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Too high: Despite drugs, blood pressure rates continue to soar in the United States

In this initial post in a series on high blood pressure, Randall Stafford, MD, PhD, outlines the scope of the problem and introduces Margaret, a patient.

Opioid pain relievers have captured the nation’s attention because so many people have overdosed, which is exceptionally tragic. But I’m most familiar with another tragedy: the burden of preventable heart attacks, strokes, and kidney disease caused by high blood pressure. Hypertension kills 359,000 people each year in the U.S., six times the number due to opioids.

It’s not that we don’t try to address hypertension. Each year, Americans spend almost $10 billion on high blood pressure medications, according to QuintilesIMS. What goes wrong? The problem can be traced, in part, to missteps by both doctors and patients. Consider the interactions between Margaret (details altered for confidentiality) and her doctor:

Margaret is a married, 53-year-old Latina who works as a department store clerk. Margaret had few health problems until age 31 when she developed pregnancy-related diabetes and hypertension; these went away after she gave birth. Over the next 15 years, her blood pressure readings inched up as she gained weight. When her blood pressure reached 146/90, she was started on medications.

While she’s moved toward a healthier diet, over the last seven years she’s continued to gain weight. Margaret now takes two drugs for hypertension, but doesn’t like them. She experiences several side effects, and occasionally forgets to take them. She sees her primary care doctor regularly and tries to follow her advice, but often feels that her doctor doesn’t understand how hard it is to change her diet and exercise more.

At today’s visit, Margaret weighs 215 pounds, which defines her as obese given her 5-feet, 4-inch height. Her blood pressure is high at 142/86. Her doctor has trouble convincing Margaret anything’s wrong. When the doctor suggests adding yet another medication, Margaret isn't pleased, citing the inconvenience and side effects of the medications she’s already taking. She is especially bothered by the ankle swelling that makes it harder for her to walk around her neighborhood with her husband in the evenings. Her doctor relents by saying “we’ll see next month.” In the meantime, she asks Margaret to get more exercise. The doctor politely notes that she’s running behind and needs to see the next patient.

Like Margaret, many others in the U.S. have high blood pressure. It’s the biggest reason for doctors’ office visits, 95 million visits in 2016, a tenth of all visits. Medications to treat hypertension are also the most frequently prescribed class of drugs at 721 million prescriptions in 2016, or 16 percent of all prescriptions.

Yet despite all of these visits and prescriptions, high blood pressure is poorly treated. More than 15 percent of people with hypertension don’t know they have it, according the federal National Health and Nutrition Examination Survey.

Even when it is detected, blood pressure is often inadequately treated, especially for minorities and low-income patients. The interaction between Margaret and her doctor illustrates a few of the common problems, including the disconnect between Margaret and her doctor on the goals of controlling blood pressure and side effects. Both patients and doctors are often hesitant to add more drugs. Non-drug approaches, such as focused help with lifestyle changes, are also frequently neglected.

The result is that many Americans have blood pressures much higher than is healthy. In 2016, 42 percent of patients with drug-treated hypertension had systolic blood pressures (the top number) greater than 140, a commonly accepted standard. An incredible 1 in 7 had systolic pressures greater than 160.

High blood pressure leads to heart attacks, strokes, and kidney failure. But we have the tools to control blood pressure and therefore to prevent many of these serious outcomes. The first step is simple: Get screened for high blood pressure and, if it is high, work with your doctor to treat it effectively.

This is the first piece in a five-part series, "Too High," on blood pressure, created for those with high blood pressure and their family and friends. Future articles will discuss the drugs used to treat hypertension, drug side effects, the power of lifestyle changes, and appropriate blood pressure targets. Some data in this series come from QuintilesIMS. For additional information, please contact rstaff@stanford.edu.

Randall Stafford, MD, PhD, a professor of medicine and director of the Program on Prevention Outcomes and Practices, practices primary care internal medicine at Stanford. He is developing practical strategies to improve how physicians and consumers approach chronic disease treatment and prevention.

Previously: Prescribing mHealth: One strategy proves helpful for blood pressure control and Investigating the role of inflammation in pulmonary hypertension: An update
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