Proportion of US Adults Potentially Affected by the 2014 Hypertension Guideline

Importance  The new 2014 blood pressure (BP) guideline released by the panel members appointed to the Eighth Joint National Committee (JNC 8; 2014 BP guideline) proposed less restrictive BP targets for adults aged 60 years or older and for those with diabetes and chronic kidney disease.

Objective  To estimate the proportion of US adults potentially affected by recent changes in recommendations for management of hypertension.

Design  Cross-sectional, nationally representative survey.

Participants  Using data from the National Health and Nutrition Examination Survey between 2005 and 2010 (n = 16 372), we evaluated hypertension control and treatment recommendations for US adults.

Main Outcomes and Measures  Proportion of adults estimated to meet guideline-based BP targets under the 2014 BP guideline and under the previous seventh Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guideline.

Results  The proportion of younger adults (18-59 years) with treatment-eligible hypertension under the JNC 7 guideline was 20.3% (95% CI, 19.1%-21.4%) and decreased to 19.2% (95% CI, 18.1%-20.4%) under the 2014 BP guideline. Larger declines were observed among older adults (≥60 years), decreasing from 68.9% (95% CI, 66.9%-70.8%) under JNC 7 to 61.2% (95% CI, 59.3%-63.0%) under the 2014 BP guideline. The proportion of adults with treatment-eligible hypertension who met BP goals increased slightly for younger adults, from 41.2% (95% CI, 38.1%-44.3%) under JNC 7 to 47.5% (95% CI, 44.4%-50.6%) under the 2014 BP guideline, and more substantially for older adults, from 40.0% (95% CI, 37.8%-42.3%) under JNC 7 to 65.8% (95% CI, 63.7%-67.9%) under the 2014 BP guideline. Overall, 1.6% (95% CI, 1.3%-1.9%) of US adults aged 18-59 years and 27.6% (95% CI, 25.9%-29.3%) of adults aged 60 years or older were receiving BP-lowering medication and meeting more stringent JNC 7 targets. These patients may be eligible for less stringent or no BP therapy with the 2014 BP guideline.

Conclusions and Relevance  Compared with the JNC 7 guideline, the 2014 BP guideline from the panel members appointed to the JNC 8 was associated with a reduction in the proportion of US adults recommended for hypertension treatment and a substantial increase in the proportion of adults considered to have achieved goal BP, primarily in older adults.

The recent release of the “2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults by Panel Members Appointed to the Eighth Joint National Committee” (JNC 8; the 2014 BP guideline)¹ included some notable differences compared with the previous guideline, issued nearly 10 years ago in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7).² Citing evidence from 2 trials demonstrating no difference in outcomes in older (≥60 years) adults with hypertension between systolic treatment targets of 140 and 150 mm Hg,^3,4 the 2014 BP guideline increased the systolic BP treatment goal from less than 140/90 mm Hg to less than 150/90 mm Hg, although committee members did not recommend it unanimously.⁵ Similarly, the 2014 BP guideline also changed targets for adults with chronic kidney disease (CKD) and diabetes from less than 130/80 mm Hg to the less than 140/90 mm Hg target goal recommended for the general population. This article sought to quantify the proportion of adults potentially affected by the recommendations from the 2014 BP guideline.

This analysis used data collected from the National Health and Nutrition Examination Survey (NHANES) between 2005 and 2010. NHANES is a cross-sectional survey designed to represent the noninstitutionalized civilian US population.

Blood pressure was measured at mobile examination centers by trained examiners, and patient-reported hypertension medication use was assessed for those interviewed.⁶ All nonpregnant adults³ aged 18 years or older were included. We estimated the proportion of adults with treatment-eligible hypertension according to both JNC 7 and the 2014 BP guideline, stratified by age group (18-59 years and ≥60 years), treatment status, and the presence or absence of diabetes or CKD. Chronic kidney disease was categorized as Modification of Diet in Renal Disease estimated glomerular filtration rate less than 60 mL/min/1.73 m². Diabetes was defined by participant-reported diagnoses. Patients were considered receiving treatment if they answered yes to the following: “Because of your high blood pressure/hypertension, have you ever been told to take prescribed medicine?” and “Are you currently taking medication to lower your blood pressure?” Characteristics of adults reclassified as above goal under JNC 7 to at goal under the 2014 BP guideline, as well as adults at goal under both guidelines and adults above goal under both guidelines, were evaluated. Adults at goal were those reporting receiving BP medications and meeting guideline targets. Given that the 2014 BP guideline specifically address adults recommended for receiving medication therapy, we defined treatment as medication therapy. Treatment-eligible hypertension was defined as either BP above target for each guideline or patients at goal BP and reporting BP treatment.

To account for the survey nature of the data, domain analysis was conducted with NHANES sample weights, which account for oversampling of subgroups and nonresponse rates to estimate the weighted percentage of adults in each segment of interest, with 95% CIs calculated.⁷ Unavailable BP information (n = 838/17 210, 4.5% overall) was considered missing at random and, given the low rate (<10%), was excluded from analysis, as with other NHANES BP estimates.⁸ Dichotomous variables were summarized with proportions and continuous variables using means, with 95% CIs constructed with normal approximation. Analyses were performed with the PROC SURVEY MEANS procedure with SAS version 9.3.

Data sets used for this analysis are publicly available. All NHANES participants gave written informed consent for participation. The National Center for Health Statistics institutional review board approved the original study.

From 2005-2010, NHANES included 16 372 participants with BP measurements. Table 1 shows the BP classification rates for US adults under the JNC 7 guideline and the 2014 BP guideline by age-specific (18-59 years and ≥60 years) and disease-specific guideline-targeted groups (with and without CKD or diabetes mellitus). Overall rates of above-goal BP defined by the JNC 7 guideline were 11.9% in young adults and 41.3% of older adults, respectively (95% CI, 11.1%-12.7% and 39.3%-43.3%, respectively) compared with 10.1% and 20.9% defined by the 2014 BP guideline in younger and older adults, respectively (95% CI, 9.3%-10.9% and 19.5%-22.3%, respectively). Among younger adults, 7.4% (95% CI, 6.8%-8.1%) had diabetes or CKD, whereas 26.3% (95% CI, 24.9%-27.8%) of older adults had CKD and an additional 12.1% (95% CI, 10.7%-13.4%) had diabetes without CKD. Under the 2014 BP guideline, BP goals for adults with CKD and diabetes were increased. As a result, 1.8% (95% CI, 1.4%-2.3%) of young adults were previously considered to have above-goal BP under JNC 7 and would be reclassified as at BP goal under the 2014 BP guideline. Blood pressure goals were also increased in adults aged 60 years or older (from <140/90 to <150/90 mm Hg). Thus, 20.4% (95% CI, 18.8%-22.0%) of adults aged 60 years or older were previously considered to have above-goal BP under JNC 7 and would be reclassified as at goal under the 2014 BP guideline.

Table 2 demonstrates the characteristics of the adults reclassified from above goal under JNC 7 to at goal under the 2014 BP guideline, as well as adults at goal BP receiving medication therapy and above goal BP under both guideline. Reclassified adults were predominantly older, included more women (44.6% men; 95% CI, 40.7%-48.4%), and had high rates of preexisting cardiovascular disease (18.8%; 95% CI, 16.0%-21.6%).

The Figure demonstrates the total proportion of adults with treatment-eligible hypertension and the proportion of US adults with treatment-eligible hypertension who met BP goals under each guideline by age group. Under JNC 7, 31.7% (95% CI, 30.4%-32.9%) of all US adults had treatment-eligible hypertension, including 20.3% (95% CI, 19.1%-21.4%) of adults aged 18-59 years, and 68.9% (95% CI, 66.9%-70.8%) of adults aged 60 years or older. Of adults with treatment-eligible hypertension under JNC 7, 40.6% (95% CI, 38.5%-42.7%) met JNC 7 recommended BP goals, including 41.2% (95% CI, 38.1%-44.3%) of younger adults and 40.0% (95% CI, 37.8%-42.3%) of older adults. Under the 2014 BP guideline, 29.0% (95% CI, 27.8%-30.3%) of all US adults, including 19.2% (95% CI, 18.1%-20.4%) of younger adults and 61.2% (95% CI, 59.3%-63.0%) of adults aged 60 years or older, had treatment-eligible hypertension. Rates of BP control among patients with treatment-eligible hypertension were increased under the 2014 BP guideline, with 56.5% (95% CI, 54.5%-58.6%) of adults with treatment-eligible hypertension meeting BP goals. The proportion of adults with treatment-eligible hypertension was slightly higher under the 2014 BP guideline for younger adults, 47.5% (95% CI, 44.4%-50.6%). A more significant increase from JNC 7 was observed in older adults, among whom the proportion with treatment-eligible hypertension who met BP goals increased to 65.8% (95% CI, 63.7%-67.9%) under the 2014 BP guideline.

Among adults with BP above goal under JNC 7, 52.2% (95% CI, 50.0%-54.5%) were not receiving antihypertensive medication treatment. Among adults with BP above goal under the 2014 BP guideline, 57.0% (95% CI, 53.9%-60.0%) were not treated with antihypertensive medications. A small proportion of younger adults (1.6%; 95% CI, 1.3%-1.9%) and larger proportion of older adults (27.6%; 95% CI, 25.9%-29.3%) were receiving BP medication and meeting more stringent JNC 7 targets and may have met the 2014 BP guideline targets while receiving reduced or potentially no therapy.

The 2014 BP guideline from the panel members appointed to JNC 8 for management of hypertension in adults relaxed BP targets for US residents aged 60 years or older and those with diabetes or CKD. This report sought to quantify the proportion of adults potentially affected by these changes, using NHANES, and to determine the potential effect on estimates of hypertension control rates in patients recommended for receiving medication therapy.

Three different groups of adults in the United States are affected by the 2014 BP guideline: adults previously considered to have treatment-eligible hypertension, but who no longer meet criteria for medication therapy initiation; a large number of adults with hypertension who are currently receiving therapy and are newly considered to have met their BP target goals under the 2014 BP guideline recommendations relative to the previous recommendations; and many adults who achieved goal BP under stricter (ie, lower) BP targets and are now potentially eligible for less intensive or even no therapy under the 2014 BP guideline.

We first estimated that the proportion of adults in the United States considered to have treatment-eligible hypertension would be decreased from 20.3% under JNC 7 to 19.2% under the 2014 BP guideline among younger adults (18-59 years) and from 68.9% under JNC 7 to 61.2% under the 2014 BP guideline among older adults (≥60 years). Extrapolating this to the population represented by this NHANES sample (US adults in 2007), this translates to a reduction in 5.8 million US adults no longer classified as needing hypertension medication (70 million under JNC 7 to 64.2 million under the 2014 BP guideline). The 2014 guideline does not address whether these adults (or adults not receiving treatment and no longer above goal) should still be considered hypertensive. According to extrapolations from our findings, an estimated 13.5 million adults not previously considered to be meeting BP targets would be considered at goal BP under the 2014 BP guideline (41.5 million above goal under JNC 7, 28.0 million above goal under the 2014 guideline), with the majority affected aged 60 years and older, and many of whom had diabetes, CKD, and cardiovascular disease.

Despite these changes, the number of hypertensive adults who had BP above their target under either JNC 7 or the 2014 BP guideline far outnumbered the number of adults reclassified as at goal under the 2014 guideline. Under the 2014 BP guideline, an estimated 28 million adults (10.1% of all adults 18-59 years and 20.9% of all adults ≥60 years), were still considered to have above-goal BP. Similarly, more than half of adults with hypertension under JNC 7 and the 2014 BP guideline who were recommended for therapy were untreated. Thus, although the definition of optimal BP target can be debated, the numbers of adults with above-goal and untreated BP remained high regardless of the definition.

In addition, we found that a significant proportion of adults were receiving treatment and meeting more stringent BP goals than required under the 2014 BP guideline. Although the authors of the 2014 guideline state that “it is not necessary to adjust medication to allow BP to increase” for those adults previously treated to a lower goal, how treatment strategies in this subgroup might change under new guideline remains to be seen. However, the medical community still lacks consensus on BP targets, particularly for the potentially millions of adults with new BP goals under the new guideline.⁵ Public health messaging should target the large number of adults in the United States with changing recommendations under new guideline to ensure that new recommendations do not result in unintended consequences in adults now with “relabeled” BP status. Additional research is needed to determine how the new guideline might affect treatment strategies and outcomes in high-risk groups.

There are several limitations to our estimates. We used BPs measured as part of the NHANES protocol, which may be inaccurate, particularly for patients for whom only 1 BP measurement was available. Whether the person had received BP medications on the day of the measurement was unknown, and medication use was based on patient self-report. A small number of observations with missing data for this treatment were considered untreated, which may underestimate treatment rates. The number of adults with treatment-eligible hypertension under the 2014 BP guideline may be an underestimate because this group does not include adults who initiated therapy for hypertension according to JNC 7 goals who would not have qualified for therapy initiation under the 2014 guideline. Our estimates were derived with NHANES data from 2005-2010, thus representing the estimated US population midway through this analysis period. Population growth since then and shifts in age distributions would result in slight changes to our estimates. BP measurements were unavailable for 4.5% of adults. In addition, CKD was based on Modification of Diet in Renal Disease estimated glomerular filtration rate, which is not validated in older adults and may have overestimated the prevalence of CKD in this population. Finally, the diagnosis of diabetes was based on self-report, which may underestimate prevalence.

We estimate that, compared with the JNC 7 guideline, the 2014 BP guideline from the panel members appointed to the JNC 8 was associated with a decrease in overall rates of treatment-eligible hypertension from 31.7% under JNC 7 to 29.0% under the 2014 BP guideline. Among patients with treatment-eligible hypertension, 40.6% had achieved goal BP under JNC 7, which increased to 56.5% under the 2014 BP guideline. Further research is needed to determine how this new guideline affects overall BP levels attained and to determine the related effects on cardiovascular disease outcomes.

Corresponding Author: Ann Marie Navar-Boggan, MD, PhD, Duke University Medical Center, Division of Cardiology, 2301 Erwin Rd, Durham, NC 27710 (ann.navar@duke.edu).

Published Online: March 29, 2014. doi:10.1001/jama.2014.2531.

Author Contributions: Dr Pencina had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Navar-Boggan, Pencina, Sniderman.

Acquisition, analysis, or interpretation of data: Navar-Boggan, Pencina, Williams, Peterson.

Drafting of the manuscript: Navar-Boggan, Peterson.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Navar-Boggan, Pencina, Williams, Peterson.

Obtained funding: Sniderman.

Administrative, technical, or material support: Navar-Boggan.

Study supervision: Peterson.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Peterson reported receiving research grant funding from Janssen and Eli Lilly, as well as compensation for consulting services to Janssen and Boehringer Ingelheim. No other disclosures were reported.

Funding/Support: This research was supported in part by Duke Clinical Research Institute’s research funds and unrestricted grants from M. Jean de Granpre and Louis and Sylvia Vogel.

Role of the Sponsors: The funding source has no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Dr Peterson, an associate editor for JAMA, was not involved in the editorial review of or decision to publish this article.

Correction: This article was corrected for a typographical error in Table 1 on July 29, 2014.