January 27, 2026American Journal of Hypertension0 citations
View Full PaperWidespread use of low efficacy antihypertensive regimens for the initial treatment of hypertension among older US adults
Key Result
Among older US adults initiating antihypertensive therapy, 74% received monotherapy, and the top 25 regimens conferred an average expected systolic/diastolic BP reduction of only 8/4 mmHg.
Key Points
- The study aims to evaluate the efficacy of initial antihypertensive regimens for older adults in the US.
- Analyzed data from a 20% sample of Medicare beneficiaries aged ≥65 with hypertension.
- Focused on antihypertensive regimens initiated within 7 days of the first claim in 2023.
- Efficacy was estimated using a model based on 484 clinical trials, considering guideline-recommended classes.
- 74% of 52,031 beneficiaries received monotherapy for hypertension.
- Top 25 regimens accounted for 70% of treatment initiations with an average expected systolic BP reduction of 8 mmHg.
- When including non-guideline regimens, average expected systolic/diastolic BP reductions were 6/3 mmHg.
Study Design
Type
Observational (n=52,031)
Multicenter
Yes
Structured PICO
What is the expected blood pressure-lowering efficacy of initial antihypertensive regimens prescribed to older US adults?
P
Population
52,031 US Medicare beneficiaries aged ≥65 years with hypertension initiating antihypertensive therapy.
E
Exposure
Initial antihypertensive regimens (including guideline-recommended and non-guideline recommended drug classes).
O
Outcome
Expected blood pressure-lowering efficacy (systolic and diastolic BP reduction) estimated using a model derived from 484 randomized trials.surrogate
Most older US adults initiating hypertension treatment receive low-efficacy monotherapy, highlighting a significant gap between current prescribing practices and optimal blood pressure control strategies.
Abstract
Abstract Background The choice of starting antihypertensive regimen is important because most patients remain on their initial treatment, even when their blood pressure (BP) remains high. We examined the expected BP lowering efficacy of antihypertensive regimens initiated among US Medicare beneficiaries. Methods We analyzed data on a 20% random sample of Medicare beneficiaries aged ≥65 years with a diagnosis of hypertension. The initial regimen comprised all fills within 7 days of the first antihypertensive claim in 2023 with no fills in the previous 365 days. The primary analysis was restricted to regimens including ≥1 drug class recommended in the 2025 American Heart Association/American College of Cardiology BP guideline and secondary analysis included all antihypertensive drug classes. Expected BP-lowering efficacy for each regimen was estimated using www.bpmodel.org, a model derived from 484 double-blind placebo controlled randomized trials. Results Among 52,031 Medicare beneficiaries initiating antihypertensive medications, 74% received monotherapy. In total, 1,060 distinct drug combinations and 2,836 unique drug-dose permutations were filled. The top twenty-five regimens accounted for 70% of initiations and conferred an average expected systolic BP reduction of 8 mmHg and diastolic BP of 4 mmHg. When including non-guideline recommended antihypertensive regimens, the top 25 regimens were filled by 67% of patients initiating treatment, with an average expected systolic/diastolic BP reduction of 6/3 mmHg. Conclusions Most antihypertensive regimens initiated among US Medicare beneficiaries were low efficacy monotherapy. Initiating more effective antihypertensive therapy has the potential to improve BP control in the US.