The US Surgeon General’s Call-to-Action to Control Hypertension: Introduction to an American Journal of Hypertension Compendium

The high prevalence of hypertension among US adults has been recognized for decades.1,2 Multiple studies have documented that more cardiovascular disease events including ischemic coronary heart disease, stroke, and heart failure events can be attributed to hypertension compared with any other modifiable risk factor.3,4 Lowering blood pressure has been shown to reduce the risk for cardiovascular disease events and meta-analyses of randomized trials have shown that both lifestyle modification and antihypertensive medication are effective approaches for lowering blood pressure.5–7 During the 1990s and 2000s, there was great progress in increasing the proportion of US adults with hypertension who had their blood pressure controlled.8 According to the National Health and Nutrition Examination Survey (NHANES), the age-standardized proportion of US adults with hypertension who had systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg increased from 32% in 1999–2000 to 54% in 2013–2014. However, this positive trend appears to have reversed and only 44% of US adults with hypertension had systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg in 2017–2018. Furthermore, in 2017–2018, only 19% of US adults had controlled blood pressure according to the 2017 American College of Cardiology/American Heart Association blood pressure guideline definition, systolic blood pressure <130 mm Hg for all adults and diastolic blood pressure <80 mm Hg for adults <65 years of age and ≥65 years of age with high cardiovascular disease risk. The decline in the proportion of US adults with hypertension that have controlled blood pressure provides the context for the publication of The Surgeon General’s Call-to-Action to Control Hypertension.9 Published in October 2020, the call-to-action summarizes data on blood pressure control in the US population, provides goals and strategies to improve blood pressure control rates, and recommends focus areas for resource-limited settings to promote health equity with respect to blood pressure control. Goals outlined include making hypertension a national priority, ensuring the places where people live, learn, work, and play support hypertension control, and optimizing patient care for hypertension control. In 2021, the American Journal of Hypertension contacted leaders in the field of hypertension to address the importance and potential impact of the US Surgeon General’s Call-to-Action. The 5 manuscripts prepared in response to this request appear in this issue of the journal and emphasize the continued need for the US population including patients, healthcare providers, health systems and the community to come together to make hypertension control a national priority. Hypertension risk factors and approaches to control blood pressure among adults with hypertension are known.7 With this background, in the compendium, Mayfield et al. question why uncontrolled blood pressure is still common and hypertension still contributes to a high proportion of cardiovascular disease events in the United States.10 They call on US government agencies to use their regulatory authority to improve the nutritional status of the nation’s food supply and reduce sodium in processed food. Also, communities and employers are called upon to provide a supportive environment that focuses on the prevention of hypertension including healthy workplaces and school cafeterias, access to blood pressure monitoring and empowering people to take charge of their health and know if they have a healthy blood pressure. Communities are called upon to address the impact of structural racism, which has been shown to be associated with an increased risk for hypertension.11 Additionally, approaches to optimize patient care to control blood pressure through increasing healthcare insurance coverage and access to care, using team-based care and community healthcare workers and aligning financial incentives with improved patient outcomes are reviewed.12,13 The authors emphasize that small changes to the approaches currently being used to prevent and treat hypertension are not going to result in substantial improvements deemed necessary by the NHANES data and called for by the Surgeon General. The disparities in blood pressure control, with a lower proportion of non-Hispanic blacks compared with non-Hispanic whites with controlled blood pressure has been documented for decades.14 Despite this knowledge, non-Hispanic blacks continue to have higher blood pressure levels when compared with non-Hispanic whites.15 The Surgeon General’s Call-to-Action recognized the need to ensure health equity to increase blood pressure control for the US population. For the compendium, Colvin et al. provide data on racial, ethnic, and socioeconomic disparities in blood pressure control and approaches to achieve health equity with respect to the prevention of hypertension and increasing blood pressure control among those with hypertension.16 In line with the Surgeon General’s Call-to-Action, the social and economic factors that are the root causes of health inequities, including hypertension control, are defined and reviewed. The authors review the evidence on mechanisms through which social determinants of health contribute to hypertension and blood pressure control. Finally, they provide background on, and results from, trials designed to lower blood pressure and increase blood pressure control by directly addressing adverse social determinants of health. In closing, policy changes that are needed to facilitate health equity, prevent hypertension and increase blood pressure control are outlined. The economic cost of hypertension and uncontrolled blood pressure are tremendous. The costs of hypertension to the US healthcare system were estimated to be $71 billion in 2016.17 The Surgeon General’s Call-to-Action emphasized the high costs of hypertension and uncontrolled blood pressure. In the compendium, Tajeu et al. provide a review of the cost-effectiveness for strategies outlined in the Surgeon General’s Call-to-Action that can increase blood pressure control for individuals with hypertension including antihypertensive medication and nonpharmacologic treatment with diet and physical activity.18 Data are provided on the cost-effectiveness of implementing intensive blood pressure lowering, as was done in the Systolic Blood Pressure Intervention Trial and a community-based approach from the Los Angeles Barbershop study. The cost-effectiveness of standardized treatment approaches and self-measured blood pressure is reviewed. In closing the authors address knowledge gaps for the cost-effectiveness of several approaches to control blood pressure including implementation of the 2017 American College of Cardiology/American Heart Association guideline, the use of combination therapy and team-based care. For decades, the National Heart, Lung, and Blood Institute (NHLBI) and the Centers for Disease Control and Prevention (CDC) have made substantial contributions to research and interventions aimed to prevent hypertension and control blood pressure among people with hypertension. Following publication of data showing the plateauing of blood pressure control rates among the US population observed in the 2015–2016 NHANES, the NHLBI and CDC planned a 2-day workshop to discuss recent data on blood pressure control and approaches to improve blood pressure control.19 This workshop was held days before the publication of the Surgeon General’s Call-to-Action and 1 month after publication of the NHANES 2017–2018 blood pressure data and provided a forum to address approaches to reverse the downward trend in blood pressure control experienced by US adults. In the compendium, the workshop participants provide a summary of their discussions including data on current blood pressure control rates and barriers and facilitators to increase blood pressure control among US adults with hypertension.20 In addition to summarizing the workshop discussions, the article provides a list of best practices for improving blood pressure control and research gaps and opportunities. Self-measured blood pressure is an evidence-based approach to control blood pressure when used with cointerventions, such as clinician/pharmacist support.21 Many guidelines recommend self-measured blood pressure to improve blood pressure control.7,22 However, approximately half of US adults with hypertension report not performing self-measured blood pressure monitoring.23 With a clear gap in care and benefits of its use, self-measured blood pressure is emphasized as an intervention in the Surgeon General’s Call-to-Action. For the compendium, Wall et al. discuss actions being taken to increase the use of self-measured blood pressure.24 Additionally, they review barriers to the use of self-measured blood pressure monitoring and approaches that can be used to overcome these barriers including increasing dissemination of information on the availability of validated devices, improved coverage and reimbursement for self-measured blood pressure, and task sharing to provide multiple avenues for training patients to perform self-measured blood pressure monitoring. Hypertension and uncontrolled blood pressure have major impacts on individuals, communities, and society. Decades of research have provided evidence on approaches for individuals with hypertension to achieve blood pressure control. In providing the 5 articles on the Surgeon General’s Call-to-Action to Control Hypertension in the current issue of the American Journal of Hypertension, the journal is reaffirming its commitment to being part of the solution and supporting evidence-based approaches to prevent hypertension and control blood pressure among people with hypertension. While ambitious goals have been proposed by the Surgeon General and small changes will not be sufficient, as he noted in his Call-to-Action, “Together, we’ve got this!”