Background Treatment of hypertension is one of the most commonclinical responsibilities of U.S. physicians, yet only one fourthof patients with hypertension have their blood pressure adequatelycontrolled.
Methods We analyzed data from the third National Health andNutrition Examination Survey to assess the role of access toand use of health care in the control of hypertension. Hypertensionwas defined as a blood pressure of at least 140/90 mm Hg orthe use of antihypertensive medication.
Results The study sample consisted of 16,095 adults who wereat least 25 years old and for whom blood-pressure values wereknown. We estimated that 27 percent of the population had hypertension,but only 23 percent of those with hypertension were taking medicationsthat controlled their condition. Among subjects with untreatedor uncontrolled hypertension, the pattern was an elevation inthe systolic blood pressure with a diastolic pressure of lessthan 90 mm Hg. The great majority had health insurance. Independentpredictors of a lack of awareness of hypertension were an ageof at least 65 years, male sex, non-Hispanic black race, andnot having visited a physician within the preceding 12 months.The same variables, except for non-Hispanic black race, wereindependently associated with poor control of hypertension amongthose who were aware of their condition. An age of at least65 years accounted for the greatest proportion of the attributablerisk of the lack of awareness of hypertension and the lack ofcontrol of hypertension among those who were aware of theircondition.
Conclusions Most cases of uncontrolled hypertension in the UnitedStates consist of isolated, mild systolic hypertension in olderadults, most of whom have access to health care and relativelyfrequent contact with physicians.
Hypertension is the leading reason for office visits to physiciansin the United States,1 and the widespread treatment of hypertensionis a major contributor to the decline in the incidence of strokeand heart disease over the past 30 years.2 However, the percentageof persons in whom hypertension is controlled (defined as asystolic blood pressure of less than 140 mm Hg and a diastolicblood pressure of less than 90 mm Hg) is widely viewed as unsatisfactoryand may in fact have decreased since 1990.3 Frequently citeddata from phase II (1992 to 1994) of the third National Healthand Nutrition Examination Survey (NHANES III) indicate that32 percent of all persons with hypertension are unaware of theircondition and are not receiving treatment, 15 percent are awareof it but are not receiving treatment, and 26 percent have treatedbut uncontrolled hypertension, leaving only 27 percent in whomhypertension is controlled.
Limitations in the extent of the control of hypertension inthe population are commonly attributed to lack of access tohealth care, noncompliance with treatment, and a disproportionateburden of hypertension among racial and ethnic minorities. However,there is growing evidence that uncontrolled hypertension alsooccurs in populations with good access to health care.4 Therole of physicians' patterns of practice is gaining attentionas a contributor to the poor control of hypertension. A nationalsurvey of primary care physicians suggests that approximatelyone third do not recommend treatment in patients whose diastolicblood pressure ranges from 90 to 100 mm Hg and that an evenhigher percentage would not treat or intensify treatment inpatients whose systolic blood pressure ranged from 140 to 160mm Hg.5 Studies that documented physicians' behavior confirmedthat physicians are unlikely to diagnose persistently elevatedsystolic pressure with a diastolic pressure of less than 90mm Hg as hypertension or to treat this condition aggressively.6,7
Because of the potential effects of more aggressive treatmentof hypertension on the costs of health care and on outcomesamong patients, efforts to improve the extent of the controlof hypertension in the population must be based on a thoroughunderstanding of the characteristics of patients and the healthcare system that contribute to poor control. Although the NHANESIII data have been analyzed from an epidemiologic perspective,8little attention has been given to the clinical implicationsof the blood-pressure levels observed in persons with poorlycontrolled hypertension or to the role of access to and useof health care services in efforts to control hypertension.Therefore, we analyzed NHANES III data to compare the actualblood-pressure levels in persons who were unaware that theyhad hypertension, those who were aware of their condition butwho were not being treated, those who had treated but uncontrolledhypertension, and those in whom hypertension was controlledby treatment. In addition, we assessed the effect of sociodemographiccharacteristics and variations in access to and the use of healthcare on the control of hypertension and determined the population-attributablerisk associated with the variables that were found to be independentlypredictive of an increased likelihood of uncontrolled hypertension.We hypothesized that most cases of uncontrolled hypertensionin the United States consist of mild elevations in systolicpressure in patients receiving regular medical care.
Methods
Details of the survey methods used in NHANES III, includingthe protocol for blood-pressure measurement, have been publishedby the National Center for Health Statistics.9 Written informedconsent was obtained from the subjects. Information on the variablesselected for the present analysis was collected during an extensiveinterview in the subject's home, and these variables have beenwidely studied by other investigators with respect to theirvalue as predictors of the outcomes of chronic disease.10,11They include sociodemographic factors (age, sex, race or ethnicbackground, and level of education), factors related to accessto health care (family income, the availability of health insurance,and the presence or absence of a usual source of care), andthe extent of the use of health care. The design of NHANES IIIincluded oversampling of persons over the age of 65 years, MexicanAmericans, and non-Hispanic blacks to provide reliable estimatesin these subgroups of the population.
We defined access to health care as the subjects' report ofhaving either public or private health insurance and a usualsource of care. The use of health care was examined both asa continuous variable (in terms of the number of visits to aphysician reported in the past 12 months) and as a dichotomousvariable (having or not having visited a physician at leastonce in the past year). Current cigarette smoking was includedas a potential confounder of the use of health care and controlof hypertension. We defined hypertension status according tothe criteria used by Burt and colleagues8 (Table 1).
Table 1. Criteria for the Classification of Hypertension.
We used descriptive statistics to compare the distribution ofstudy variables among all categories of hypertension. We usedlogistic-regression analysis to identify the independent contributionof sociodemographic factors and factors related to access toand use of health care to the risk of having hypertension butbeing unaware of the condition and to the risk of having acknowledgedbut uncontrolled hypertension (defined as a blood pressure ofat least 140/90 mm Hg). To assess the relative risk of havinghypertension but being unaware of the condition that was associatedwith access to and use of health care, we used subjects withouthypertension as the comparison group, since the diagnosis ofhypertension is, in itself, likely to alter a person's patternsof health care use. The conventional definitions of categoriesof hypertension applied to data from NHANES III do not permitmultivariate modeling of the contribution of drug treatmentto the control of hypertension in the population, since subjectswho reported having been told they had hypertension, who werenot taking antihypertensive agents, and yet whose blood pressurewas less than 140/90 mm Hg were assigned to the group withouthypertension. We conducted additional multivariate modelingto verify that the estimates of relative risks obtained forour main study variables were not altered by the inclusion ofother potential confounders of hypertension control, includingthe body-mass index and the level of alcohol consumption.
We used the estimates of relative risks for significant variablesin the logistic-regression analyses to calculate population-attributablerisks associated with specific variables.12 This measure providesan additional perspective on the extent to which the controlof hypertension in the population could be improved by addressinga specific risk factor, since very large relative risks mayhave a small effect on a population when the prevalence of therisk factor is low.
All analyses were performed with the use of SUDAAN, a statisticalpackage that adjusts all estimates, including odds ratios andtheir standard errors, for the complex survey design.13 Sincethe observations contributed by each person in the sample mustbe weighted for the differential probabilities of selectionand nonresponse, the actual sample sizes in each category ofhypertension are not included in the tabulated results. Totalpopulation sizes, represented by each person in the sample forwhom data were available, are included in the results obtainedwith the use of SUDAAN.
Results
The NHANES III sample included a total of 16,095 adults whowere at least 25 years old and for whom blood-pressure valuesand hypertensive-medication status were known. The projectedsize of the population in each category of hypertension in theU.S. population as a whole on the basis of the NHANES III sampleis presented in Figure 1. Of the estimated 41.9 million peoplewith hypertension, 31 percent (approximately 13.1 million) wereunaware of their hypertension, 17 percent (7.0 million) wereaware of their condition but were not being treated, 29 percent(12.0 million) were being treated but their hypertension remaineduncontrolled, and only 23 percent (9.7 million) were takingmedications that controlled their hypertension. Although persons65 years of age or older represent only 19 percent of the totalpopulation, they constituted 45 percent of the persons who wereunaware of their condition, 32 percent of those who were awareof their condition but not being treated, and 57 percent ofthose who had treated but uncontrolled hypertension. The largestsegment of the population was 25 to 44 years old, but only 22percent of the subjects who were unaware of their hypertension,27 percent of those who were aware but not being treated, andless than 10 percent of those with treated but uncontrolledhypertension were in this age group. Among persons who werebeing treated, hypertension was controlled in 65 percent ofthose who were 25 to 44 years old, 52 percent of those who were45 to 64 years old, and 34 percent of those 65 or older.
Figure 1. Number of Persons Classified in the Various Categories of Hypertension in Each Age Group among the Members of the U.S. Population Who Were at Least 25 Years Old.
Data are from the third National Health and Nutrition Examination Survey. At the time of the survey (1988 to 1994), an estimated 154.2 million people in the United States were at least 25 years of age; of this number, an estimated 41.9 million (27 percent) had hypertension. Because of rounding, not all bars sum to the totals shown.
The proportion of non-Hispanic whites, non-Hispanic blacks,and Mexican Americans who were in each category is shown inFigure 2. A higher percentage of non-Hispanic blacks than ofnon-Hispanic whites had hypertension. A slightly smaller percentageof non-Hispanic blacks than of non-Hispanic whites were unawareof their condition, and the percentage of non-Hispanic blackswith controlled hypertension was essentially the same as thatamong non-Hispanic whites. Although the overall prevalence ofhypertension is lower among Mexican Americans than in the othertwo groups, Mexican Americans were markedly more likely thannon-Hispanic whites or non-Hispanic blacks to be unaware thatthey had hypertension and less likely to have controlled hypertensionif they were receiving treatment.
Figure 2. Extent of Awareness, Treatment, and Control of Hypertension among Non-Hispanic Whites, Non-Hispanic Blacks, and Mexican Americans with Hypertension in the Third National Health and Nutrition Examination Survey.
Sample sizes for other racial and ethnic groups were too small to analyze separately. Percentages may not sum to 100 because of rounding.
The mean blood pressure in each category of uncontrolled hypertensionis shown according to age in Table 2. More than 75 percent ofall the subjects who were unaware that they had hypertensionand of those with uncontrolled, treated hypertension, as wellas about 60 percent of those with acknowledged, untreated hypertension,had a diastolic blood pressure of less than 90 mm Hg. The elevationin systolic blood pressure in the three groups was mild, asassessed on the basis of historical standards. A pattern ofelevation in the systolic blood pressure with a diastolic bloodpressure of less than 90 mm Hg was dominant in both the groupthat was 45 to 64 years of age and the group that was 65 yearsof age or older. Only in the youngest group did the averagediastolic blood pressure equal or exceed 90 mm Hg. Yet evenin this stratum, over 50 percent of those who were unaware thatthey had hypertension had a diastolic blood pressure of lessthan 90 mm Hg with a systolic blood pressure of 140 mm Hg ormore.
Table 2. Blood-Pressure Levels in Subjects with Uncontrolled Hypertension, According to Age.
Data on demographic characteristics and the extent of accessto and use of health care according to category of hypertensionare presented in Table 3. Although there were some differencesin access and use among the groups, 92 percent of all subjectswith uncontrolled hypertension had health insurance, 86 percentreported having a usual source of care, and the mean numberof visits to physicians in this group was 4.28 per year. About75 percent of the subjects who were unaware that they had hypertensionhad had their blood pressure measured by a health professionalin the preceding year. Subjects who were unaware of their hypertensionwere less frequent users of health care than other subjectswith hypertension, but their frequency of use was quite similarto that of the subjects without hypertension. Subjects who wereunaware of their hypertension and those with acknowledged, untreatedhypertension still averaged at least three visits to physiciansper year, and over 40 percent of the subjects in each groupwere taking a prescription drug but not an antihypertensivedrug. There was little difference in the use of health carebetween subjects with treated controlled hypertension and subjectswith treated uncontrolled hypertension; subjects in both groupshad made a mean of more than six visits to a physician in thepast 12 months.
Table 3. Demographic Factors and Factors Reflecting the Extent of Access to and Use of Health Care, According to Category of Hypertension.
Results of the logistic-regression analyses are reported inTable 4. Male sex, non-Hispanic black race, and not having seena physician in the past year increased the risk of being classifiedas having hypertension but being unaware of the condition —by 57 percent, 45 percent, and 41 percent, respectively. Anage of at least 65 years was by far the strongest risk factorfor the lack of awareness of hypertension. Having health insurancedid not affect the risk, even in models that did not includethe variable concerning the frequency of visits to physicians.Treating the number of visits to physicians as a continuousvariable did not significantly change the odds ratios associatedwith other variables concerning the extent of access to healthcare. Similarly, when body-mass index and alcohol consumptionwere included in the model, these variables did not alter themagnitude of the odds ratios associated with variables concerningaccess to and use of health care.
Table 4. Results of Multivariate Analysis of Predictors of the Lack of Awareness and Lack of Control of Hypertension in the U.S. Population.
In the model that assessed the risk of having acknowledged butuncontrolled hypertension, male sex, not having seen a physicianin the preceding 12 months, and an age of at least 65 yearswere significant risk factors. Again, having health insurancewas not independently related to the likelihood of having acknowledged,uncontrolled hypertension, even in models that did not includethe frequency of visits to physicians. These results were notaltered by the inclusion of body-mass index and alcohol consumptionin the model.
In Table 5, the population attributable risks are presentedfor the risk factors that were found to be significant in themultivariate analysis. An age of at least 65 years was associatedwith the largest attributable risk for both outcomes. Male sexwas also associated with a substantial attributable risk. Nothaving visited a physician in the preceding 12 months accountedfor less than 10 percent of the attributable risk, and non-Hispanicblack race accounted for less than 5 percent.
Table 5. Proportion of Cases of Uncontrolled Hypertension in Each Population Subgroup Attributable to Identified Risk Factors.
Discussion
Our analysis yielded four important observations regarding thefactors underlying poor control of hypertension in the UnitedStates: undiagnosed hypertension and treated but uncontrolledhypertension occur largely under the watchful eye of the healthcare system; the problems of the lack of awareness of hypertensionand lack of adequate control with treatment are heavily concentratedamong older members of our society; the lack of control of hypertensionis not confined to the poor, the uninsured, or minorities; andthe pattern of an elevation in the systolic blood pressure witha diastolic blood pressure of less than 90 mm Hg predominatesnot only in the elderly, but also among the middle-aged. Thesefindings dispel the stereotype that the typical patient withuncontrolled hypertension is a young man (often non-Hispanicblack) who does not visit the physician or who will not takeantihypertensive drugs regularly.
The multivariate analysis of predictors of the lack of awarenessof hypertension indicated that biologic factors known to affectblood-pressure levels, such as increasing age, male sex, andnon-Hispanic black race, completely overshadow the contributionof infrequent use of health care. By comparing subjects whowere unaware of their hypertension with subjects who did nothave hypertension, we were able to assess the role of accessto and use of health care in this cross-sectional study withoutthe risk of confounding posed by the diagnosis of hypertensionitself.
The largest relative risk and attributable risk of uncontrolledhypertension were associated with an age of at least 65 years.The elderly have the most frequent contact with the health systemand are the most likely to have medical insurance. They arenot likely to be less compliant than younger adults about takingprescribed medications. Thus, the main challenge in this groupis to identify effective therapeutic regimens to achieve targetedblood-pressure levels. There is persistent controversy aboutthe appropriateness of the current treatment goal of a systolicblood pressure of less than 140 mm Hg in this group.14 Sincein the U.S. population, the highest prevalence of uncontrolledhypertension is in middle-aged and older persons who have mildelevations in systolic blood pressure but not in diastolic bloodpressure, more clinical trials may be needed, especially inview of a recent clinical advisory from the National High BloodPressure Education Program calling for the use of systolic bloodpressure as the chief diagnostic and management criterion.15
Although a lack of health insurance may partially explain thelower frequency of visits to physicians among subjects who wereunaware that they had hypertension and those who had acknowledged,untreated hypertension, it is clearly not the main determinant.The rates of awareness and control of hypertension are significantlyhigher in the United States than in developed countries withnational health insurance systems, suggesting that access tohealth care is a less important factor than standards of practice.16,17
Our study has some limitations. The NHANES III used self-reporteddata on measures concerning access to and use of health care,and the blood-pressure values used in the analysis were obtainedby survey personnel, not by the subjects' health care providers.The survey did not include an examination of the subjects' medicalrecords. Therefore, although we know that the subjects saw physiciansand had mild elevations in systolic blood pressure, we cannotdirectly associate the behavior of these physicians with theblood pressures measured during the survey. The fact that ablood-pressure measurement obtained on a single occasion wasused to determine the subjects' awareness of having hypertensionand the control of the condition is another possible limitationof the study. However, this large, national sample providesthe best available estimates of blood-pressure levels in thepopulation and is the source of data used to evaluate nationalpublic health goals. Although some persons would be reclassifiedas having either hypertension or normotension on remeasurement,the overall proportions in each category should remain the same.
Nearly 10 years has elapsed since the last NHANES survey wascompleted. Despite the growing realization of the importanceof systolic blood pressure in the control of hypertension, morerecent data documenting the actual practices of physicians donot suggest that there have been any major shifts in behavior.7,18A new national health examination survey is under way, but theresults for a sample size similar to that of NHANES III willnot be available for several years. Given the importance ofcontrolling hypertension and the number of people affected byefforts to improve control, NHANES III is still the best availablesource of data on determinants of the degree of awareness andcontrol of hypertension in the general population.
The prevalence of the lack of awareness and control of hypertensionthat we found differs slightly from other published estimatesbecause we used 25 years as the lower age limit and we did nothave an upper age limit. Other frequently cited sources reportdata for subjects 18 to 74 years of age, so as to permit comparisonwith data from previous NHANES.8 We chose this age range becausethe new standards of the Health Plan Employer Data and InformationSet (HEDIS), published by the National Committee for QualityAssurance, define controlled hypertension as a systolic bloodpressure of less than 140 mm Hg and a diastolic blood pressureof less than 90 mm Hg; this criterion is recommended for gradingthe effectiveness of health care organizations,19 with no upperage limit suggested. In addition, persons who are 18 to 25 yearsof age have a low prevalence of hypertension, and their accessto health care may be dependent on that of their parents.
We elected to use a standard definition of controlled hypertensionthat was based on the criteria used in previous reports. Duringthe time frame covered by the survey, separate, lower standardsfor persons with diabetes mellitus, renal insufficiency, orcongestive heart failure were not in place and thus cannot legitimatelybe applied to an evaluation of the effect of factors relatedto the health system on the control of hypertension. We suspectthat if lower blood-pressure values were used to define controlledhypertension, even more of those with uncontrolled hypertensionwould be found to be under medical care.
In summary, we found that the majority of subjects with uncontrolledhypertension — whether or not they were aware of theircondition and whether or not they were taking antihypertensivedrugs — were persons who had access to medical care andwho had a mild elevation in systolic blood pressure with a diastolicblood pressure of less than 90 mm Hg. Randomized clinical trialshave provided evidence of the benefit of antihypertensive drugsin elderly patients with a systolic blood pressure of more than160 mm Hg and a diastolic blood pressure of less than 90 mmHg,20,21 but there is no such evidence regarding persons withonly a mild elevation in systolic blood pressure.
The guidelines of the sixth report of the Joint National Committeeon Prevention, Detection, Evaluation, and Treatment of HighBlood Pressure3 recommend drug treatment for persons with asystolic blood pressure of less than 140 mm Hg who have concomitantdiabetes, congestive heart failure, or chronic renal insufficiency.Even if such persons are excluded from the calculation, thenumber of Americans with a systolic blood pressure between 140and 160 mm Hg and a diastolic blood pressure of less than 90mm Hg who are classified as being unaware of their condition,as having acknowledged but untreated hypertension, or as havingtreated but uncontrolled hypertension exceeds 10 million. Whencalling for improved control of hypertension, the medical communityshould be aware of the magnitude of the efforts required toachieve this goal and of the characteristics of those labeledas having uncontrolled hypertension.
Source Information
From the Departments of Medicine (D.J.H.) and Family and Community Medicine (V.N.P.), Baylor College of Medicine, Houston.
Address reprint requests to Dr. Hyman at the Department of Medicine, Ben Taub General Hospital, 1504 Taub Loop, Houston, TX 77030, or at dhyman{at}bcm.tmc.edu.
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(2006). Advancing the Study of Stroke in Women: Summary and Recommendations for Future Research From an NINDS-Sponsored Multidisciplinary Working Group. Stroke
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Moser, M., Setaro, J. F.
(2006). Clinical practice. Resistant or difficult-to-control hypertension.. NEJM
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Goldstein, L. B., Adams, R., Alberts, M. J., Appel, L. J., Brass, L. M., Bushnell, C. D., Culebras, A., DeGraba, T. J., Gorelick, P. B., Guyton, J. R., Hart, R. G., Howard, G., Kelly-Hayes, M., Nixon, J.V., Sacco, R. L.
(2006). Primary Prevention of Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline.. Circulation
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Neutel, J. M.
(2006). The role of combination therapy in the management of hypertension.. Nephrol Dial Transplant
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Zillich, A. J., Haines, S. T.
(2006). ASHP Therapeutic Position Statement on the Treatment of Hypertension.. Am J Health Syst Pharm
63: 1074-1080
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Goldstein, L. B., Adams, R., Alberts, M. J., Appel, L. J., Brass, L. M., Bushnell, C. D., Culebras, A., DeGraba, T. J., Gorelick, P. B., Guyton, J. R., Hart, R. G., Howard, G., Kelly-Hayes, M., Nixon, J.V., Sacco, R. L.
(2006). Primary Prevention of Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline.. Stroke
37: 1583-1633
[Abstract][Full Text]
Rodondi, N., Peng, T., Karter, A. J., Bauer, D. C., Vittinghoff, E., Tang, S., Pettitt, D., Kerr, E. A., Selby, J. V.
(2006). Therapy Modifications in Response to Poorly Controlled Hypertension, Dyslipidemia, and Diabetes Mellitus. ANN INTERN MED
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Schmitz, N., Thefeld, W., Kruse, J.
(2006). Mental disorders and hypertension: factors associated with awareness and treatment of hypertension in the general population of Germany.. Psychosom. Med.
68: 246-252
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Okonofua, E. C., Simpson, K. N., Jesri, A., Rehman, S. U., Durkalski, V. L., Egan, B. M.
(2006). Therapeutic Inertia Is an Impediment to Achieving the Healthy People 2010 Blood Pressure Control Goals. Hypertension
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Seshadri, S., Beiser, A., Kelly-Hayes, M., Kase, C. S., Au, R., Kannel, W. B., Wolf, P. A.
(2006). The Lifetime Risk of Stroke: Estimates From the Framingham Study. Stroke
37: 345-350
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Claiborne, N.
(2006). Efficiency of a Care Coordination Model: A Randomized Study With Stroke Patients. Research on Social Work Practice
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[Abstract]
Cheng, H. Y.
(2005). Hypertension in Adults Across Age Groups. JAMA
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Hertz, R. P., Unger, A. N., Cornell, J. A., Saunders, E.
(2005). Racial Disparities in Hypertension Prevalence, Awareness, and Management. Arch Intern Med
165: 2098-2104
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Assmann, G., Cullen, P., Evers, T., Petzinna, D., Schulte, H.
(2005). Importance of arterial pulse pressure as a predictor of coronary heart disease risk in PROCAM. Eur Heart J
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Wang, T. J., Vasan, R. S.
(2005). Epidemiology of Uncontrolled Hypertension in the United States. Circulation
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Labovitz, D. L., Halim, A., Boden-Albala, B., Hauser, W. A., Sacco, R. L.
(2005). The incidence of deep and lobar intracerebral hemorrhage in whites, blacks, and Hispanics. Neurology
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46: 1-6
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Peralta, C. A., Hicks, L. S., Chertow, G. M., Ayanian, J. Z., Vittinghoff, E., Lin, F., Shlipak, M. G.
(2005). Control of Hypertension in Adults With Chronic Kidney Disease in the United States. Hypertension
45: 1119-1124
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Rehman, S. U., Hutchison, F. N., Hendrix, K., Okonofua, E. C., Egan, B. M.
(2005). Ethnic Differences in Blood Pressure Control Among Men at Veterans Affairs Clinics and Other Health Care Sites. Arch Intern Med
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Dolder, C. R., Furtek, K., Lacro, J. P., Jeste, D. V.
(2005). Antihypertensive Medication Adherence and Blood Pressure Control in Patients With Psychotic Disorders Compared to Persons Without Psychiatric Illness. Psychosomatics
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(2005). Mandatory computer field for blood pressure measurement improves screening. Fam Pract
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Nesbitt, S. D.
(2005). Nitrates as Adjunct Hypertensive Treatment: A Possible Answer to Resistant Systolic Hypertension. Hypertension
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Hicks, L. S., Fairchild, D. G., Horng, M. S., Orav, E. J., Bates, D. W., Ayanian, J. Z.
(2004). Determinants of JNC VI Guideline Adherence, Intensity of Drug Therapy, and Blood Pressure Control by Race and Ethnicity. Hypertension
44: 429-434
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(2004). Systolic Hypertension in Older Persons. JAMA
292: 1074-1080
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(2004). The Economic Implications of Three Biochemical Screening Algorithms for Pheochromocytoma. J. Clin. Endocrinol. Metab.
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Pasternak, R. C., Criqui, M. H., Benjamin, E. J., Fowkes, F. G. R., Isselbacher, E. M., McCullough, P. A., Wolf, P. A., Zheng, Z.-J.
(2004). Atherosclerotic Vascular Disease Conference: Writing Group I: Epidemiology. Circulation
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Majumdar, S. R., McAlister, F. A., Furberg, C. D.
(2004). From knowledge to practice in chronic cardiovascular disease: a long and winding road. J Am Coll Cardiol
43: 1738-1742
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Ho, P. M., Masoudi, F. A., Peterson, E. D., Grunwald, G. K., Sales, A. E., Hammermeister, K. E., Rumsfeld, J. S.
(2004). Cardiology management improves secondary prevention measures among patients with coronary artery disease. J Am Coll Cardiol
43: 1517-1523
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Muntner, P., Gu, D., Wu, X., Duan, X., Wenqi, G., Whelton, P. K., He, J., for the InterASIA Collaborative Group,
(2004). Factors Associated With Hypertension Awareness, Treatment, and Control in a Representative Sample of the Chinese Population. Hypertension
43: 578-585
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Raji, M. A, Kuo, Y.-F., Salazar, J. A, Satish, S., Goodwin, J. S
(2004). Ethnic Differences in Antihypertensive Medication Use in the Elderly. The Annals of Pharmacotherapy
38: 209-214
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Singh, H., Kalavar, J.
(2004). Quality of Care for Hypertension and Diabetes in Federal- Versus Commercial-Managed Care Organizations. American Journal of Medical Quality
19: 19-24
[Abstract]
Wolf-Maier, K., Cooper, R. S., Kramer, H., Banegas, J. R., Giampaoli, S., Joffres, M. R., Poulter, N., Primatesta, P., Stegmayr, B., Thamm, M.
(2004). Hypertension Treatment and Control in Five European Countries, Canada, and the United States. Hypertension
43: 10-17
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Sutton-Tyrrell, K., Wildman, R., Newman, A., Kuller, L. H.
(2003). Extent of Cardiovascular Risk Reduction Associated With Treatment of Isolated Systolic Hypertension. Arch Intern Med
163: 2728-2731
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Ayanian, J. Z., Zaslavsky, A. M., Weissman, J. S., Schneider, E. C., Ginsburg, J. A.
(2003). Undiagnosed Hypertension and Hypercholesterolemia Among Uninsured and Insured Adults in the Third National Health and Nutrition Examination Survey. Am. J. Public Health
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Chobanian, A. V., Bakris, G. L., Black, H. R., Cushman, W. C., Green, L. A., Izzo, J. L. Jr, Jones, D. W., Materson, B. J., Oparil, S., Wright, J. T. Jr, Roccella, E. J., the National High Blood Pressure Education Program,
(2003). Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension
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Oparil, S., Zaman, M. A., Calhoun, D. A.
(2003). Pathogenesis of Hypertension. ANN INTERN MED
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Dornbrook-Lavender, K. A, Pieper, J. A, Roth, M. T
(2003). Primary Prevention of Coronary Heart Disease in the Elderly. The Annals of Pharmacotherapy
37: 1654-1663
[Abstract][Full Text]
Newman, A. B., Arnold, A. M., Naydeck, B. L., Fried, L. P., Burke, G. L., Enright, P., Gottdiener, J., Hirsch, C., O'Leary, D., Tracy, R.
(2003). "Successful Aging": Effect of Subclinical Cardiovascular Disease. Arch Intern Med
163: 2315-2322
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Carter, B. L, Zillich, A. J
(2003). Pharmaceutical Care Services for Patients with Hypertension. The Annals of Pharmacotherapy
37: 1335-1337
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Textor, S. C., Schwartz, G. L., Frye, R. L.
(2003). The New Hypertension Guidelines From JNC 7: Is the Devil in the Details?. Mayo Clin Proc.
78: 1078-1081
Khot, U. N., Khot, M. B., Bajzer, C. T., Sapp, S. K., Ohman, E. M., Brener, S. J., Ellis, S. G., Lincoff, A. M., Topol, E. J.
(2003). Prevalence of Conventional Risk Factors in Patients With Coronary Heart Disease. JAMA
290: 898-904
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Bakris, G. L., Weir, M. R., Shanifar, S., Zhang, Z., Douglas, J., van Dijk, D. J., Brenner, B. M.
(2003). Effects of Blood Pressure Level on Progression of Diabetic Nephropathy: Results From the RENAAL Study. Arch Intern Med
163: 1555-1565
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Hajjar, I., Kotchen, T. A.
(2003). Trends in Prevalence, Awareness, Treatment, and Control of Hypertension in the United States, 1988-2000. JAMA
290: 199-206
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Newman, A. B.
(2003). Commentary. Journals of Gerontology Series A: Biological Sciences and Medical Sciences
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McGlynn, E. A., Asch, S. M., Adams, J., Keesey, J., Hicks, J., DeCristofaro, A., Kerr, E. A.
(2003). The Quality of Health Care Delivered to Adults in the United States. NEJM
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Koopman, R. J., Mainous, A. G. III, Baker, R., Gill, J. M., Gilbert, G. E.
(2003). Continuity of Care and Recognition of Diabetes, Hypertension, and Hypercholesterolemia. Arch Intern Med
163: 1357-1361
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Chobanian, A. V., Bakris, G. L., Black, H. R., Cushman, W. C., Green, L. A., Izzo, J. L. Jr, Jones, D. W., Materson, B. J., Oparil, S., Wright, J. T. Jr, Roccella, E. J.
(2003). The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. JAMA
289: 2560-2571
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Flack, J. M., Oparil, S., Pratt, J. H., Roniker, B., Garthwaite, S., Kleiman, J. H., Yang, Y., Krause, S. L., Workman, D., Saunders, E.
(2003). Efficacy and tolerability of eplerenone and losartan in hypertensive black and white patients. J Am Coll Cardiol
41: 1148-1155
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Filippi, A., Bignamini, A. A., Sessa, E., Samani, F., Mazzaglia, G.
(2003). Secondary Prevention of Stroke in Italy: A Cross-Sectional Survey in Family Practice. Stroke
34: 1010-1014
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Egan, B. M., Lackland, D. T., Cutler, N. E.
(2003). Awareness, Knowledge, and Attitudes of Older Americans About High Blood Pressure: Implications for Health Care Policy, Education, and Research. Arch Intern Med
163: 681-687
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Pellegrini, F., Belfiglio, M., De Berardis, G., Franciosi, M., Di Nardo, B., Greenfield, S., Kaplan, S. H., Sacco, M., Tognoni, G., Valentini, M., Corrado, D., D'Ettorre, A., Nicolucci, A., for the QuED Study Group,
(2003). Role of Organizational Factors in Poor Blood Pressure Control in Patients With Type 2 Diabetes: The QuED Study Group--Quality of Care and Outcomes in Type 2 Diabetes. Arch Intern Med
163: 473-480
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Berlowitz, D. R., Ash, A. S., Hickey, E. C., Glickman, M., Friedman, R., Kader, B.
(2003). Hypertension Management in Patients With Diabetes: The need for more aggressive therapy. Diabetes Care
26: 355-359
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Appel, L. J.
(2002). The Verdict From ALLHAT--Thiazide Diuretics Are the Preferred Initial Therapy for Hypertension. JAMA
288: 3039-3042
[Full Text]
Psaty, B. M., Manolio, T. A., Smith, N. L., Heckbert, S. R., Gottdiener, J. S., Burke, G. L., Weissfeld, J., Enright, P., Lumley, T., Powe, N., Furberg, C. D.
(2002). Time Trends in High Blood Pressure Control and the Use of Antihypertensive Medications in Older Adults: The Cardiovascular Health Study. Arch Intern Med
162: 2325-2332
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Young, J. H., Klag, M. J., Muntner, P., Whyte, J. L., Pahor, M., Coresh, J.
(2002). Blood Pressure and Decline in Kidney Function: Findings from the Systolic Hypertension in the Elderly Program (SHEP). J. Am. Soc. Nephrol.
13: 2776-2782
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Lloyd-Jones, D. M., Evans, J. C., Larson, M. G., Levy, D.
(2002). Treatment and Control of Hypertension in the Community: A Prospective Analysis. Hypertension
40: 640-646
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Basile, J. N
(2002). Systolic blood pressure. BMJ
325: 917-918
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Singer, G. M., Izhar, M., Black, H. R.
(2002). Goal-Oriented Hypertension Management: Translating Clinical Trials to Practice. Hypertension
40: 464-469
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Hense, H. W., Maziak, W., Heidrich, J.
(2002). Why is blood pressure control unsatisfactory--or is it?. Nephrol Dial Transplant
17: 1547-1550
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Hajjar, I., Miller, K., Hirth, V.
(2002). Age-Related Bias in the Management of Hypertension: A National Survey of Physicians' Opinions on Hypertension in Elderly Adults. Journals of Gerontology Series A: Biological Sciences and Medical Sciences
57: M487-491
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Tuhrim, S, Levine, S R
(2002). Hypertension+MRI changes=impaired cognition. J. Neurol. Neurosurg. Psychiatry
72: 690-690
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de Gaudemaris, R., Lang, T., Chatellier, G., Larabi, L., Lauwers-Cances, V., Maitre, A., Diene, E.
(2002). Socioeconomic Inequalities in Hypertension Prevalence and Care: The IHPAF Study. Hypertension
39: 1119-1125
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O'Rourke, M.
(2002). Target organ damage: use of pulse wave analysis as a manifestation of aortic degeneration in the assessment of hypertension. Vasc Med
7: 83-85
Deedwania, P. C.
(2002). The Changing Face of Hypertension: Is Systolic Blood Pressure the Final Answer?. Arch Intern Med
162: 506-508
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Blacher, J., Safar, M.
(2002). Specific aspects of high blood pressure in the elderly. Journal of Renin-Angiotensin-Aldosterone System
3: S10-S15
Cohen, J. D.
(2002). Superior Physicians and the Treatment of Hypertension. Arch Intern Med
162: 387-388
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Baker, D. W., Portnoi, V. A., Hyman, D. J., Pavlik, V. N., Chobanian, A. V.
(2001). Control of Hypertension. NEJM
345: 1778-1780
[Full Text]
A correction has been published: N Engl J Med 2002;346(7):544.
