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Prevalence of Self-Reported Hypertension and Antihypertensive Medication Use Among Adults — United States, 2017–2021
Weekly / March 7, 2024 / 73(9);191–198
Ahlia Sekkarie, PhD1; Jing Fang, MD1; Donald Hayes, MD1; Fleetwood Loustalot, PhD1 (View author affiliations)
View suggested citationSummary
What is already known about this topic?
High blood pressure (hypertension) is a major risk factor for heart disease and stroke. It increases with age and varies by different populations and states. In 2017, updated guidelines recommended lowering the blood pressure threshold for diagnosis of hypertension in adults.
What is added by this report?
From 2017 to 2021, approximately one third of U.S. adults reported diagnosed hypertension; prevalence varied by sociodemographic characteristics and state of residence. Among persons reporting hypertension, the prevalence of antihypertensive medication use increased by approximately 3 percentage points.
What are the implications for public health practice?
Knowledge of hypertension diagnosis and treatment prevalence and trends can help guide the development of policies and implementation of evidence-based interventions to reduce disparities in this important risk factor for cardiovascular disease.
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Abstract
Hypertension, or high blood pressure, is a major risk factor for heart disease and stroke. It increases with age and is highest among non-Hispanic Black or African American persons, men, persons aged ≥65 years, those of lower socioeconomic status, and those who live in the southern United States. Hypertension affects approximately one half of U.S. adults, and approximately one quarter of those persons have their blood pressure under control. Reducing population-level hypertension prevalence and improving control is a national priority. In 2017, updated guidelines for high blood pressure in adults recommended lowering the blood pressure threshold for diagnosis of hypertension. Analysis of data from the Behavioral Risk Factor Surveillance System found that age-standardized, self-reported diagnosed hypertension was approximately 30% during 2017–2021, with persistent differences by age, sex, race and ethnicity, level of education, and state of residence. During this period, the age-standardized prevalence of antihypertensive medication use among persons with hypertension increased by 3.1 percentage points, from 59.8% to 62.9% (p<0.001). Increases in antihypertensive medication use were observed in most sociodemographic groups and in many states. Assessing current trends in hypertension diagnosis and treatment can help guide the development of policies and implementation of interventions to reduce this important risk factor for cardiovascular disease and can aid in addressing health disparities.
Introduction
Hypertension, or high blood pressure, is a major risk factor for heart disease and stroke (1). Hypertension affects approximately one in two U.S. adults aged ≥18 years, approximately one quarter of whom have their blood pressure under control (1). Prevalence of hypertension is highest among non-Hispanic Black or African American (Black) persons, men, persons aged ≥65 years, those of lower socioeconomic status, and those who live in the southern United States (2). Improving population-level hypertension prevalence and control is a national priority.* In 2017, updated guidelines for high blood pressure in adults recommended lowering the blood pressure threshold for diagnosis of hypertension (3). This change would be expected to lead to increased diagnosed hypertension prevalence. CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) to examine characteristics and trends in prevalence of self-reported diagnosed hypertension and antihypertensive medication use.
Methods
Data Source and Primary Measures
CDC analyzed data from BRFSS, a state-based telephone survey of noninstitutionalized U.S. adults aged ≥18 years.† The median response rates for the 50 states and the District of Columbia in 2017, 2019, and 2021 were 45.8% (range = 30.6%–64.1%), 49.4% (37.3%–73.1%), and 43.8% (23.5%–60.5%), respectively.§ Self-reported diagnosed hypertension (hypertension) was defined as an affirmative response to the question, “Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?” Respondents who reported that they were told they had blood pressure levels that were borderline high, elevated, prehypertensive, or had high blood pressure only during pregnancy were not classified as having hypertension. To determine whether persons with hypertension were being treated, respondents who answered the first question affirmatively were then asked, “Are you currently taking medicine for your high blood pressure?” Hypertension and treatment were assessed by age group (18–44, 45–64, and ≥65 years), sex (female and male), race and ethnicity (non-Hispanic White [White]; Black; Hispanic or Latino; non-Hispanic Asian [Asian]; non-Hispanic Native Hawaiian or other Pacific Islander [NH/OPI]; non-Hispanic American Indian or Alaska Native [AI/AN]; and non-Hispanic other [other] persons), highest level of education attained (less than high school graduate, high school diploma or general educational development certificate, some college, or college graduate or higher), and state of residence.
Data Analysis
Prevalence estimates were age-standardized to the 2000 U.S. Census Bureau population using three age groups (18–44, 45–64, and ≥65 years) for all characteristics except age-specific estimates. Prevalence differences (i.e., percentage point differences) between 2017 and 2021 were assessed using t-tests adjusted for sex, age, and race and ethnicity in a logistic regression model. P–values <0.05 were considered statistically significant. All analyses were conducted using SAS-callable SUDAAN (version 11.0.4; RTI International) to account for the complex sampling design and weighting. This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy.¶
Results
During 2017, 2019, and 2021, a total of 444,023, 409,810, and 431,639 participants, respectively, were interviewed. After investigators excluded participants who were pregnant (0.5%–0.6%), missing data for hypertension variables (0.4%–0.5%), and other covariates (3.2%–3.9%), the final analytic samples for 2017, 2019, and 2021 were 425,417 (96% of original sample), 392,100 (96%), and 410,318 (95%), respectively.
Hypertension Prevalence
From 2017 to 2021, the overall age-standardized prevalence of hypertension did not change, remaining at almost exactly 30% (Table 1). In 2021, hypertension prevalence was higher among men (33.2%) than among women (27.0%), among adults aged ≥65 years (60.6%) than among those aged 18–44 years (14.5%) and 45–64 years (40.3%), among Black adults (40.2%) than among Asian adults (22.7%), and among persons with less than a high school education (33.8%) than among those with some college (31.2%) or a college degree or higher education (25.5%).
Although the overall prevalence of hypertension remained unchanged, among persons with less than high school education, hypertension prevalence declined from 36.1% in 2017 to 33.8% in 2021 (p = 0.006). In contrast, a small but statistically significant increase in hypertension prevalence was observed among persons with some college (from 30.2% to 31.2%; p = 0.013) and among persons with college degrees or higher education (from 24.7% to 25.5%; p = 0.004).
By state, the age-standardized prevalence of hypertension ranged from 24.6% in Colorado to 40.6% in Mississippi in 2021. From 2017 to 2021, increases in the prevalence of hypertension were observed in five states (Georgia, Minnesota, Mississippi, Missouri, and Utah) and decreases were observed in three states (Hawaii, Illinois, and New Jersey). Hypertension prevalence was, in general, higher in southeastern and Appalachian states and lower in western states (Figure).
Antihypertensive Medication Use
From 2017 to 2021, age-standardized prevalence of antihypertensive medication use among adults with self-reported hypertension increased by 3.1 percentage points, from 59.8% to 62.9% (p<0.001) (Table 2). In 2021, the prevalence of medication use was higher among women (68.5%) than among men (59.4%), among adults aged ≥65 years (92.5%) than among those aged 18–44 years (42.5%), and among Black (71.3%) than among White adults (62%).
From 2017 to 2021, increases in antihypertensive medication use among persons with hypertension were reported among both men and women, persons aged 18–44 and 45–64 years, White adults, Black adults, and persons at all education levels except among those with less than a high school education, among whom medication use prevalence did not change.
By state, the prevalence of medication use among persons with reported hypertension ranged from 52.2% in Utah to 72.8% in Mississippi in 2021. Antihypertensive medication use increased in 11 states and did not decrease significantly in any state. In general, similar to the prevalence of hypertension, the prevalence of medication use among persons with hypertension was higher in southeastern and Appalachian states and lower in western states (Figure).
Discussion
Among U.S. adults, the age-standardized prevalence of self-reported diagnosed hypertension remained stable at approximately 30% from 2017 to 2021. Among persons with self-reported hypertension, reported antihypertensive medication use increased by approximately 3 percentage points from 2017 to 2021. Prevalences of hypertension and antihypertensive medication use among persons with hypertension differed by age, sex, race and ethnicity, education, and state of residence.
The 2017 Guideline for High Blood Pressure in Adults recommended lowering the blood pressure threshold for diagnosis of hypertension from ≥140 mmHg (systolic) to ≥130 mmHg, and from ≥90 mmHg (diastolic) to ≥80 mmHg (3). Significant increases in diagnosed hypertension prevalence would be anticipated with lower thresholds for diagnosis (4); however, despite this lower threshold, the prevalence of self-reported diagnosed hypertension did not change between 2017 and 2021. Using these lower thresholds for the diagnosis of hypertension (3), approximately one half of adults aged ≥18 years had hypertension during 2017–2020 (1). However, this analysis found that approximately one third of adults reported a diagnosis of hypertension. Several reasons could account for this finding. First, broad implementation of changes to clinical guidelines takes time, and differing guidelines that use higher thresholds (140/90 mmHg)** might attenuate any changes in diagnosed hypertension prevalence. Second, some clinical performance measures, which serve as tools to advance the translation of guidelines into clinical practice, were not modified to align with the lower thresholds (5). For example, the threshold for adequately controlled blood pressure for various insured populations used by one organization remains at the higher threshold of 140/90 mmHg.†† In addition, the COVID-19 pandemic might have affected blood pressure levels and diagnosis of hypertension. Early in the COVID-19 pandemic, an increase in measured blood pressure levels was reported in one longitudinal study (6). However, self-reported diagnosed hypertension prevalence did not increase among the overall U.S. population, which might have resulted, in part, from fewer visits to health care providers during the pandemic (7).
Application of the 2017 Hypertension Guideline was also expected to increase the number of adults who needed to initiate or increase medication to treat hypertension (8). Before 2017, reported antihypertensive medication use had been decreasing among persons with hypertension (9). Data in this report provide evidence that starting in 2017, antihypertensive medication use increased overall and across most sociodemographic subgroups and many states.
An increase in medication use will likely lead to improved control of hypertension among those treated. BRFSS does not measure hypertension control; however, data from the National Health and Nutrition Examination Survey showed that the prevalence of controlled blood pressure, using the 2017 blood pressure guideline definitions, did not significantly change from 2009–2012 (25.8%) to 2017–2020 (24.3%; p-value trend = 0.417) (10).
Limitations
The findings in this report are subject to at least five limitations. First, results are based on self-reported data, which likely underestimate actual hypertension prevalence. Second, median response rates of <50% across states might limit representatives of the BRFSS sample, resulting in either under- or overestimates of prevalence. However, the application of sampling weights likely reduces the impact of some nonresponse bias. Third, findings do not extend to adults in long-term care facilities, prisons, or those without a telephone, because BRFSS only collects data from noninstitutionalized adults with a landline or mobile telephone. Fourth, New Jersey in 2019 and Florida in 2021 were unable to collect sufficient BRFSS data to meet the minimum requirements for inclusion in the public-use data set; this might further limit the representativeness of the sample. Finally, because of small sample sizes in some demographic categories and jurisdictions, changes in prevalence might not be detectable.
Implications for Public Health Practice
Using the most recent self-reported state-level hypertension surveillance data, this report found that hypertension remains a significant public health concern with approximately one third of U.S. adults reporting hypertension, and approximately 60% of those persons reporting antihypertensive medication use. These findings can be used to increase awareness of hypertension and promote lifestyle modifications and antihypertensive medication use to optimize blood pressure control and reduce disparities in prevalence and control. Knowledge of trends in diagnosed hypertension and treatment is an essential tool for guiding state-level, individual, clinical, and public health policies and interventions, such as those promoted by the Million Hearts national initiative, to prevent cardiovascular disease.§§
Acknowledgments
Yanfeng Li, Wen Zhou, Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC.
Corresponding author: Ahlia Sekkarie, [email protected].
1Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC.
All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.
* https://www.cdc.gov/bloodpressure/docs/SG-CTA-HTN-Control-Report-508.pdf
§ https://www.cdc.gov/brfss/annual_data/2021/pdf/2021-DQR-508.pdf
¶ 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
†† https://www.ncqa.org/hedis/measures/controlling-high-blood-pressure/
§§ https://millionhearts.hhs.gov/about-million-hearts/optimizing-care/bp-control.html
References
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Abbreviations: AI/AN = American Indian or Alaska Native; BRFSS = Behavioral Risk Factor Surveillance System; GED = general educational development certificate; NH = non-Hispanic; NH/OPI = Native Hawaiian or other Pacific Islander.
* Directly standardized to the 2000 U.S. Census Bureau standard population.
† Adjusted for sex, age group, and race and ethnicity.
§ Persons of Hispanic or Latino (Hispanic) origin might be of any race but are categorized as Hispanic; all racial groups are non-Hispanic. The “other” category includes participants of multiple racial and ethnicity groups.
¶ New Jersey in 2019 and Florida in 2021 were unable to collect enough BRFSS data to meet the minimum requirements for inclusion in the BRFSS public-use data set.
FIGURE. Age-standardized prevalence* of self-reported diagnosed hypertension among adults (A) and use of antihypertensive medication among adults with hypertension (B), by state and the District of Columbia — Behavioral Risk Factor Surveillance System, United States, 2021
Abbreviation: DC = District of Columbia.
* Data are categorized as quintiles. In 2021, Florida was unable to collect enough Behavioral Risk Factor Surveillance System data to meet the minimum requirements for inclusion in the Behavioral Risk Factor Surveillance System public-use data set.
Abbreviations: AI/AN = American Indian or Alaska Native; BRFSS = Behavioral Risk Factor Surveillance System; GED = general educational development certificate; NH = non-Hispanic; NH/OPI = Native Hawaiian or other Pacific Islander.
* Directly standardized to the 2000 U.S. Census Bureau standard population.
† Adjusted for sex, age group, and race and ethnicity.
§ Persons of Hispanic or Latino (Hispanic) origin might be of any race but are categorized as Hispanic; all racial groups are non-Hispanic. The “other” category includes participants of multiple racial and ethnicity groups.
¶ New Jersey (2019) and Florida (2021) were unable to collect sufficient BRFSS data to meet the minimum requirements for inclusion in the BRFSS public-use data set.
Suggested citation for this article: Sekkarie A, Fang J, Hayes D, Loustalot F. Prevalence of Self-Reported Hypertension and Antihypertensive Medication Use Among Adults — United States, 2017–2021. MMWR Morb Mortal Wkly Rep 2024;73:191–198. DOI: http://dx.doi.org/10.15585/mmwr.mm7309a1.
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