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US Adults Affected by 2014 Hypertension Guidelines

By Roshini Isabell Selladurai

High blood pressure (hypertension) is a common condition that can lead to a variety of health problems, such as heart disease and kidney disease among others. In general, the more blood pumped by your heart and the narrower your arteries, the higher your blood pressure. Hypertension is known as the “silent killer,” because a person can be hypertensive for many years before experiencing any symptoms at all. Because high blood pressure can lead to serious health conditions, it is very important to diagnose hypertension as early as possible.


When measuring blood pressure, a nurse or physician will place an inflatable arm cuff around your arm and measure blood pressure (BP) using a pressure-measuring gauge. The BP reading is given in millimeters of mercury (mm Hg) and has two numbers (i.e. 120/80 mm Hg). The first number is the systolic pressure: this is the pressure in your arteries when your heart beats to pump out blood. The second number is the diastolic pressure: this is the pressure in your arteries between beats when your heart is being filled with blood.


Until recently, the guideline for systolic blood pressure treatment goal (JNC 7) was less than 140/90 mm Hg. Two recent trials, however, have demonstrated that there was no difference in outcomes in older (≥ 60 years) adults with hypertension between systolic treatment targets of 140 and 150 mm Hg. Therefore, the 2014 BP guideline increased the systolic BP treatment goal from less than 140/90 mm Hg to less than 150/90 mm Hg. 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.


Researchers sought to quantify the proportion of adults potentially affected by the new recommendations from the 2014 BP guideline. Their analysis used data from the National Health and Nutrition Examination Survey (NHANES) between 2005 and 2010. NHANES is designed to represent the non-institutionalized civilian US population. The NHANES sample weights were used for domain analysis to estimate the weighted percentage of adults in each segment of interest. Trained examiners measured blood pressure at mobile examination centers, and patient-reported hypertension medication use was assessed for those interviewed. The researchers 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. Since the 2014 BP guidelines specifically address adults recommended for receiving medication therapy, the researchers 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.


From 2005-2010, NHANES included 16,372 participants who had their BP measured. Overall rates of above-goal BP defined by the JNC 7 guideline were 11.9% and 41.3% in younger adults and in older adults, respectively, compared with 10.1% and 20.9% defined by the 2014 BP guideline in younger and older adults, respectively. Among younger adults, 7.4% had diabetes or CKD, whereas 26.3% of older adults had CKD and an additional 12.1% of older adults had diabetes without CKD. As mentioned above, the 2014 BP guideline increased the BP goals for adults with CKD and diabetes. As a result, 1.8% of young adults who were previously considered to have above-goal BP under JNC 7, now 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. Thus, 20.4% of adults aged 60 years or older who were previously considered to have above-goal BP under JNC 7, now would be reclassified as at goal under the 2014 BP guideline. Reclassified adults were predominantly older, included more women, and had high rates of pre-existing cardiovascular disease.


Under JNC, 31.7% of all US adults had treatment-eligible hypertension. Of adults with treatment-eligible hypertension under JNC 7, 40.6% met JNC 7 recommended BP goals. Under the 2014 BP guideline, 29.0% of all US adults had treatment-eligible hypertension. Rates of BP control among patients with treatment-eligible hypertension were increased under the 2014 BP guideline, with 56.5% of adults with treatment-eligible hypertension meeting BP goals.


In summary, three different groups of adults in the United States are affected by the 2014 BP guideline: 1) adults previously considered to have treatment-eligible hypertension, but who no longer meet criteria for medication therapy initiation; 2) 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; and 3) adults who achieved goal BP under stricter (i.e., lower) BP targets and are now potentially eligible for less intensive or even no therapy at all under the 2014 BP guideline. 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. Even with the new 2014 BP guidelines, however, an estimated 28 million adults were still considered to have above-goal BP. So even though the definition of optimal BP target can be debated, the numbers of adults with above-goal and untreated BP remains high.

So what does this mean for you? Well, if you are already on medication for hypertension, you should consult your physician about potentially adjusting your treatment. Since the new guidelines have raised the target BP, you may no longer be considered to have treatment-eligible hypertension. If you are not on medication or if you’re unsure about your blood pressure, you should consult your physician for a blood pressure reading to determine if treatment is necessary. Although the target systolic BP has been raised from 140 to 150 mm Hg, hypertension is still a common medical issue that must be taken seriously. Taking blood pressure measurements, even if you’re not experiencing any symptoms, can be to your benefit. The earlier hypertension is diagnosed, the earlier you can treat it, and the better the outcome!



Navar-Boggan AM, Pencina MJ, Williams K, Sniderman AD, Peterson, ED. Proportion of US Adults Potentially Affected by the 2014 Hypertension Guideline. JAMA. 2014;311(14):1424-1429.