other populations, including the general United States population. Additionally, we note that reducing BP cutoffs in these other populations led to a larger magnitude of increase in the prevalence of hypertension than that observed within VHA. For example, among adults aged 30–74 years in Korea, the prevalence rates of hypertension were 9.6–18.4% utilizing BP cutoff at least 140/90 mmHg. These more than doubled based on the 2017 ACC/AHA guideline (40.6–44.8%) [9]. A similar trend was observed in Saudi Arabia [6], India [5], China, [11] Spain [7], Canada [8], and in the general United States population [10,11].

The significant increase in the prevalence of hypertension in other populations is only partially related to the application of the stricter DBP cutoff of less than 80 mmHg based on the 2017 ACC/AHA guideline as opposed to less than 90 mmHg in the latest VHA/DoD CPG (Fig. 1). It is likely that characteristics of the Veteran cohort may explain these findings, most importantly the older age. While the average age reported in the other cohorts ranged from 30 to 60 years, the mean (SD) age of our cohort was 66 (13) years. This interpretation is in agreement with findings from the National Health and Nutrition Examination Survey (NHANES) where a significantly higher prevalence rate of hypertension was reported in older adults (>63% in individuals older than 65 years were noted to have hypertension defined as ≥140/90 mmHg) [10]. Here, similar to our data, the impact of the latest ACC/AHA 2017 guideline was less prominent in the elderly (defining hypertension as ≥130/80 mmHg increased the prevalence of hypertension by less than 3% in those aged ≥65 years versus 14% in those <45 years). Collectively, these data indicate that the impact of redefining the hypertension diagnostic cutoffs on the prevalence of hypertension is less pronounced in older adults where a significantly higher prevalence of hypertension existed with the more lenient diagnostic cutoffs. This is supported by our finding that the Veterans with newly identified hypertension based on BP at least 130/90 mmHg were significantly younger than those diagnosed based on the previous criteria.

Veterans with newly identified hypertension, in addition to being younger, had lower BMI, and presented a significantly lower burden of comorbid conditions such as diabetes, coronary artery disease, and peripheral vascular disease. Thirty-eight percent of those with newly identified hypertension defined as at least 130/90 mmHg per the VHA/DoD guideline (n = 186 577) and 18% of those with newly identified isolated diastolic hypertension defined as DBP at least 80 mmHg per the ACC/AHA guideline (n = 49 038) were found to have at least one risk factor for CVD and would require active BP management, including the initiation of pharmacologic therapy. As such, while many of the Veterans with newly identified hypertension would be candidates for pharmacological therapy in accordance with the ACC/AHA and VHA/DoD CPG guidelines [4,13], the majority of these Veterans that are not likely to benefit from active BP management. The implications of labeling such individuals as hypertensive patients are unknown.

Another important finding of this analysis is the low number of Veterans with one cardiovascular risk factor who achieved the target SBP of less than 130 mmHg over time. This proportion of controlled hypertension is significantly lower than previously reported in VHA utilizing the JNC 7/ESH recommended BP goal where 77% of Veterans with hypertension were found to have achieved their BP targets in 2010 [14]. It is interesting that DBP control was generally better than SBP control, especially considering that the lower ACC/AHA DBP goal of less than 80 mmHg has not been consistently associated with improved outcomes [21]. The lower DBP values are likely a reflection of widening pulse pressure and increased vascular stiffness in this aging population [22]. The small percent of Veterans with SBP less than 130 mmHg in year 1 after the index date is not unexpected considering the findings of SPRINT were published just prior to the designated cohort follow-up period. Barriers to targeting lower BP goals surely exist. Such barriers may include skepticism towards the recommended lower target fueled by the controversial views and recommendations expressed by other medical societies and working groups [23–25]. In addition, it is possible that providers maintain concerns about the potential adverse events of more aggressive BP lowering, including hypotension and acute kidney injury [23–25]. Identifying strategies for providers and healthcare systems to meet these new guidelines is necessary.

Our study has several limitations. First, this is retrospective analysis. Second, our cohort is composed predominantly of older men. As such, our findings may not be generalizable to other populations. Third, we utilized BP measurements that are available within the healthcare system and were obtained during outpatient visits. These represent conventional office BP measurements, the assessment of which may vary across different facilities. Fourth, the follow-up period included the COVID-19 pandemic, and it is possible that this has impacted the management of hypertension. Lastly, our analysis of BP over time excluded patients without complete data, and thus may be biased to the extent that missing BP is associated with hypertension control. Notwithstanding these limitations, our analysis has several strengths. First, we offer an understanding of the impact of redefining hypertension diagnostic and management criteria in VHA, one of the largest healthcare systems in the United States. Second, we evaluated a number of BP values over a year rather than one value in a cross-section of time, an approach that reduces misclassification bias. Lastly, our data indicate a lag in the implementation of the societal guidelines to target lower office BP goals. Further studies are needed to understand the barriers to implementing such guidelines in healthcare systems.

In conclusion, redefining the diagnostic criteria for hypertension as SBP at least 130 mmHg or DBP at least 90 mmHg increases the prevalence of hypertension in VHA. Similarly, lowering the goal for individuals with a diagnosis of hypertension significantly increases the number of Veterans with uncontrolled hypertension who require intensification of therapy. Updated societal guidelines, while critical, are not sufficient to change practice patterns, especially in the absence of consensus between the various societies. Healthcare delivery interventions are additionally needed to optimize BP management across healthcare systems.

ACKNOWLEDGEMENTS

Sources of funding: the work was conducted with funding from the Center for Access & Delivery Research and Evaluation at the Iowa City VA Healthcare System, via the Small Award Initiative for Impact (D.J.) with additional support from the NIH funded grant R01HL134738 (D.J.).

Conflicts of interest

There are no conflicts of interest.

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Keywords:

blood pressure goal; hypertension; prevalence

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