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2009 dhdsp all-grantee meeting plenary session 2

. Robert Merritt, MABranch ChiefEpidemiology and Surveillance BranchDivision for Heart Disease and Stroke PreventionCenters for Disease Control and Prevention. The Burden of Hypertension in the United States. Overview. Burden of high blood pressureAwareness, treatment and controlCDC/DHDSP/ESB in Action.

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2009 dhdsp all-grantee meeting plenary session 2

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    1. 2009 DHDSP All-Grantee Meeting Plenary Session 2 Hypertension: Why is it so hard to control and what can we do about it?

    3. Overview Burden of high blood pressure Awareness, treatment and control CDC/DHDSP/ESB in Action Today, I will be speaking on hypertension (or high blood pressure) and its burden as defined by mortality and morbidity. I will also touch on the areas of awareness and treatment of high blood pressure and discuss control and its challenges. My last topic will be to share with you an example of how DHDSP/ESB is assisting states to identify their specific burden of hypertension and its associated issues.Today, I will be speaking on hypertension (or high blood pressure) and its burden as defined by mortality and morbidity. I will also touch on the areas of awareness and treatment of high blood pressure and discuss control and its challenges. My last topic will be to share with you an example of how DHDSP/ESB is assisting states to identify their specific burden of hypertension and its associated issues.

    4. High Blood Pressure Silent Killer When uncontrolled can lead to: Stroke Heart Attack Heart Failure Kidney Failure Control has improved but still remains inadequate Hypertension (or high blood pressure) is sometimes called the silent killer. Many people are unaware that they have high blood pressure. Not controlling high blood pressure, in other words, not keeping blood pressure less than 140/80mg Hg, can lead to many cardiovascular diseases. While control of high blood pressure has improved there is still a long way to go to ensure that this silent killer loses most of its ability to cause harm.Hypertension (or high blood pressure) is sometimes called the silent killer. Many people are unaware that they have high blood pressure. Not controlling high blood pressure, in other words, not keeping blood pressure less than 140/80mg Hg, can lead to many cardiovascular diseases. While control of high blood pressure has improved there is still a long way to go to ensure that this silent killer loses most of its ability to cause harm.

    5. Blood Pressure Classification Source: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) JNC 7 National Heart Lung and Blood Institute National High Blood Pressure Education ProgramJNC 7 National Heart Lung and Blood Institute National High Blood Pressure Education Program

    6. Burden of Hypertension – Morbidity by age group from 1999-2006 Prevalence of: Measured BP>140/90 Current BP lowering medication use Source: NHANES 1999-2006 This slide illustrates prevalence of HTN by age group over 4 cycles of NHANES. Estimates of the prevalence of hypertension may vary because of differences in the definition of hypertension In this analysis, someone could be classified as having hypertension if 1. their actual blood pressure measurement during the NHANES examination was greater or equal to 140//90. Or They reported currently taking anti-hypertensive medication Someone who is diagnosed with hypertension but currently had a measured BP less than 140/90 is STILL classified as having hypertension even though control was obtained. That is why this definition is not based solely on measurement values. In 2005-2006, 29 % of US adults 18 years and older were hypertensive. 18-39 99-00 7.75 01-02 7.31 03-04 7.11 05-06 7.04 40-59 99-00 30.60 01-02 28.44 03-04 32.42 05-06 31.71 60+ 99-00 64.68 01-02 66.13 03-04 66.13 05-06 65.27 This slide illustrates prevalence of HTN by age group over 4 cycles of NHANES. Estimates of the prevalence of hypertension may vary because of differences in the definition of hypertension In this analysis, someone could be classified as having hypertension if 1. their actual blood pressure measurement during the NHANES examination was greater or equal to 140//90. Or They reported currently taking anti-hypertensive medication Someone who is diagnosed with hypertension but currently had a measured BP less than 140/90 is STILL classified as having hypertension even though control was obtained. That is why this definition is not based solely on measurement values. In 2005-2006, 29 % of US adults 18 years and older were hypertensive. 18-39 99-00 7.75 01-02 7.31 03-04 7.11 05-06 7.04 40-59 99-00 30.60 01-02 28.44 03-04 32.42 05-06 31.71 60+ 99-00 64.68 01-02 66.13 03-04 66.13 05-06 65.27

    7. Hypertension – Awareness Among those with hypertension, the prevalence of: Reported current blood pressure lowering medication use Ever been told by their health care provider that they had high blood pressure Source: NHANES 1999-2006 In 2005-2006, 78% of hypertensive adults were aware that they had high blood pressure. Awareness increased by age group. 18-39 99-00 49.77 01-02 44.61 03-04 51.98 05-06 52.67 40-59 99-00 72.17 01-02 73.87 03-04 75.57 05-06 78.59 60+ 99-00 70.93 01-02 73.56 03-04 80.89 05-06 82.32 In 2005-2006, 78% of hypertensive adults were aware that they had high blood pressure. Awareness increased by age group. 18-39 99-00 49.77 01-02 44.61 03-04 51.98 05-06 52.67 40-59 99-00 72.17 01-02 73.87 03-04 75.57 05-06 78.59 60+ 99-00 70.93 01-02 73.56 03-04 80.89 05-06 82.32

    8. Treatment Overview Source: JNC 7 Too often treatment of hypertension is seen as taking medication. However, the first step in the algorithm for treating high blood pressure is to try lifestyle modifications as a way to lower blood pressure. Show algorithm….next slideSource: JNC 7 Too often treatment of hypertension is seen as taking medication. However, the first step in the algorithm for treating high blood pressure is to try lifestyle modifications as a way to lower blood pressure. Show algorithm….next slide

    9. Algorithm for Treatment of Hypertension The simple point I want to emphasize by showing this complicated figure is that lifestyle modifications are the first step in treatment of hypertension. If the lifestyle modifications do not reduce blood pressure to the desired level, the physician then prescribes one or more anti-hypertensive medications. Notice also that the line from the lifestyle modification box extends through the medication approach. Main point: Lifestyle modifications FIRST and in CONJUNCTION with medication. Notice also, that control is not automatically reached after the first medication is tried. Reducing high blood pressure is difficult even with medication. The simple point I want to emphasize by showing this complicated figure is that lifestyle modifications are the first step in treatment of hypertension. If the lifestyle modifications do not reduce blood pressure to the desired level, the physician then prescribes one or more anti-hypertensive medications. Notice also that the line from the lifestyle modification box extends through the medication approach. Main point: Lifestyle modifications FIRST and in CONJUNCTION with medication. Notice also, that control is not automatically reached after the first medication is tried. Reducing high blood pressure is difficult even with medication.

    10. Lifestyle Modifications The approximate reductions in SBP may seem inconsequential, but on an individual and on a population level, these reductions can be significant in reducing blood pressure. And from a clinical perspective, The approximate reductions in SBP may seem inconsequential, but on an individual and on a population level, these reductions can be significant in reducing blood pressure. And from a clinical perspective,

    11. Hypertension – Treatment Among those with hypertension: Prevalence of those reporting current blood pressure lowering medication use Source: NHANES 1999-2006 The denominator is those who have hypertension. The numerator is those who report that they are currently taking blood pressure lowering medication. We have other data on lifestyle modifications among those with hypertension but time constraints prevent presenting that information here. 18-39 99-00 25.58 01-02 31.69 03-04 36.68 05-06 30.06 40-59 99-00 61.78 01-02 60.01 03-04 62.73 05-06 65.59 60+ 99-00 63.64 01-02 66.58 03-04 73.60 05-06 76.86 The denominator is those who have hypertension. The numerator is those who report that they are currently taking blood pressure lowering medication. We have other data on lifestyle modifications among those with hypertension but time constraints prevent presenting that information here. 18-39 99-00 25.58 01-02 31.69 03-04 36.68 05-06 30.06 40-59 99-00 61.78 01-02 60.01 03-04 62.73 05-06 65.59 60+ 99-00 63.64 01-02 66.58 03-04 73.60 05-06 76.86

    12. Hypertension – Control among those with hypertension Among hypertensives: Prevalence of those with measured blood pressure <140/90 Source: NHANES 1999-2006 This slide illustrates the percentage of people with hypertension who achieve control (treatment method not specified) Notice the variability over time among each age group. This speaks to the importance of using several years of data to obtain a stable estimate of control. 18-39 99-00 12.56 01-02 24.79 03-04 28.48 05-06 25.03 40-59 99-00 41.59 01-02 37.92 03-04 42.90 05-06 47.96 60+ 99-00 28.58 01-02 35.61 03-04 41.99 05-06 46.48 This slide illustrates the percentage of people with hypertension who achieve control (treatment method not specified) Notice the variability over time among each age group. This speaks to the importance of using several years of data to obtain a stable estimate of control. 18-39 99-00 12.56 01-02 24.79 03-04 28.48 05-06 25.03 40-59 99-00 41.59 01-02 37.92 03-04 42.90 05-06 47.96 60+ 99-00 28.58 01-02 35.61 03-04 41.99 05-06 46.48

    13. Hypertension – Control among those taking anti-hypertensive medication Among those reporting current blood pressure lowering medication use: Prevalence of those with measured blood pressure <140/90 Source: NHANES 1999-2006 This slide is also about control but the denominator is those with hypertension who are taking antihypertensive medication The numerator is those who are controlled Again, note the variability over time. 18-39 99-00 49.12 01-02 78.21 03-04 77.64 05-06 83.24 40-59 99-00 67.31 01-02 63.19 03-04 68.40 05-06 73.12 60+ 99-00 44.91 01-02 53.49 03-04 57.05 05-06 60.47 This slide is also about control but the denominator is those with hypertension who are taking antihypertensive medication The numerator is those who are controlled Again, note the variability over time. 18-39 99-00 49.12 01-02 78.21 03-04 77.64 05-06 83.24 40-59 99-00 67.31 01-02 63.19 03-04 68.40 05-06 73.12 60+ 99-00 44.91 01-02 53.49 03-04 57.05 05-06 60.47

    14. Hypertension – Estimated Direct and Indirect Cost in the U.S. (in billions of U.S. dollars) Source: AHA Heart Disease and Stroke Statistics Updates 2006 -2009 and 2010 unpublished estimates. Heart Disease and Stroke Statistics-2006 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2006:113(6):e85-e151 Heart Disease and Stroke Statistics-2007 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007;115:e69-e171. Heart Disease and Stroke Statistics-2008 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2008;117:e25-e146. Heart Disease and Stroke Statistics—2009 Update. A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009;119:e21-e181. Heart Disease and Stroke Statistics—2010 Update. A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Unpublished estimates. Heart Disease and Stroke Statistics-2006 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2006:113(6):e85-e151 Heart Disease and Stroke Statistics-2007 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007;115:e69-e171. Heart Disease and Stroke Statistics-2008 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2008;117:e25-e146. Heart Disease and Stroke Statistics—2009 Update. A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009;119:e21-e181. Heart Disease and Stroke Statistics—2010 Update. A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Unpublished estimates.

    15. CDC In Action – CVHES Demonstration Project – 4 states Purpose: Collect data on measured levels of blood pressure and blood cholesterol Compare data between priority and general populations Provide information to guide development of control strategies for hypertension and cholesterol control Example: Arkansas Findings In 2005 and 2006, the CDC funded 4 states (Arkansas, Washington, Kansas, Oklahoma) to develop and implement a demonstration model of a cardiovascular health examination survey. This survey was comparable to National Health and Nutrition Examination Survey (NHANES). These surveys were intended to enhance the capacity at the state level to collect blood pressure and blood cholesterol data that are specific to their population and to use that data to develop, implement, and evaluate control strategies for hypertension and cholesterol. Another purpose of the survey was to assist in eliminating health disparities by each state identifying a priority population. In one example, the State of Arkansas found that their data uncovered a great level of undiagnosed and uncontrolled hypertension—25% of adults with hypertension are not aware that they have it; and among adults with hypertension who are being treated with antihypertensive medication, only 59% are controlled. (information provided by Namvar Zohoori – Arkansas Department of Health) In 2005 and 2006, the CDC funded 4 states (Arkansas, Washington, Kansas, Oklahoma) to develop and implement a demonstration model of a cardiovascular health examination survey. This survey was comparable to National Health and Nutrition Examination Survey (NHANES). These surveys were intended to enhance the capacity at the state level to collect blood pressure and blood cholesterol data that are specific to their population and to use that data to develop, implement, and evaluate control strategies for hypertension and cholesterol. Another purpose of the survey was to assist in eliminating health disparities by each state identifying a priority population. In one example, the State of Arkansas found that their data uncovered a great level of undiagnosed and uncontrolled hypertension—25% of adults with hypertension are not aware that they have it; and among adults with hypertension who are being treated with antihypertensive medication, only 59% are controlled. (information provided by Namvar Zohoori – Arkansas Department of Health)

    16. Summary Hypertension Control has shown improvement Advances in control still inadequate Collaborations with States Provides promising data on hypertension for state specific populations Allows for more targeted interventions Moving onto disparities in control of hypertension, here is a slide showing disparities in control across racial/ethnic groups from 1999-2006. Next slide…..Moving onto disparities in control of hypertension, here is a slide showing disparities in control across racial/ethnic groups from 1999-2006. Next slide…..

    17. Hypertension – Low Control Rates Among those reporting current blood pressure lowering medication use. Prevalence of those with measured blood pressure <140/90. 40-59 years: Non-Hispanic white 72.96 Non-Hispanic black 58.07 Mexican-American 62.58 Other 54.22 60+ years: Non-Hispanic white 55.49 Non-Hispanic black 50.36 Mexican-American 50.77 Other 51.52 40-59 years: Non-Hispanic white 72.96 Non-Hispanic black 58.07 Mexican-American 62.58 Other 54.22 60+ years: Non-Hispanic white 55.49 Non-Hispanic black 50.36 Mexican-American 50.77 Other 51.52

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