Hypertension Awareness, Treatment, and Control in US Adults

Trends in the Hypertension Control Cascade by Population Subgroup (National Health and Nutrition Examination Survey, 1999-2016)

Kathryn Foti; Dan Wang; Lawrence J. Appel; Elizabeth Selvin


Am J Epidemiol. 2019;188(12):2165-2174. 

In This Article

Abstract and Introduction


Examination of changes in hypertension awareness, treatment, and control (i.e., the hypertension control cascade) by population subgroup can inform targeted efforts to improve hypertension control and reduce disparities. We analyzed 1999–2016 data from the National Health and Nutrition Examination Survey and examined trends across 6-year periods in hypertension awareness, treatment, and control by age, sex, and race/ethnicity. We included 39,589 participants (16,141 with hypertension). Hypertension awareness, treatment, and control increased from 1999 to 2016 among all age groups. However, there were few changes after 2010. Across all time periods, awareness, treatment, and control were higher among younger women (ages 25–44 years) than among younger men, while control was higher among older men (ages ≥65 years) than among older women. Hypertension control was persistently lower for blacks than for whites of all ages, and awareness, treatment, and control were lower among younger Hispanics. There have been few changes in hypertension awareness, treatment, and control since 2010. Disparities in hypertension control by sex highlight the need for effective interventions among younger men and older women. Concerted efforts are also needed to reduce persistent racial/ethnic disparities, particularly to improve treatment control among blacks and to further address gaps at all stages among younger Hispanics.


Hypertension (blood pressure ≥140/90 mm Hg) is a leading modifiable risk factor for cardiovascular disease, the number 1 cause of death in the United States and globally.[1] Further, there are long-standing racial/ethnic disparities in cardiovascular risk factors, particularly hypertension.[2]

The hypertension control cascade, which includes hypertension awareness, treatment, and control, has been proposed as a framework for improving blood pressure control in the population.[3] The proportion of adults with hypertension who have their blood pressure controlled (<140/90 mm Hg) increased from the late 1990s through 2010 due to increases in both awareness of hypertension and control among those treated.[4,5]

However, national data show that there has been no change since, and currently, less than half of all US adults with hypertension have their blood pressure controlled.[6] This plateau has occurred despite increased knowledge of effective strategies at the organizational, provider, and patient levels to improve control of hypertension.[7] Communities[5] and health-care systems[8] around the country have demonstrated that it is possible to achieve much higher rates of blood pressure control, and with concerted efforts, it should be possible to reach 70% hypertension control in the population.[9]

It is unclear whether the recent lack of progress in hypertension control is attributable to a lack of progress at a particular stage in the cascade and whether patterns are uniform across major demographic groups. Previous research has shown that barriers to hypertension control differ by age, sex, and race/ethnicity.[3,10] Additionally, there are a number of contextual changes which may have influenced approaches to hypertension management for different patient subgroups in recent years. Such changes include increases in the prevalence of obesity and diabetes, expanded insurance coverage, and the publication of multiple clinical practice guidelines for hypertension.[11–14]

Understanding changes over time in hypertension awareness, treatment, and control overall and among different subpopulations can inform targeted efforts to improve hypertension management and reduce disparities. We conducted serial cross-sectional analyses of the most recent national data available from the National Health and Nutrition Examination Survey (NHANES) to better understand changes in the hypertension control cascade over time, overall and by subgroup.