The prevalence and treatment of hypertension in Veterans Health Administration, assessing the impact of the updated clinical guidelines

INTRODUCTION

Hypertension (HTN) is the leading risk factor for cardiovascular disease (CVD) worldwide [1]. The landmark study, Systolic Blood PRessure INtervention Trial (SPRINT), demonstrated a compelling reduction in the risk of death and cardiovascular events with the targeting of lower blood pressure (BP) goals (SBP <120 mmHg) than previously recommended in individuals at high risk of CVD with SBP at least 130 mmHg [2]. Over the last few years, there has been a move to redefine lower BP cutoffs for the diagnosis of hypertension and to recommend targeting lower BP goals in patients with a diagnosis of hypertension. For example, the American College of Cardiology (ACC)/American Heart Association (AHA) undertook a systematic review [3] leading to the redefinition of hypertension as a BP at least 130/80 mmHg and the recommendation to lower BP goals to less than 130/80 mmHg for individuals at increased cardiovascular risk [4].

Several studies have shown that redefining hypertension increases the burden of hypertension significantly in several populations [5–11]. However, no study to date, has evaluated the impact of redefining hypertension among Veterans, a patient population with markedly increased risk of CVD and an already high prevalence of hypertension [12]. In March 2020, Veterans Health Administration (VHA), which represents one of the largest healthcare systems in the US, embraced a more stringent definition of hypertension for the SBP cutoff. Specifically, VHA and the Department of Defense (DoD) in conjunction with the Hypertension Clinical Practice Guideline (HTN CPG) working group have supported defining hypertension as SBP at least 130 mmHg and/or DBP at least 90 mmHg [13]. In addition, the working group recommended lowering the SBP goal to less than 130 mmHg for all patients with hypertension including those with diabetes. The potential implications of the more stringent guidelines on the prevalence and management of hypertension among Veterans are unknown. Here, we sought to evaluate the impact of the VHA/DoD and the ACC/AHA guidelines on the prevalence of hypertension in VHA and, among Veterans with known hypertension, we evaluated the implications of lowering the SBP treatment goal. In addition, we evaluated whether BP control improved over time.

METHODS Data source and study population

The data source for this study was the US Veterans Health Administration (VHA) database, which houses inpatient and outpatient medical records for all healthcare encounters within VHA. We performed a retrospective cohort study of Veterans who received care at the VA between 1 January 2016 and 31 December 2017. To be included in the analysis, Veterans were required to have had at least two outpatient measurements of BP during the period 1 January 2016 and 31 December 2017. This time-period was selected considering the ACC/AHA guideline was released in 2017. Patients were excluded if they had a history of dementia, metastatic cancer, severe liver disease, end-stage kidney disease, or were on palliative status or receiving midodrine. The ICD-10-CM diagnostic codes for the exclusion criteria are shown in Supplemental Table 1, https://links.lww.com/HJH/C167. To evaluate BP control over time, for each patient, a baseline period for assessing mean BP and hypertension was defined as the 12 months following the first BP measurement after 1 January 2016. Patients were followed up to 31 December 2021.

Blood pressure measurements

We included BP values during the baseline period if they were recorded during outpatient visits. These office BP values were obtained conventionally. We excluded nonphysiologic values as well as erroneous entries (i.e. SBP less than 40 mmHg or greater than 300 mmHg; DBP less than 10; and SBP less than DBP) [14,15]. If multiple readings were recorded for a single date, then we used the lowest systolic and lowest DBP [14,16]. To evaluate BP control over time (after the baseline period), we required at least one BP reading per year for the years of follow-up. For this portion of this analysis, in addition to the aforementioned exclusion criteria, we excluded Veterans who died prior to the follow-up period or those with SBP less than 100 mmHg at baseline (n = 62 052, 1.3%). If more than one BP reading was available per year, then average BP was utilized.

Definition of prevalent hypertension

Prevalent hypertension was evaluated to include known (diagnosed) hypertension and unknown (newly identified hypertension). Diagnosed hypertension was defined as either two or more separate outpatient visits with an ICD-10 CM diagnostic code related to hypertension during the study baseline period (Supplemental Table 2, https://links.lww.com/HJH/C167) [17], or receipt of any first-line therapy for hypertension management based on the VHA and ACC/AHA guidelines [4,13]. A detailed list of the included medications is shown in Supplemental Table 3, https://links.lww.com/HJH/C167. Newly identified hypertension was defined as at least two or more occurrences of elevated outpatient BP measurements (in accordance with the different guidelines) during the baseline period, with no ICD-10-CM Code for hypertension and no receipt of oral antihypertensive medications during the cohort period. Newly identified hypertension was evaluated based on the 2020 VHA/DoD HTN CPG defined as SBP at least 130 mmHg and/or DBP at least 90 mmHg, based on the 2017 ACC/AHA criteria defined as SBP at least 130 mmHg and/or DBP at least 80 mmHg [4], or based on the less stringent criteria of the Joint National Committee (JNC) 7 [18] and the European Society of Hypertension (ESH) 2021 [19] as SBP at least 140 mmHg and/or DBP at least 90 mmHg.

Definition of controlled versus uncontrolled hypertension

Among Veterans with known (diagnosed) hypertension, we evaluated the following categories: Uncontrolled per the VHA/DoD HTN CPG guideline defined as SBP at least 130 mmHg and/or DBP at least 90 mmHg, additionally uncontrolled based on the ACC/AHA criteria including those with DBP 80–89 mmHg, and controlled hypertension based on the ACC/AHA criteria defined as SBP less than 130 mmHg and DBP less than 80 mmHg [4].

Covariates

The baseline data included for the covariates were obtained at the time of first BP measurements. The following baseline variables were included in the analysis: age (years), sex (male, female), race (white, black, other), BMI that was calculated by height and weight measurements (kg/m2), and baseline comorbidity defined by the Agency for Healthcare Research and Quality Elixhauser comorbidity index [20].

Statistical analysis

First, we calculated the overall prevalence of hypertension including both diagnosed and newly identified hypertension and assessed the difference in the hypertension prevalence using the VHA/DoD criteria, the ACC/AHA criteria, and the JNC 7 and ESH criteria. We evaluated the demographics and clinical characteristics of the Veterans with newly identified hypertension according to three categories: SBP at least 140 or DBP at least 90 mmHg (JNC 7 and ESH), SBP at least 130 mmHg or DBP at least 90 mmHg (VHA/DoD), and DBP at least 80 mmHg (isolated diastolic hypertension according to the ACC/AHA criteria). We also examined the differences in individual components of hypertension diagnosis (ICD-10 CM, oral antihypertensive drugs, and actual BP values) according to the different cutoffs. Second, in those with known hypertension, we compared the baseline demographics and clinical characteristics for Veterans categorized as: controlled hypertension per the ACC/AHA guideline (SBP <130 mmHg and DBP <80 mmHg), uncontrolled hypertension per the VHA/DoD guideline (SBP ≥130 mmHg or DBP ≥90 mmHg), and those who are additional uncontrolled based on the ACC/AHA (DBP 80–89 mmHg).

Lastly, to better understand how the more stringent guidelines have impacted BP control over time, we evaluated BP over 5 years of follow-up among the Veterans with newly identified hypertension or known hypertension who are designated uncontrolled per the updated VHA/DoD or the ACC/AHA guidelines and who have at least one risk factor for CVD [2]. Only Veterans with complete BP data over the 5-year follow-up period were included. We report the mean (SD) of BP and the n (%) of Veterans with controlled BP over 5 years after the baseline period. Then we describe the n (%) with SBP in the following categories less than 130, 130–139, and at least 140 mmHg and DBP categories less than 80, 80–89, and at least 90 mmHg for years 1 through 5. A two-sided P value of 0.05 was considered to be statistically significant, and 95% CIs were presented for all relative risks. Analyses were conducted with SAS software version 9.4 (SAS Institute, Cary, North Carolina, USA).

RESULTS Overall prevalence of hypertension among veterans

We identified 5 224 462 patients with two or more valid BP measurements during 2016–2017, of which 385 911 were removed because of the presence of exclusion criteria. Of the 4 838 551 Veterans remaining for analysis, 3 438 363 (71%) Veterans were found to have prevalent hypertension based on ICD-10-CM codes, oral antihypertensive drug prescription, SBP at least 140, or DBP at least 90 mmHg (JNC 7 and ESH 2021) (Fig. 1). Of these hypertensive Veterans, 88% (n = 3 027 300) were captured either by ICD-10-CM codes or drug prescription (i.e. known/diagnosed hypertension) while the remaining 12% (n = 411 063) were identified based on their outpatient BP readings (SBP ≥140 or DBP ≥90 mmHg). When the VHA/DoD criteria were applied (SBP ≥130 mmHg or DBP ≥90 mmHg), an additional 492 106 Veterans were found to have hypertension and the prevalence of hypertension increased to 3 930 469 (81%). When applying the ACC/AHA diastolic cutoff (DBP ≥80 mmHg), another additional 268 732 Veterans were found to have hypertension with an overall prevalence of 87% (n = 4 199 201). These data are shown in Fig. 1.

F1FIGURE 1:

The change in the prevalence of hypertension based on each blood pressure cutoff. This depicts the change in the overall prevalence of hypertension based on the blood pressure (BP) cutoffs. The prevalence of hypertension was noted to increase from 71% with a definition of at least 140/90 mmHg (JNC 7 and ESC/ESH 2021 guidelines) to 81% with a definition of ≥at least 130/90 mmHg per the updated VHA/DoD guideline. Of note, applying the ACC/AHA definition of ≥130/80 mmHg increased the prevalence of hypertension to 87%. ACC/AHA, American College of Cardiology/American Heart Association; DoD, Department of Defense.

Next, we evaluated the patient factors of the 492 106 and the 268 732 Veterans with newly identified hypertension based on the VHA/DoD and ACC/AHA. These are shown in Table 1 in contrast to the 3 438 363 Veterans who were found to have prevalent hypertension based on ICD-10-CM codes, oral antihypertensive drug prescription, or BP cutoff based on the JNC 7/ESH criteria. The Veterans with newly identified hypertension based on the VHA/DoD and ACC/AHA criteria were younger and had a significantly lower burden of comorbid conditions than the Veterans diagnosed per the JNC 7/ESH 2021 criteria. Of the 492 106 Veterans with newly identified hypertension based on the VHA/DoD guideline, 186 577 (38%) were found to have at least one of the following CVD risk factors: age at least 65 years, history of diabetes, coronary artery disease, ischemic stroke, or advanced chronic kidney disease [4]. Among the additional 268 732 Veterans with newly identified isolated diastolic hypertension based on the ACC/AHA guidelines, 49 038 Veterans (18%) had at least one of the aforementioned CVD risk factors.

TABLE 1 - Clinical characteristics of Veterans with hypertension based on the more stringent criteria Characteristic Per JNC/ESH criteriaa (n = 3 438 363) Newly identified per VHA/DoD criteria (n = 492 106) Newly identified IDH per ACC/AHA criteriab (n = 268 732) P value Age (mean ± SD) 64.6 ± 13.7 54.5 ± 17.1 46.9 ± 14.4 <0.0001 Male gender [n (%)] 3 231 709 (94) 439 553 (89) 220 857 (82) <0.0001 Race [n (%)]  White 2 363 299 (69) 336 827 (68) 174 469 (65) <0.0001  Black 623 924 (18) 76 972 (16) 47 182 (18) <0.0001  Other 278 831 (8) 52 535 (11) 33 779 (13) <0.0001 Mean BMI (kg/m2) ± SD 30.7 ± 6.1 29.4 ± 5.5 29.2 ± 5.3 <0.0001 Comorbidities [n (%)]  Smoking history 442 070 (13) 56 604 (12) 29 938 (11) <0.0001  Diabetes mellitus 1 093 956 (32) 45 565 (9) 13 838 (5) <0.0001  Advanced CKDc 212 700 (6) 6211 (1) 1729 (0.6) <0.0001  Congestive heart failure 143 355 (4) 1993 (0.4) 526 (0.2) <0.0001  Cardiomyopathy 54 297 (2) 776 (0.2) 348 (0.1) <0.0001  Coronary artery disease 610 898 (18) 19 872 (4) 4447 (2) <0.0001  Atrial fibrillation 235 879 (7) 8388 (2) 2711 (1) <0.0001  Cardiac device use 70 709 (2) 2078 (0.4) 601 (0.2) <0.0001  Peripheral artery disease 207 778 (6) 8601 (2) 2189 (0.8) <0.0001  Ischemic stroke 144 680 (4) 5588 (1) 1590 (0.6) <0.0001  Chronic lung disease 519 836 (15) 49 191 (10) 21 392 (8) <0.0001  Pulmonary arterial hypertension 32 392 (0.9) 1868 (0.4) 753 (0.3) <0.0001  Sleep apnea 493 048 (14) 47 738 (10) 24 730 (9) <0.0001

CKD, chronic kidney disease; IDH, isolated diastolic hypertension; JNH, Joint National Committee; DoD, Department of Defense; VHA, Veterans Health Administration.

aPrevalent hypertension based on the previous definition including ICD-10-CM codes, oral antihypertensive drug prescription, or BP cutoff at least 140/90 mmHg in accordance with JNC 7 and ESC/ESH guidelines.

bVeterans with isolated diastolic hypertension in accordance with the ACC/AHA guidelines.

cAdvanced CKD without dialysis.


Prevalence of uncontrolled hypertension among veterans with known hypertension

Next, we evaluated BP control among Veterans with known hypertension by using mean SBP during the baseline period. Of the 2 768 826 Veterans with known hypertension, 949 875 (34%) were found to have controlled hypertension defined per the VHA/DoD guideline as mean SBP less than 130 mmHg and DBP less than 90 mmHg and 1 818 951 (66%) were found to have uncontrolled hypertension defined as mean SBP at least 130 mmHg or DBP at least 90 mmHg. When applying the ACC/AHA 2017 guideline, an additional 166 995 (6%) were found to have uncontrolled BP based on DBP at least 80 mmHg. Patient characteristics are shown in Table 2 for the following categories: controlled hypertension per the ACC/AHA guideline (SBP <130 mmHg and DBP <80 mmHg), uncontrolled hypertension per the VHA/DoD guideline (SBP ≥130 mmHg or DBP ≥90 mmHg), those who are additional uncontrolled based on the ACC/AHA (DBP 80–89 mmHg). Those with uncontrolled hypertension defined per the VHA/DoD guidelines were older, more likely to be of black race, and had higher BMI. In addition, they had higher rates of diabetes, congestive heart failure, coronary artery disease, chronic obstructive lung disease, and sleep apnea. Of note, the additional Veterans identified to have uncontrolled DBP based on the ACC/AHA guideline (n = 166 995) were generally younger and had lower rates of comorbidities including diabetes mellitus coronary artery disease, and congestive heart failure. Among the 1 818 951 with uncontrolled hypertension based on the VHA/DoD guideline, we identified n = 1 370 545 (75%) Veterans who had at least one risk factor for CVD. Among the additional 166 995 Veterans with uncontrolled DBP based on the ACC/AHA guideline, approximately 82 770 (50%) had at least one risk factor for CVD.

TABLE 2 - Characteristics of Veterans with known hypertension Baseline characteristics Class Overall (n = 2 768 826) Controlleda (ACC/AHA) (n = 782 880) Uncontrolled (VHA/DoD) (n = 1 818 951) Additional uncontrolled (ACC/AHA) (n = 166 995) P value Age category (years) [n (%)] <40 124 689 (5) 40 100 (5) 65 512 (4) 19 077 (11) <0.001 40–49 198 504 (7) 45 030 (6) 122 440 (7) 31 034 (19) 50–59 435 289 (16) 104 775 (13) 284 179 (16) 46 335 (28) 60–69 1 053 092 (38) 292 441 (37) 708 841 (30) 51 810 (3) 70–79 603 108 (22) 184 413 (24) 404 053 (22) 14 642 (9) ≥80 354 144 (13) 116 121 (15) 233 926 (13) 4097 (3) Male gender [n (%)] 2 615 045 (94) 733 619 (94) 1 730 309 (95) 151 117 (91) <0.001 Race category [n (%)] White 1 900 919 (69) 568 311 (73) 1 229 177 (68) 103 431 (62) <0.001 Black 507 309 (18) 110 634 (14) 356 855 (20) 39 820 (24) Other 222 398 (8) 62 899 (8) 143 176 (8) 16 323 (10) Mean BMI (kg/m2), SD 30.8 ± 6.1 30.3 ± 6.1 31.0 ± 6.1 31.0 ± 5.6 <0.001 Comorbidity [n (%)]  Smoking history 363 176 (13) 107 164 (14) 230 088 (13) 25 924 (16) <0.0001  Diabetes mellitus 982 565 (36) 292 007 (37) 651 804 (36) 38 754 (23) <0.0001  Advanced CKDb 193 449 (7) 58 235 (7) 129 383 (7) 5831 (4) <0.0001  Congestive heart failure 132 804 (5) 61 236 (8) 66 872 (4) 4696 (3) <0.0001  Cardiomyopathy 51 261 (2) 26 186 (3) 22 272 (1) 2803 (2) <0.0001  Coronary artery disease 554 291 (20) 207 714 (27) 328 892 (18) 17 685 (11) <0.0001  Atrial fibrillation 212 921 (8) 87 210 (11) 115 706 (6) 10 005 (6) <0.0001  Cardiac device use 64 801 (2) 31 488 (4) 30 798 (2) 2515 (2) <0.0001  Peripheral artery disease 186 465 (7) 61 202 (8) 119 869 (7) 5394 (3) <0.0001  Ischemic stroke 129 186 (5) 40 101 (5) 84 857 (5) 4228 (3) 0.59  Chronic lung disease 441 675 (16) 147 048 (19) 272 744 (15) 21 883 (13) <0.0001  Pulmonary arterial hypertension 28 839 (1) 11 322 (1) 16 026 (1) 1491 (1) <0.0001  Sleep apnea 429 284 (16) 126 670 (16) 273 185 (15) 29 429 (18) <0.0001

aControlled hypertension is defined as SBP less than 130 and DBP less than 90 mmHg per the VHA/DoD guideline.

bAdvanced CKD without dialysis.


Blood pressure control among veterans with newly identified hypertension who have at least one risk factor for cardiovascular disease

Among those Veterans at high risk of CVD, we found that neither mean SBP nor DBP improved over a 5-year follow-up period after baseline (Table 3). When we defined controlled hypertension as SBP less than 130 mmHg and DBP less than 90 mmHg, we observed a decline in the overall n (%) of Veterans with controlled hypertension from 16 513 (51%) in year 1 to 15 952 (50%), 15 669 (49%), 13 350 (41%), and 14 343 (45%) in years 2, 3, 4, and 5, respectively (P value for trend <0.0001). Additionally, the percent of Veterans with SBP in each of the following categories was evaluated over time: less than 130, 130–139 mmHg, and at least 140 mmHg. The number (%) of Veterans with SBP less than 130 mmHg decreased significantly and the number (%) of Veterans with SBP at least 140 mmHg increased significantly over time (Table 4). A similar trend was observed for the DBP categories less than 80, 80–89 mmHg, and at least 90 mmHg in this group and among the Veterans with newly identified hypertension based on the ACC/AHA criteria for DBP who had at least one CVD risk factor (Table 5).

TABLE 3 - Blood pressure valuesa over time for the Veterans with hypertension and at least one additional cardiovascular disease risk factor who have newly identified hypertension or known hypertension who are now uncontrolled based on the Veterans Health Administration/Department of Defense guideline Year 1 Year 2 Year 3 Year 4 Year 5 P value for trend Veterans with newly identified hypertension and ≥1 CVD risk factor SBP 130.1 (10.2) 130.9 (11.7) 131.2 (12.1) 133.5 (14.2) 132.5 (15.4) <0.0001 DBP 75.5 (7.1) 75.5 (7.3) 75.3 (7.2) 76.0 (8.0) 75.3 (8.5) <0.0001 Veterans with known hypertension, newly uncontrolled and ≥1 CVD risk factor SBP 141.9 (13.1) 141.3 (13.5) 140.8 (13.9) 142.5 (16.3) 141.4 (17.9) <0.0001 DBP 77.7 (8.4) 77.0 (8.2) 76.5 (8.1) 76.9 (8.9) 76.2 (9.5) <0.0001

aBP shown as mean (SD) for each year.


TABLE 4 - Blood pressure control among Veterans with newly identified hypertension based on the Veterans Health Administration/Department of Defense guideline SBP categories (mmHg) DBP categories (mmHg) Year <130 130–139 ≥140 <80 80–89 ≥90 Year 1 16 530 (51) 11 309 (35) 4382 (14) 23 504 (75) 8045 (24) 672 (2) Year 2 15 963 (49) 9968 (31) 6290 (20) 23 615 (75) 7821 (23) 785 (2) Year 3 15 679 (49) 9741 (30) 6801 (21) 23 955 (76) 7487 (22) 779 (2) Year 4 13 380 (41) 9506 (30) 9335 (29) 22 106 (71) 8825 (26) 1290 (3) Year 5 14 376 (45) 8890 (28) 8955 (28) 22 582 (72) 8244 (24) 1395 (4) Overall P value <0.0001 <0.0001
TABLE 5 - Blood pressure control among Veterans with newly identified isolated diastolic hypertension based on the ACC/AHA guideline DBP categories (mmHg) Year <80 80–89 ≥90 Year 1 5101 (67) 2375 (30) 181 (2) Year 2 5205 (69) 2226 (29) 226 (3) Year 3 5357 (71) 2069 (26) 231 (3) Year 4 4772 (63) 2508 (32) 377 (4) Year 5 4776 (63) 2451 (32) 430 (5) Overall P value <0.0001
Blood pressure control among veterans with known hypertension, who are uncontrolled with at least one risk factor for cardiovascular disease

As shown in Table 3, mean BP decreased significantly over time (P value for trend analysis, <0.0001) although the change in BP values was not clinically significant (less than 1 mmHg). Among the Veterans with uncontrolled hypertension defined as SBP at least 130 mmHg or DBP at least 90 mmHg and at least one CVD risk factor, we observed an increase in the overall n (%) of Veterans with controlled hypertension (defined as <130/90 mmHg) from 65 645 (16.4%) in year 1 to 75 953 (19%), 83 499 (21%), 84 022 (21%), and 102 455 (26%) in years 2–5, respectively (P value <0.0001). When we evaluated the n (%) of Veterans with SBP in each of the following categories: <130, 130–139 mmHg, and at least 130 mmHg, SBP control improved over time although the n (

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