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2017 Guideline for High Blood Pressure in Adults

The following are key points to remember from the 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults:

Part 1: General Approach, Screening, and Follow-up

The 2017 guideline is an update of the “Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure” (JNC 7), published in 2003. The 2017 guideline is a comprehensive guideline incorporating new information from studies regarding blood pressure (BP)-related risk of cardiovascular disease (CVD), ambulatory BP monitoring (ABPM), home BP monitoring (HBPM), BP thresholds to initiate antihypertensive drug treatment, BP goals of treatment, strategies to improve hypertension treatment and control, and various other important issues.
It is critical that health care providers follow the standards for accurate BP measurement. BP should be categorized as normal, elevated, or stages 1 or 2 hypertension to prevent and treat high BP. Normal BP is defined as <120/<80 mm Hg; elevated BP 120-129/<80 mm Hg; hypertension stage 1 is 130-139 or 80-89 mm Hg, and hypertension stage 2 is ≥140 or ≥90 mm Hg. Prior to labeling a person with hypertension, it is important to use an average based on ≥2 readings obtained on ≥2 occasions to estimate the individual’s level of BP. Out-of-office and self-monitoring of BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with clinical interventions and telehealth counseling. Corresponding BPs based on site/methods are: office/clinic 140/90, HBPM 135/85, daytime ABPM 135/85, night-time ABPM 120/70, and 24-hour ABPM 130/80 mm Hg. In adults with an untreated systolic BP (SBP) >130 but <160 mm Hg or diastolic BP (DBP) >80 but <100 mm Hg, it is reasonable to screen for the presence of white coat hypertension using either daytime ABPM or HBPM prior to diagnosis of hypertension. In adults with elevated office BP (120-129/<80) but not meeting the criteria for hypertension, screening for masked hypertension with daytime ABPM or HBPM is reasonable.
For an adult 45 years of age without hypertension, the 40-year risk for developing hypertension is 93% for African Americans, 92% for Hispanics, 86% for whites, and 84% for Chinese adults. In 2010, hypertension was the leading cause of death and disability-adjusted life-years worldwide, and a greater contributor to events in women and African Americans compared with whites. Often overlooked, the risk for CVD increases in a log-linear fashion; from SBP levels <115 mm Hg to >180 mm Hg, and from DBP levels <75 mm Hg to >105 mm Hg. A 20 mm Hg higher SBP and 10 mm Hg higher DBP are each associated with a doubling in the risk of death from stroke, heart disease, or other vascular disease. In persons ≥30 years of age, higher SBP and DBP are associated with increased risk for CVD, angina, myocardial infarction (MI), heart failure (HF), stroke, peripheral arterial disease, and abdominal aortic aneurysm. SBP has consistently been associated with increased CVD risk after adjustment for, or within strata of, SBP; this is not true for DBP.
It is important to screen for and manage other CVD risk factors in adults with hypertension: smoking, diabetes, dyslipidemia, excessive weight, low fitness, unhealthy diet, psychosocial stress, and sleep apnea. Basic testing for primary hypertension includes fasting blood glucose, complete blood cell count, lipids, basic metabolic panel, thyroid stimulating hormone, urinalysis, electrocardiogram with optional echocardiogram, uric acid, and urinary albumin-to-creatinine ratio.
Screening for secondary causes of hypertension is necessary for new-onset or uncontrolled hypertension in adults including drug-resistant (≥3 drugs), abrupt onset, age <30 years, excessive target organ damage (cerebral vascular disease, retinopathy, left ventricular hypertrophy, HF with preserved ejection fraction [HFpEF] and HF with reserved EF [HFrEF], coronary artery disease [CAD], chronic kidney disease [CKD], peripheral artery disease, albuminuria) or for onset of diastolic hypertension in older adults or in the presence of unprovoked or excessive hypokalemia. Screening includes testing for CKD, renovascular disease, primary aldosteronism, obstructive sleep apnea, drug-induced hypertension (nonsteroidal anti-inflammatory drugs, steroids/androgens, decongestants, caffeine, monoamine oxidase inhibitors), and alcohol-induced hypertension. If more specific clinical characteristics are present, screening for uncommon causes of secondary hypertension is indicated (pheochromocytoma, Cushing’s syndrome, congenital adrenal hyperplasia, hypothyroidism, hyperthyroidism, and aortic coarctation). Physicians are advised to refer patients screening positive for these conditions to a clinician with specific expertise in the condition.
Nonpharmacologic interventions to reduce BP include: weight loss for overweight or obese patients with a heart healthy diet, sodium restriction, and potassium supplementation within the diet; and increased physical activity with a structured exercise program. Men should be limited to no more than 2 and women no more than 1 standard alcohol drink(s) per day. The usual impact of each lifestyle change is a 4-5 mm Hg decrease in SBP and 2-4 mm Hg decrease in DBP; but diet low in sodium, saturated fat, and total fat and increase in fruits, vegetables, and grains may decrease SBP by approximately 11 mm Hg.
The benefit of pharmacologic treatment for BP reduction is related to atherosclerotic CVD (ASCVD) risk. For a given magnitude reduction of BP, fewer individuals with high ASCVD risk would need to be treated to prevent a CVD event (i.e., lower number needed to treat) such as in older persons, those with coronary disease, diabetes, hyperlipidemia, smokers, and CKD. Use of BP-lowering medications is recommended for secondary prevention of recurrent CVD events in patients with clinical CVD and an average SBP ≥130 mm Hg or a DBP ≥80 mm Hg, or for primary prevention in adults with no history of CVD but with an estimated 10-year ASCVD risk of ≥10% and SBP ≥130 mm Hg or DBP ≥80 mm Hg. Use of BP-lowering medication is also recommended for primary prevention of CVD in adults with no history of CVD and with an estimated 10-year ASCVD risk <10% and a SBP ≥140 mm Hg or a DBP ≥90 mm Hg. The prevalence of hypertension is lower in women compared with men until about the fifth decade, but is higher later in life. While no randomized controlled trials have been powered to assess outcome specifically in women (e.g., SPRINT), other than special recommendations for management of hypertension during pregnancy, there is no evidence that the BP threshold for initiating drug treatment, the treatment target, the choice of initial antihypertensive medication, or the combination of medications for lowering BP differs for women compared with men. For adults with confirmed hypertension and known CVD or 10-year ASCVD event risk of 10% or higher, a BP target of <130/80 mm Hg is recommended. For adults with confirmed hypertension, but without additional markers of increased CVD risk, a BP target of <130/80 mm Hg is recommended as reasonable.
Follow-up: In low-risk adults with elevated BP or stage 1 hypertension with low ASCVD risk, BP should be repeated after 3-6 months of nonpharmacologic therapy. Adults with stage 1 hypertension and high ASCVD risk (≥10% 10-year ASCVD risk) should be managed with both nonpharmacologic and antihypertensive drug therapy with repeat BP in 1 month. Adults with stage 2 hypertension should be evaluated by a primary care provider within 1 month of initial diagnosis, and be treated with a combination of nonpharmacologic therapy and 2 antihypertensive drugs of different classes with repeat BP evaluation in 1 month. For adults with a very high average BP (e.g., ≥160 mm Hg or DBP ≥100 mm Hg), prompt evaluation and drug treatment followed by careful monitoring and upward dose adjustment is recommended.

Part 2: Principles of Drug Therapy and Special Populations

Principles of drug therapy: Chlorthalidone (12.5-25 mg) is the preferred diuretic because of long half-life and proven reduction of CVD risk. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), and direct renin inhibitors should not be used in combination. ACE inhibitors and ARBs increase the risk of hyperkalemia in CKD and with supplemental K + or K + -sparing drugs. ACE inhibitors and ARBs should be discontinued during pregnancy. Calcium channel blocker (CCB) dihydropyridines cause edema. Non-dihydropyridine CCBs are associated with bradycardia and heart block and should be avoided in HFrEF. Loop diuretics are preferred in HF and when glomerular filtration rate (GFR) is <30 ml/min. Amiloride and triamterene can be used with thiazides in adults with low serum K + , but should be avoided with GFR <45 ml/min. Spironolactone or eplerenone is preferred for the treatment of primary aldosteronism and in resistant hypertension. Beta-blockers are not first-line therapy except in CAD and HFrEF. Abrupt cessation of beta-blockers should be avoided. Bisoprolol and metoprolol succinate are preferred in hypertension with HFrEF and bisoprolol when needed for hypertension in the setting of bronchospastic airway disease. Beta-blockers with both alpha- and beta-receptor activity such as carvedilol are preferred in HFrEF. Alpha-1 blockers are associated with orthostatic hypotension; this drug class may be considered in men with symptoms of benign prostatic hyperplasia. Central acting alpha 2 -agonists should be avoided, and are reserved as last-line due to side effects and the need to avoid sudden discontinuation. Direct-acting vasodilators are associated with sodium and water retention and must be used with a diuretic and beta-blocker.
Initial first-line therapy for stage 1 hypertension includes thiazide diuretics, CCBs, and ACE inhibitors or ARBs. Two first-line drugs of different classes are recommended with stage 2 hypertension and average BP of 20/10 mm Hg above the BP target. Improved adherence can be achieved with once-daily drug dosing, rather than multiple dosing, and with combination therapy rather than administration of the free individual components. For adults with confirmed hypertension and known stable CVD or ≥10% 10-year ASCVD risk, a BP target of <130/80 mm Hg is recommended. The strategy is to first follow standard treatment guidelines for CAD, HFrEF, previous MI, and stable angina, with the addition of other drugs as needed to further control BP. In HFpEF with symptoms of volume overload, diuretics should be used to control hypertension, following which ACE inhibitors or ARBs and beta-blockers should be titrated to SBP <130 mm Hg. Treatment of hypertension with an ARB can be useful for prevention of recurrence of atrial fibrillation.
CKD: BP goal should be <130/80 mm Hg. In those with stage 3 or higher CKD or stage 1 or 2 CKD with albuminuria (>300 mg/day), treatment with an ACE inhibitor is reasonable to slow progression of kidney disease. An ARB is reasonable if an ACE inhibitor is not tolerated.
Adults with stroke and cerebral vascular disease are complex. To accommodate the variety of important issues pertaining to BP management in the stroke patient, treatment recommendations require recognition of stroke acuity, stroke type, and therapeutic objectives, which along with ideal antihypertensive therapeutic class have not been fully studied in clinical trials. In adults with acute intracranial hemorrhage and SBP >220 mm Hg, it may be reasonable to use continuous intravenous drug infusion with close BP monitoring to lower SBP. Immediate lowering of SBP to <140 mm Hg from 150-220 mm Hg is not of benefit to reduce death, and may cause harm. In acute ischemic stroke, BP should be lowered slowly to <185/110 mm Hg prior to thrombolytic therapy and maintained to <180/105 mm Hg for at least the first 24 hours after initiating drug therapy. Starting or restarting antihypertensive therapy during the hospitalization when patients with ischemic stroke are stable with BP >140/90 mm Hg is reasonable. In those who do not undergo reperfusion therapy with thrombolytics or endovascular treatment, if the BP is ≥220/120 mm Hg, the benefit of lowering BP is not clear, but it is reasonable to consider lowering BP by 15% during the first 24 hours post onset of stroke. However, initiating or restarting treatment when BP is <220/120 mm Hg within the first 48-72 hours post-acute ischemic stroke is not effective. Secondary prevention following a stroke or transient ischemic attack (TIA) should begin by restarting treatment after the first few days of the index event to reduce recurrence. Treatment with ACE inhibitor or ARB with thiazide diuretic is useful. Those not previously treated for hypertension and who have a BP ≥140/90 mm Hg should begin antihypertensive therapy a few days after the index event. Selection of drugs should be based on comorbidities. A goal of <130/80 mm Hg may be reasonable for those with a stroke or TIA. For those with an ischemic stroke and no previous treatment for hypertension, there is no evidence of treatment benefit if the BP is <140/90 mm Hg.
Diabetes mellitus (DM) and hypertension: Antihypertensive drug treatment should be initiated at a BP ≥130/80 mm Hg with a treatment goal of <130/80 mm Hg. In adults with DM and hypertension, all first-line classes of antihypertensive agents (i.e., diuretics, ACE inhibitors, ARBs, and CCBs) are useful and effective. ACE inhibitors or ARBs may be considered in the presence of albuminuria.
Metabolic syndrome: Lifestyle modification with an emphasis on improving insulin sensitivity by means of dietary modification, weight reduction, and exercise is the foundation of treatment of the metabolic syndrome. The optimal antihypertensive drug therapy for patients with hypertension in the setting of the metabolic syndrome has not been clearly defined. Chlorthalidone was at least as effective for reducing CV events as the other antihypertensive agents in the ALLHAT study. Traditional beta-blockers should be avoided unless used for ischemic heart disease.
Valvular heart disease: Asymptomatic aortic stenosis with hypertension should be treated with pharmacotherapy, starting at a low dose, and gradually titrated upward as needed. In patients with chronic aortic insufficiency, treatment of systolic hypertension is reasonable with agents that do not slow the heart rate (e.g., avoid beta-blockers).
Aortic disease: Beta-blockers are recommended as the preferred antihypertensive drug class in patients with hypertension and thoracic aortic disease.
Race/ethnicity: In African American adults with hypertension but without HF or CKD, including those with DM, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. Two or more antihypertensive medications are recommended to achieve a BP target of <130/80 mm Hg in most adults, especially in African American adults, with hypertension.
Age-related issues: Treatment of hypertension is recommended for noninstitutionalized ambulatory community-dwelling adults (≥65 years of age), with an average SBP ≥130 mm Hg with SBP treatment goal of <130 mm Hg. For older adults (≥65 years of age) with hypertension and a high burden of comorbidity and/or limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs. BP lowering is reasonable to prevent cognitive decline and dementia.
Preoperative surgical procedures: Beta-blockers should be continued in persons with hypertension undergoing major surgery, as should other antihypertensive drug therapy until surgery. Discontinuation of ACE inhibitors and ARBs perioperatively may be considered. For patients with planned elective major surgery and SBP ≥180 mm Hg or DBP ≥110 mm Hg, deferring surgery may be considered. Abrupt preoperative discontinuation of beta-blockers or clonidine may be harmful. Intraoperative hypertension should be managed with intravenous medication until oral medications can be resumed.
For discussion regarding hypertensive crises with and without comorbidities, refer to Section 11.2: Hypertensive Crises–Emergencies and Urgencies in the Guideline.
Every adult with hypertension should have a clear, detailed, and current evidence-based plan of care that ensures the achievement of treatment and self-management goals; effective management of comorbid conditions; timely follow-up with the healthcare team; and adheres to CVD evidence-based guidelines. Effective behavioral and motivational strategies are recommended to promote lifestyle modification. A structured team-based approach including a physician, nurse, and pharmacist collaborative model is recommended, along with integrating home-based monitoring and telehealth interventions. Outcome may be improved with quality improvement strategies at the health system, provider, and patient level. Financial incentives paid to providers can be useful.

Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Stable Ischemic Heart Disease, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Diet, Exercise, Hypertension, Chronic Angina

Keywords: Adrenergic beta-Antagonists, AHA17, AHA Annual Scientific Sessions, Antihypertensive Agents, Aortic Diseases, Atherosclerosis, Atrial Fibrillation, Blood Pressure, Blood Pressure Monitoring, Ambulatory, Body Weight Changes, Cerebral Hemorrhage, Cerebrovascular Disorders, Coronary Artery Disease, Diabetes Mellitus, Diagnostic Imaging, Diagnostic Techniques, Cardiovascular, Diet, Electronic Health Records, Exercise, Geriatrics, Heart Failure, Heart Valve Diseases, Hypertension, Life Style, Mass Screening, Medical History Taking, Metabolic Syndrome, Patient Compliance, Patient Care Team, Perioperative Period, Peripheral Arterial Disease, Peripheral Vascular Diseases, Pregnancy, Primary Prevention, Quality of Health Care, Renal Insufficiency, Chronic, Risk Assessment, Risk Factors, Risk Reduction Behavior, Secondary Prevention, Self Care, Angina, Stable, Stroke, Telemedicine, Therapeutics, Transplantation

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Case Study Questions

1 . According to the U.S. Preventive Services Task Force (USPSTF) recommendation statement, which one of the following steps regarding screening for hypertension is appropriate for M.C.?

A. Screen M.C. for hypertension today because of the patient's history of polycystic ovary syndrome.

B. Defer screening M.C. for hypertension for another two to four years because the patient's blood pressure was not elevated one year ago.

C. Screen M.C. for hypertension today because the patient's body mass index is in the overweight range.

D. Defer screening M.C. for hypertension until 40 years of age.

E. Ask M.C. to begin monitoring their blood pressure at home.

2 . M.C. had a blood pressure of 143/81 mm Hg upon arrival in the examination room. M.C. reports no headache, blurry vision, chest pain, shortness of breath, or blood in urine. According to the USPSTF recommendation statement, which one of the following steps is correct?

A. Prescribe the patient an angiotensin-converting enzyme inhibitor, such as lisinopril, and schedule a follow-up visit in three months.

B. Ask M.C. to monitor their blood pressure at home and schedule a follow-up visit to discuss the results.

C. Prescribe the patient a calcium channel blocker, such as amlodipine (Norvasc), and schedule a follow-up visit in three months.

D. Wait until the next follow-up visit in six to 12 months to confirm the diagnosis of hypertension.

E. Repeat the blood pressure measurement today and prescribe an antihypertensive medication if the blood pressure remains elevated.

3 . Which of the following blood pressure monitoring methods can you use to confirm a diagnosis of hypertension in this patient?

A. Ask M.C. to wear a programmed portable device that automatically takes blood pressure measurements, typically in 20- to 30-minute intervals over 12 to 24 hours, while patients go about their normal activities or are sleeping.

B. Ask M.C. to measure their own blood pressure at home with an automated device placed on the upper arm.

C. Ask M.C. to follow up in the office in two months to reassess their blood pressure on another day.

D. No additional blood pressure readings are necessary to confirm the diagnosis of hypertension.

1. The correct answer is C . Although available evidence on optimal screening intervals for hypertension remains limited, 1 the USPSTF suggests annual screening for hypertension in adults 40 years or older and for adults at increased risk for hypertension, including Black people, people with high-normal blood pressure, or people who are overweight or obese. Screening less frequently (i.e., every three to five years) is appropriate for adults 18 to 39 years of age not at increased risk for hypertension and with a previous normal blood pressure reading. 2 Polycystic ovary syndrome is not considered, in itself, an indication for annual blood pressure screening.

2. The correct answer is B . For adults 18 years or older without known hypertension, the USPSTF recommends screening for hypertension with office blood pressure measurement. The USPSTF recommends obtaining blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment. 2 Selection of treatment can vary depending on severity of blood pressure elevation, age, and other risk factors.

3. The answers are A and B . The USPSTF recommends obtaining blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment. 2 Either ambulatory or home blood pressure monitoring with validated and accurate devices can be used to confirm a diagnosis of hypertension before starting treatment. Ambulatory blood pressure monitoring involves wearing a programmed device that automatically takes frequent blood pressure measurements over the course of a day (or day and night). Ambulatory blood pressure monitoring devices are small, portable machines that record blood pressure noninvasively at typically 20- to 30-minute intervals over 12 to 24 hours while patients go about their normal activities or are sleeping. See a related article in FPM about implementing ambulatory blood pressure monitoring for more information. 3 Home blood pressure monitoring involves patients measuring their own blood pressure at home with a home blood pressure monitoring device. Home blood pressure monitoring devices are fully automated oscillometer devices that record measurements taken from the patient's brachial artery. Home blood pressure monitoring devices are activated by patients or caregivers, and measurements are taken much less frequently than with ambulatory blood pressure monitoring (e.g., one to two times a day or week, although the blood pressure measurements can be spread out over more time). 2

The views expressed in this work are those of the authors and do not reflect the official policy or position of the Johns Hopkins Bloomberg School of Public Health or the U.S. government.

This PPIP quiz is based on the recommendations of the USPSTF. More information is available in the USPSTF Recommendation Statement and supporting documents on the USPSTF website ( https://www.uspreventiveservicestaskforce.org ). The practice recommendations in this activity are available at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hypertension-in-adults-screening .

Guirguis-Blake JM, Evans CV, Webber EM, et al. Screening for hypertension in adults: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2021;325(16):1657-1669.

Krist AH, Davidson KW, Mangione CM. Screening for hypertension in adults: US Preventive Services Task Force reaffirmation recommendation statement. JAMA. 2021;325(16):1650-1656.

Kronish IM, Hughes C, Quispe K, et al. Implementing ambulatory blood pressure monitoring in primary care practice. FPM. 2020;27(3):19-25. Accessed June 13, 2021. https://www.aafp.org/fpm/2020/0500/p19.html

This series is coordinated by Joanna Drowos, DO, contributing editor.

A collection of Putting Prevention Into Practice published in AFP is available at https://www.aafp.org/afp/ppip.

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The impact of routine follow-up with health care teams on blood pressure control among patients with hypertension

Hui-Juan Zuo 1 na1 ,
Ji-Xiang Ma 2 na1 ,
Jin-Wen Wang 1 ,
Xiao-Rong Chen 2 &
Lei Hou 2

Journal of Human Hypertension volume 33 , pages 466–474 ( 2019 ) Cite this article

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Disease prevention
Hypertension

A series of guidelines concerning hypertension emphasize the importance of follow-up in patients’ management. The aim of this study was to assess the impact of routine follow-up on blood pressure (BP) control. A total of 1511 patients with hypertension aged ≥ 35 years were selected randomly from 17 communities in two cities and four townships located in Shandong and Jiangsu provinces in China. About half of the patients visited the community clinic four or more times yearly; follow-up was conducted by telephone for 43.3%. Forty-four point two percent of patients who did not visit a community clinic received telephonic follow-up; a higher percentage of telephonic follow-up was found in patients who visited community clinics frequently. Positive changes in BP level and BP control were associated with the number of clinical visits, while no significant correlations were found with telephonic follow-up. After adjustment for covariates, a higher number of clinic visits was associated with better BP control, with odds ratios of 1.628 (95% confidence interval (CI): 1.141–2.322), 1.472 (95% CI: 1.008–2.271), and 1.790 (95% CI: 1.154–2.778) for 4–6, 7–12, and >12 visits/year, respectively. Taking an antihypertensive drug showed a strong, positive association with the number of clinic visits (OR 1.747, 95% CI: 1.484–2.056). These data suggest that health care systems may achieve greater success by increasing the frequency of clinical visits and that the positive changes may be related to improvement in medication adherence. Routine follow-up by telephone was not significantly associated with BP level and BP control.

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Blood pressure outcomes at 12 months in primary care patients prescribed remote physiological monitoring for hypertension: a prospective cohort study

A randomized controlled trial on home blood pressure monitoring and quality of care in stage 2 and 3 hypertension

Remote follow-up by pharmacists for blood pressure control in patients with hypertension: a systematic review and a meta-analysis of randomized controlled trials

National Center for Cardiovascular Disease, China. Report on cardiovascular disease in China. Beijing: Encyclopedia of China Publishing House; 2017. p. 16-18.

Wang J, Zhang L, Wang F, Liu L, Wang H, on behalf of the China National Survey of Chronic Kidney Disease Working Group. Prevalence, awareness, treatment and control of hypertension in China: results from a national survey. Am J Hypertens. 2014;27:1355–61.

Article CAS Google Scholar

Guo F, He D, Zhang W, Walton RG. Trends in prevalence awareness management and control of hypertension among United States adults 1999 to 2010. J Am Coll Cardiol. 2012;60:599–606.

Article Google Scholar

Kelly TN, Gu D, Chen J, Huang J, Chen J, Duan X, et al. Hypertension subtype and risk of cardiovascular disease in Chinese adults. Circulation. 2008;118:1558–66.

Marshall IJ, Wolfe CD, McKevitt C. Lay perspectives on hypertension and drug adherence: systematic review of qualitative research. BMJ. 2012;345:e3953.

Fort MP, Alvaradomolina N, Peña L, Montano CM, Murrillo S. Barriers and facilitating factors for disease self-management: a qualitative analysis of perceptions of patients receiving care for type 2 diabetes and/or hypertension in San José, Costa Rica and Tuxtla Gutiérrez, Mexico. BMC Fam Prac. 2013;14:1–9.

Chobanian AV. The hypertension paradox—more uncontrolled disease despite improved therapy. N Engl J Med. 2009;361:878–87.

Jaffe MG, Lee GA, Young JD, Go AS. Improved blood pressure control associated with a large-scale hypertension program. JAMA. 2013;310:699–705.

Fletcher RD, Amdur RL, Kolodner R, Mcmanus C, Jones R, Faselis C, et al. Blood pressure control among US veterans: a large multiyear analysis of blood pressure data from the Veterans Administration health data repository. Circulation. 2012;125:2462–8.

Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison HC, et al. 2017 ACC/AHA/AAPA /ABC/ACPM/AGS/APhA /ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension. 2017; https://doi.org/10.1161/HYP.0000000000000065 .

Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Lzzo JL, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560–72.

Revision Committee of China guideline on hypertension prevention and control. Hypertension prevention and cure guideline of China 2010. Zhong Hua Xin Xue Guan Bing Za Zhi. 2011;39:579–616.

Google Scholar

Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353:487–97.

Vrijens B, Vincze G, Kristanto P, Urquhart J, Burnier M. Adherence to prescribed antihypertensive drug treatments: longitudinal study of electronically compiled dosing histories. BMJ. 2008;336:1114–7.

James PA, Oparil S, Carter BL, Cushman WC, Gennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA . 2014;311:507–20.

Giuseppe M, Robert F, Krzysztof N, Josep R, Alberto Z, Michael B, et al. ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2013;2013:1281–357.

Ministry of Health, People’s Republic of China. On the Issuance of “National Basic Public Health Services Specification (2011 edition)”; 2017. http://www.nhfpc.gov.cn/cmsresources/mohfybjysqwss/cmsrsdocument/doc12006.do c.

Turchin A, Goldberg SI, Shubina M, Einbinder JS, Conlin PR. Encounter frequency and blood pressure in hypertensive patients with diabetes mellitus. Hypertension. 2010;56:68–74.

Li Y, Ren DF, Ding PF, Zhang Q, Zhang J, Shi WS, et al. Evaluation on programs regarding the community—based management of hypertension and type 2 diabetes mellitus patients in eight provinces, China. Zhong Hua Liu Xing Bing Xue Za Zhi. 2014;35:35–9.

Wang ZW, Wang X, Wang W, Chen WW, Zhu ML, Hu SS, et al. The current situation of blood pressure control and the influencing factors on hypertensive patients in residential communities of China. Zhong hua liu xing Bing xue za zhi. 2012;33:903–6.

Pulgarón ER, Hernandez J, Dehaan H, Patiño-Fernandez AM, Carrillo A, Sanchez J, et al. Clinic attendance and health outcomes of youth with type 2 diabetes mellitus. Int J Adolesc Med Health. 2015;27:271–4.

Fontil V, Bibbins-Domingo K, Dhruv SK, Stephen S, Pamela GC, Raman K, et al. Simulating strategies for improving control of hypertension among patients with usual source of care in the United States: The Blood Pressure Control Model. J Gen Intern Med. 2015;30:1147–55.

Morgado MP, Morgado SR, Mendes LC, Pereira LJ, Castelo-Branco M. Pharmacist interventions to enhance blood pressure control and adherence to antihypertensive therapy: review and meta-analysis. Am J Health Syst Pharm. 2011;68:241–53.

Rader F, Elashoff RM, Niknezhad S, Victor RG. Differential treatment of hypertension by primary care providers and hypertension specialists in a barber-based intervention trial to control hypertension in Black men. Am J Cardiol. 2013;112:1421–6.

Tang S, Ghose JB, Ji L, Feng D, Fang H, Fu H, et al. Improving the blood pressure control with the proactive attitude of hypertensive patients seeking follow-up services: evidence from China. Medicine. 2016;95:e3233.

Reed SD, Li Y, Oddone EZ, Nearly AM, Orr MM, Grubber JM, et al. Economic evaluation of home blood pressure monitoring with or without telephonic behavioral self-management in patients with hypertension. Am J Hypertens. 2010;23:142–8.

Hallberg I, Taft C, Ranerup A, Bengtsson U, Hoffmann M, Höfer S, et al. Phases in development of an interactive mobile phone-based system to support self-management of hypertension. Integr Blood Press Control. 2014;7:19–28.

Bengtsson U, Kjellgren K, Höfer S, Taft C, Ring L. Developing an interactive mobile phone self-report system for self-management of hypertension. Part 2: Content validity and usability. Blood Press. 2014;23:296–306.

Sim JJ, Shi J, Kovesdy CP, et al. Impact of achieved blood pressures on mortality risk and end-stage renal disease among a large, diverse hypertension population. J Am Coll Cardiol. 2014;64:588–97.

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Acknowledgements

We thank the staff of the Community Health Service Centers and CDC in Shandong and Jiangsu province for their assistance and their organizational support. We also thank Richard Lipkin, PhD, from Liwen Bianji, Edanz Group China ( www.liwenbianji.cn/ac ), for editing the English text of a draft of this manuscript.

This publication (journal article, etc.) was supported by the Cooperative Agreement Number, 5 U19 GH 000636, funded by The US Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.

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These authors contributed equally: Hui-Juan Zuo, Ji-Xiang Ma

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Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, 100029, Beijing, China

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Department of Chronic Non-communicable Diseases Prevention, Chinese Center for Disease Control and Prevention, 100050, Beijing, China

Ji-Xiang Ma, Xiao-Rong Chen & Lei Hou

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Zuo, HJ., Ma, JX., Wang, JW. et al. The impact of routine follow-up with health care teams on blood pressure control among patients with hypertension. J Hum Hypertens 33 , 466–474 (2019). https://doi.org/10.1038/s41371-018-0158-7

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Accepted : 13 December 2018

Published : 15 January 2019

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Recommendations

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Recommendation Topics
Recommendation: Hypertension in Adults: Screening

Final Recommendation Statement

Hypertension in adults: screening, april 27, 2021.

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Recommendation Summary

Clinician summary.

The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation.

View the Clinician Summary in PDF

Additional Information

Supporting Evidence and Research Taxonomy
Related Resources & Tools
Final Evidence Review (April 27, 2021)
Evidence Summary (April 27, 2021)
Final Research Plan (October 04, 2018)
Screening for Hypertension in Adults: AFP's Putting Prevention Into Practice - Educational Tools
Hypertension Resources for Health Professionals (Centers for Disease Control and Prevention) - For Providers
The Surgeon General's Call to Action to Control Hypertension - For Providers
The Community Guide: Cardiovascular Disease - For Providers
Million Hearts Initiative - For Providers
Detección de la hipertensión en adultos
JAMA Patient Page: Screening for Hypertension in Adults
JAMA Podcast: Screening for Hypertension in Adults
Measure Your Blood Pressure (Centers for Disease Control and Prevention)

Recommendation Information

Full recommendation:.

Hypertension is a prevalent condition, affects approximately 45% of the adult US population, 1 and is the most commonly diagnosed condition at outpatient office visits. Hypertension is a major contributing risk factor for heart failure, myocardial infarction, stroke, and chronic kidney disease.

Reaffirmation

In 2015, the US Preventive Services Task Force (USPSTF) reviewed the evidence for screening for hypertension in adults and issued an A recommendation. 2 The USPSTF has decided to use a reaffirmation deliberation process to update this A recommendation. The USPSTF uses the reaffirmation process for well-established, evidence-based standards of practice in current primary care practice for which only a very high level of evidence would justify a change in the grade of the recommendation. 3 In its deliberation of the evidence, the USPSTF considers whether any new evidence is of sufficient strength and quality to change its previous conclusions about the evidence.

Using a reaffirmation deliberation process, the USPSTF concludes with high certainty that screening for hypertension in adults has substantial net benefit .

See the Table for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual. 3

Patient Population Under Consideration

This recommendation applies to adults 18 years or older without known hypertension.

Definitions

Increasing blood pressure predicts an increased risk of cardiovascular disease. 4 , 5 Generally, the threshold used to define hypertension vs normal blood pressure by various organizations ranges from 130/80 mm Hg or greater to 140/90 mm Hg or greater. 6 , 7 For the purposes of this recommendation, the USPSTF reviewed evidence from studies that included any threshold used to define hypertension. 8 , 9 Hypertension (also referred to as “sustained hypertension”) is when a person has repeatedly high blood pressure measurements over time and in various settings.

Assessment of Risk

Although all adults should be screened for hypertension, risk factors that increase a person’s risk for the condition include older age, Black race, family history, excess weight and obesity, lifestyle habits (lack of physical activity, stress, and tobacco use), and dietary factors (diet high in fat or sodium, diet low in potassium, or excessive alcohol intake). 8-10

Screening Tests

Initial screening for hypertension should be performed with office blood pressure measurement (OBPM). Office blood pressure measurement is most commonly performed using a manual or automated sphygmomanometer. 8 , 9 Various OBPM protocols are available; however, in the studies reviewed by the USPSTF, OBPM was measured at the brachial artery (upper arm) with the patient most commonly in a seated position after 5 minutes of rest and medical personnel present during measurement. 8 , 9 Ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) with validated and accurate devices should be used outside of a clinical setting to confirm a diagnosis of hypertension before starting treatment. Ambulatory blood pressure monitoring involves wearing a programmed device that automatically takes frequent blood pressure measurements over the course of a day (or day and night); HBPM involves patients measuring their own blood pressure at home with an HBPM device.

Screening Intervals

Available evidence on optimal screening intervals for hypertension remains limited. 8 , 9 The USPSTF suggests annual screening for hypertension in adults 40 years or older and for adults at increased risk for hypertension (such as Black persons, persons with high-normal blood pressure, or persons who are overweight or obese). Screening less frequently (ie, every 3 to 5 years) is appropriate for adults aged 18 to 39 years not at increased risk for hypertension and with a prior normal blood pressure reading.

The benefits of treatment of hypertension in preventing important health outcomes such as stroke, heart failure, and coronary heart disease events are well documented. 11 Treatment can include lifestyle changes, pharmacotherapy, or both. Selection of treatment can vary depending on severity of blood pressure elevation, age, and other risk factors.

Implementation

Ambulatory blood pressure monitoring offers the most evidence-based risk information for future cardiovascular events. Ambulatory blood pressure monitoring devices are small portable machines that record blood pressure noninvasively at typically 20- to 30-minute intervals over 12 to 24 hours while patients go about their normal activities or are sleeping. Home blood pressure monitoring devices are fully automated oscillometer devices that record measurements taken from the patient’s brachial artery. Home blood pressure monitoring devices are activated by patients or caregivers and measurements are taken much less frequently than with ABPM (eg, 1 to 2 times a day or week, although the blood pressure measurements can be spread out over more time).

Additional Tools and Resources

Hypertension resources for health professionals are available through these resources:

The Surgeon General’s Call to Action to Control Hypertension https://www.cdc.gov/bloodpressure/docs/SG-CTA-HTN-Control-Report-508.pdf
Centers for Disease Control and Prevention’s Hypertension Resources for Health Professionals https://www.cdc.gov/bloodpressure/educational_materials.htm ;
Million Hearts Initiative https://millionhearts.hhs.gov/

Information on how to measure blood pressure is available at https://www.cdc.gov/bloodpressure/measure.htm . The Community Preventive Services Task Force has several resources related to community-focused interventions for blood pressure monitoring, management, and control, available at https://www.thecommunityguide.org/topic/cardiovascular-disease .

Other Related USPSTF Recommendations

The USPSTF has several recommendations addressing cardiovascular health.

Risk assessment for cardiovascular disease with nontraditional risk factors 12
Screening for atrial fibrillation with electrocardiography 13
Behavioral counseling interventions to promote a healthy diet and physical activity for cardiovascular disease prevention
In adults with cardiovascular risk factors 14
In adults without known cardiovascular risk factors 15
Statin use for the primary prevention of cardiovascular disease in adults 16
Aspirin use to prevent cardiovascular disease and colorectal cancer 17
Screening for high blood pressure in children and adolescents 18

This recommendation is a reaffirmation of the 2015 recommendation statement on screening for high blood pressure in adults (A recommendation). The USPSTF has issued an A recommendation on screening for high blood pressure in adults since 1996 (updated in 2003, reaffirmed in 2007, and then updated in 2015). In 2015, the USPSTF recommended screening for high blood pressure in adults 18 years or older and obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment. The USPSTF found no new substantial evidence that could change its recommendation and therefore reaffirms its recommendation. The current reaffirmation clarifies that initial screening should be performed with OBPM, updates language to be more consistent with current evidence, and clarifies implementation strategies.

Scope of Review

The USPSTF commissioned a systematic review to evaluate the benefits and harms of screening for hypertension in adults, the accuracy of OBPM for initial screening, and the accuracy of various confirmatory blood pressure measurement methods. 8 , 9

Accuracy of Screening Tests

The USPSTF reviewed evidence from 20 studies (n = 12,614) on the test accuracy of OBPM for initial screening for hypertension. 8 , 9 In all studies, blood pressure was measured at the brachial artery and ABPM was used as the reference standard. Studies reflected a wide range of clinical characteristics and most commonly included community-based samples; mean ages of participants ranged from 25 to 70 years, and 37.9% to 72.3% of participants were women. 8 , 9 Although reported less frequently, race/ethnicity was predominately White in those studies that did report it. 8 , 9 Meta-analyses of 15 studies (n = 11,309) showed a pooled sensitivity of 0.54 (95% CI, 0.37-0.70) and a pooled specificity of 0.90 (95% CI, 0.84-0.95) when using an OBPM threshold of 140/90 mm Hg compared with a reference 24-hour ABPM of 130/80 mm Hg or reference daytime ABPM of 135/85 mm Hg. 8 , 9

Eighteen studies (n = 57,128) provided evidence on the accuracy of various methods to evaluate adults who initially screened positive for hypertension by OBPM. 8 , 9 Again, blood pressure was taken at the brachial artery and ABPM was used as the reference standard in all studies. The mean age of study participants was generally older (46-60 years), reflecting the preselected study populations. Zero percent to 66.7% of study participants were women. Again, few studies reported race/ethnicity of participants and those that did included predominantly White participants. Meta-analysis of 8 studies (n = 53,183) of repeat OBPM showed a pooled sensitivity of 0.80 (95% CI, 0.68-0.88) and pooled specificity of 0.55 (95% CI, 0.42-0.66) using an OBPM threshold of 140/90 mm Hg compared with a reference 24-hour ABPM of 130/80 mm Hg or reference daytime ABPM of 135/85 mm Hg. Meta-analysis of 4 studies (n = 1001) on HBPM found a pooled sensitivity of 0.84 (95% CI, 0.76-0.90) and a pooled specificity of 0.60 (95% CI, 0.48-0.71) using an HBPM threshold of 135/85 mm Hg compared with a reference 24-hour ABPM of 130/80 mm Hg or reference daytime ABPM of 135/85 mm Hg. Limited evidence is available on the accuracy of automated office-based blood pressure measurement (taking repeated measurements while the patient is alone in a quiet room). 8 , 9

Benefits of Early Detection

No trials have compared the effectiveness of screening for hypertension vs no screening. However, a Canadian community-based, cluster randomized clinical trial 8 , 9 , 19 evaluated a multicomponent cardiovascular disease health promotion program that assessed cardiovascular disease outcomes of 140,642 community members in 39 clusters. 8 , 9 , 19 Community residents (targeted age of 65 years or older) were invited to pharmacy-based blood pressure screening and a cardiovascular disease risk assessment. Risk-specific educational materials were provided and results were communicated to the participant’s clinician. At 1 year of follow-up, a 9% reduction in the number of hospital admissions for acute myocardial infarction, congestive heart failure, or stroke was found; however, no difference in all-cause mortality was noted. 20 Although there is limited direct trial evidence on benefits of screening for hypertension on health outcomes, based on the available indirect evidence on the accuracy of screening tests for hypertension and robust foundational evidence showing that treatment of hypertension (detected in office-based settings) improves health outcomes, 11 the USPSTF found convincing evidence that screening for hypertension in adults provides health benefits.

Harms of Early Detection

The USPSTF reviewed 13 studies (n = 5150) that reported on harms of screening for hypertension. 8 , 9 Results from 5 studies (n = 1321) suggested that screening is not associated with any substantial short-term quality of life changes or adverse psychological outcomes. Evidence from 2 work-site studies (n = 502) reported mixed findings on whether absenteeism increased with screening. Seven studies (n = 3505) reported minor adverse events such as sleep disturbance, pain/discomfort, bruising, and skin irritation with ABPM. Overall, the USPSTF determined that the harms of screening for hypertension are minor.

Response to Public Comment

A draft version of this recommendation statement was posted for public comment on the USPSTF website from June 23 through July 20, 2020. Several comments requested clarification about specific techniques to accurately measure blood pressure and the use of validated blood pressure devices at the brachial artery. A brief description of how blood pressure was measured in studies is included in the Practice Considerations section, and language clarifying that the blood pressure measurements included in this review were taken at the brachial artery has been added. More resources for accurately measuring blood pressure are provided in the Additional Tools and Resources section. Other organizations provide information on validated devices, which is described in the Recommendations of Others section. Some comments expressed concern about the burden and barriers patients may experience trying to measure their blood pressure outside of a clinic setting. Resources to address these issues were added in the Additional Tools and Resources section. Comments regarding in-office blood pressure monitoring recommended adding annual screening during wellness visits for patients aged 18 to 40 years. Available evidence on optimal screening intervals for hypertension remains limited; however, the screening intervals described in the Practice Considerations section are based on the best available data.

How Does Evidence Fit With Biological Understanding?

There are different types of hypertension, including “sustained” hypertension (blood pressure measurements that are high when obtained both in a clinical office setting and outside the office, referred to as “hypertension” in the current recommendation), “white coat” hypertension (blood pressure measurements that are high when obtained in a clinical office setting but normal when obtained outside the office), and “masked” hypertension (blood pressure measurements that are high when obtained outside the office but normal when obtained in clinical office settings). Cardiovascular disease risk is highest among persons with sustained hypertension, followed by those with masked hypertension and then those with white coat hypertension. 20-25 The prevalence of white coat hypertension and masked hypertension in the US is unknown, but estimates based on data from international cohorts 26 are 8% and 14%, respectively. 8 Analyses of participants of a US-based study estimates a prevalence of 12.3% for masked hypertension. 27

White coat hypertension can be detected by obtaining out-of-office blood pressure measurements (either through HBPM or ABPM) after an elevated blood pressure measurement is detected in the office. Masked hypertension is more difficult to identify and can only be detected when out-of-office blood pressure measurements are obtained. Current screening algorithms that focus on performing OBPM first, then following up with ABPM or HBPM in persons with elevated blood pressure measured with OBPM are not able to identify persons with masked hypertension. The USPSTF hypothesizes that screening strategies that use OBPM for both initial screening and confirmation, with traditional thresholds, would miss a greater number of cases of sustained hypertension and would lead to overtreatment of a greater number of cases of white coat hypertension. Follow-up ABPM or HBPM after an initial positive OBPM screening result would result in fewer cases of sustained hypertension being missed and fewer cases of white coat hypertension being overtreated. Confirmation with ABPM would result in the greatest number of cases of sustained hypertension being identified without any cases of white coat hypertension being treated (by definition, ABPM is considered the gold standard). Importantly, cases of masked hypertension would be missed with all 3 of these screening strategies, at least when using OBPM with traditional thresholds.

Although the association of masked hypertension and white coat hypertension with increased cardiovascular risk has been well documented, it is unclear whether treatment of either of these types of hypertension improves health outcomes. The USPSTF considers this a critical evidence gap.

The association of masked hypertension and white coat hypertension with increased cardiovascular risk has been well documented; however, more evidence is needed to understand whether early detection and treatment of these hypertension types lead to an improvement in health. More research is needed on the following.

The benefits and harms of early detection and treatment of masked hypertension and white coat hypertension:
Does early detection of masked hypertension and white coat hypertension lead to improved health outcomes?
Does treating masked hypertension improve cardiovascular health outcomes?
Does treating white coat hypertension cause harms?
The prevalence of masked hypertension and white coat hypertension in the US.
How frequently do adults transition between the different types of hypertension, and how long is the length of time it takes to transition (eg, what percentage of persons with masked hypertension transition to sustained hypertension, and how long does that transition take)?
Identification of feasible methods for early detection of masked hypertension.
Inclusion of diverse and underrepresented persons in all of the above studies is needed to determine optimal screening for all types of hypertension.

The report from the panel members of the Eighth Joint National Committee did not address the diagnosis of hypertension in its 2014 guidelines. 11 The Seventh Joint National Committee recommended screening for high blood pressure at least once every 2 years in adults with blood pressure less than 120/80 mm Hg and every year in adults with blood pressure of 120 to 139/80 to 89 mm Hg. 6 The American College of Cardiology and the American Heart Association recommend proper measurement methods be used for diagnosis and management of high blood pressure and that out-of-office blood pressure measurement be performed to confirm the diagnosis of hypertension. 7 , 28 They also suggest screening for masked hypertension with ABPM or HBPM in adults who consistently have systolic blood pressure measurements of 120 to 129 mm Hg or diastolic blood pressure measurements of 75 to 79 mm Hg in the office 7 , 28 and screening for white coat hypertension in adults who consistently have systolic blood pressure measurements of 130 to 160 mm Hg or diastolic measurements of 80 to 100 mm Hg in the office. Additionally, in 2019, the Centers for Medicare & Medicaid Services added coverage of ABPM to diagnose patients with suspected white coat and masked hypertension. 29 In 2020, the American Heart Association and the American Medical Association released a joint statement supporting out-of-office self-measurement of blood pressure using a validated device to evaluate hypertension. 30 , 31 The American Academy of Family Physicians supports the 2015 USPSTF recommendation statement on screening for high blood pressure. 32

The US Preventive Services Task Force members include the following individuals: Alex H. Krist, MD, MPH (Fairfax Family Practice Residency, Fairfax, Virginia, and Virginia Commonwealth University, Richmond); Karina W. Davidson, PhD, MASc (Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York); Carol M. Mangione, MD, MSPH (University of California, Los Angeles); Michael Cabana, MD, MA, MPH (Albert Einstein College of Medicine, New York, New York); Aaron B. Caughey, MD, PhD (Oregon Health & Science University, Portland); Esa M. Davis, MD, MPH (University of Pittsburgh, Pittsburgh); Katrina E. Donahue, MD, MPH (University of North Carolina at Chapel Hill); Chyke A. Doubeni, MD, MPH (Mayo Clinic, Rochester, Minnesota); Martha Kubik, PhD, RN (George Mason University, Fairfax, Virginia); Li Li, MD, PhD, MPH (University of Virginia, Charlottesville); Gbenga Ogedegbe, MD, MPH (New York University, New York, New York); Lori Pbert, PhD (University of Massachusetts Medical School, Worcester); Michael Silverstein, MD, MPH (Boston University, Boston, Massachusetts); James Stevermer, MD, MSPH (University of Missouri, Columbia); Chien-Wen Tseng, MD, MPH, MSEE (University of Hawaii, Honolulu); John B. Wong, MD (Tufts University School of Medicine, Boston, Massachusetts).

Conflict of Interest Disclosures: Authors followed the policy regarding conflicts of interest described at https://uspreventiveservicestaskforce.org/uspstf/about-uspstf/conflict-interest-disclosures . All members of the USPSTF receive travel reimbursement and an honorarium for participating in USPSTF meetings.

Funding/Support: The USPSTF is an independent, voluntary body. The US Congress mandates that the Agency for Healthcare Research and Quality (AHRQ) support the operations of the USPSTF.

Role of the Funder/Sponsor: AHRQ staff assisted in the following: development and review of the research plan, commission of the systematic evidence review from an Evidence-based Practice Center, coordination of expert review and public comment of the draft evidence report and draft recommendation statement, and the writing and preparation of the final recommendation statement and its submission for publication. AHRQ staff had no role in the approval of the final recommendation statement or the decision to submit for publication.

Disclaimer: Recommendations made by the USPSTF are independent of the US government. They should not be construed as an official position of AHRQ or the US Department of Health and Human Services.

Additional Information: The US Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms. It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment. The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision-making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.

Copyright Notice: USPSTF recommendations are based on a rigorous review of existing peer-reviewed evidence and are intended to help primary care clinicians and patients decide together whether a preventive service is right for a patient's needs. To encourage widespread discussion, consideration, adoption, and implementation of USPSTF recommendations, AHRQ permits members of the public to reproduce, redistribute, publicly display, and incorporate USPSTF work into other materials provided that it is reproduced without any changes to the work of portions thereof, except as permitted as fair use under the US Copyright Act.

AHRQ and the US Department of Health and Human Services cannot endorse, or appear to endorse, derivative or excerpted materials, and they cannot be held liable for the content or use of adapted products that are incorporated on other Web sites. Any adaptations of these electronic documents and resources must include a disclaimer to this effect. Advertising or implied endorsement for any commercial products or services is strictly prohibited.

This work may not be reproduced, reprinted, or redistributed for a fee, nor may the work be sold for profit or incorporated into a profit-making venture without the express written permission of AHRQ. This work is subject to the restrictions of Section 1140 of the Social Security Act, 42 U.S.C. §320b-10. When parts of a recommendation statement are used or quoted, the USPSTF Web page should be cited as the source.

1. Ostchega Y, Fryar C, Nwankwo T, Nguyen DT. Hypertension Prevalence Among Adults Aged 18 and Over: United States, 2017–2018. Published 2020. Accessed March 10, 2021. https://www.cdc.gov/nchs/products/databriefs/db364.htm 2. Siu AL; U.S. Preventive Services Task Force. Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015;163(10):778-786. Medline:26458123 doi:10.7326/M15-2223 3. Procedure Manual. U.S. Preventive Services Task Force. Published 2018. Accessed March 10, 2021. https://www.uspreventiveservicestaskforce.org/uspstf/procedure-manual 4. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360(9349):1903-1913. Medline:12493255 doi:10.1016/S0140-6736(02)11911-8 5. Flint AC, Conell C, Ren X, et al. Effect of systolic and diastolic blood pressure on cardiovascular outcomes. N Engl J Med. 2019;381(3):243-251. Medline:12493255 doi:10.1016/S0140-6736(02)11911-8 6. National High Blood Pressure Education Program. The Seventh Report on the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure . Washington, DC: National Institutes of Health; 2004. 7. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):e13-e115. Medline:29133356 8. Guirguis-Blake JM, Evans CV, Webber EM, Coppola EL, Perdue LA, Weyrich MS. Screening for Hypertension in Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force . Evidence Synthesis No. 197. Agency for Healthcare Research and Quality; 2021. AHRQ publication 20-05265-EF-1. 9. Guirguis-Blake JM, Evans CV, Webber EM, Coppola EL, Perdue LA, Weyrich MS. Screening for hypertension in adults: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA . Published April 27, 2021. doi:10.1001/jama.2020.21669 10. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation. 2017;135(10):e146-e603. Medline:28122885 doi:10.1161/CIR.0000000000000485 11. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. Medline:24352797 doi:10.1001/jama.2013.284427 12. Curry SJ, Krist AH, Owens DK, et al; US Preventive Services Task Force. Risk assessment for cardiovascular disease with nontraditional risk factors: US Preventive Services Task Force recommendation statement. JAMA. 2018;320(3):272-280. Medline:29998297 doi:10.1001/jama.2018.8359 13. Curry SJ, Krist AH, Owens DK, et al; US Preventive Services Task Force. Screening for atrial fibrillation with electrocardiography: US Preventive Services Task Force recommendation statement. JAMA. 2018;320(5):478-484. Medline:30088016 doi:10.1001/jama.2018.10321 14. LeFevre ML; US Preventive Services Task Force. Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;161(8):587-593. Medline:25155419 doi:10.7326/M14-1796 15. Grossman DC, Bibbins-Domingo K, Curry SJ, et al; US Preventive Services Task Force. Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults without cardiovascular risk factors: US Preventive Services Task Force recommendation statement. JAMA. 2017;318(2):167-174. Medline:28697260 doi:10.1001/jama.2017.7171 16. Bibbins-Domingo K, Grossman DC, Curry SJ, et al; US Preventive Services Task Force. Statin use for the primary prevention of cardiovascular disease in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;316(19):1997-2007. Medline:27838723 doi:10.1001/jama.2016.15450 17. Bibbins-Domingo K; U.S. Preventive Services Task Force. Aspirin use for the primary prevention of cardiovascular disease and colorectal cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2016;164(12):836-845. Medline:27064677 doi:10.7326/M16-0577 18. Moyer VA; U.S. Preventive Services Task Force. Screening for primary hypertension in children and adolescents: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159:613-619. Medline:24097285 doi:10.7326/0003-4819-159-9-201311050-00725 19. Kaczorowski J, Chambers LW, Dolovich L, et al. Improving cardiovascular health at population level: 39 community cluster randomised trial of Cardiovascular Health Awareness Program (CHAP). BMJ. 2011;342:d442. Medline:21300712 doi:10.1136/bmj.d442 20. Pierdomenico SD, Cuccurullo F. Prognostic value of white-coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: an updated meta analysis. Am J Hypertens . 2011;24(1):52-58. Medline:20847724 doi:10.1038/ajh.2010.203 21. Briasoulis A, Androulakis E, Palla M, Papageorgiou N, Tousoulis D. White-coat hypertension and cardiovascular events: a meta-analysis. J Hypertension. 2016;34(4):593-599. Medline:26734955 doi:10.1097/HJH.0000000000000832 22. Huang Y, Huang W, Mai W, et al. White-coat hypertension is a risk factor for cardiovascular diseases and total mortality. J Hypertension. 2017;35(4):677-688. Medline:28253216 doi:10.1097/HJH.0000000000001226 23. Asayama K, Thijs L, Li Y, et al; International Database on Ambulatory Blood Pressure in Relation to Cardiovascular Outcomes (IDACO) Investigators. Setting thresholds to varying blood pressure monitoring intervals differentially affects risk estimates associated with white-coat and masked hypertension in the population. Hypertension . 2014;64(5):935-942. Medline:25135185 doi:10.1161/HYPERTENSIONAHA.114.03614 24. Cohen JB, Lotito MJ, Trivedi UK, Denker MG, Cohen DL, Townsend RR. Cardiovascular events and mortality in white coat hypertension: a systematic review and meta-analysis. Ann Intern Med. 2019;170(12):853-862. Medline:31181575 doi:10.7326/M19-0223 25. Shimbo D, Muntner P. Should out-of-office monitoring be performed for detecting white coat hypertension? Ann Intern Med. 2019;170(12):890-892. Medline:31181573 doi:10.7326/M19-1134 26. Conen D, Aeschbacher S, Thijs L, et al. Age-specific differences between conventional and ambulatory daytime blood pressure values. Hypertension. 2014;64(5):1073-1079. Medline:25185130 doi:10.1161/HYPERTENSIONAHA.114.03957 27. Wang YC, Shimbo D, Muntner P, Moran AE, Krakoff LR, Schwartz JE. Prevalence of masked hypertension among US adults with nonelevated clinic blood pressure. Am J Epidemiol . 2017;185(3):194-202. Medline:28100465 doi:10.1093/aje/kww237 28. Muntner P, Shimbo D, Carey RM, et al. Measurement of blood pressure in humans: a scientific statement from the American Heart Association. Hypertension. 2019;73(5):e35-e66. Medline:30827125 doi:10.1161/HYP.0000000000000087 29. Centers for Medicare & Medicaid Services. Decision Memo for Ambulatory Blood Pressure Monitoring (ABPM) (CAG-00067R2). Published 2019. Accessed March 10, 2021. https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=294 30. Shimbo D, Artinian NT, Basile JN, et al; American Heart Association and the American Medical Association. Self-measured blood pressure monitoring at home: a joint policy statement from the American Heart Association and American Medical Association. Circulation . 2020;142(4):e42-e63. Medline:32567342 doi:10.1161/CIR.0000000000000803 31. American Medical Association. US blood pressure validated device listing. Published 2021. Accessed March 10, 2021. https://www.validatebp.org 32. American Academy of Family Physicians. Clinical Preventive Services Recommendation: Hypertension. Accessed March 10, 2021. https://www.aafp.org/patient-care/clinical-recommendations/all/hypertension.html

Center on Health Equity and Access
Health Care Cost
Health Care Delivery
Value-Based Care

Evidence-Based Guidelines to Determine Follow-up Intervals: A Call for Action

Alexa Boer Kimball, MD, MPH

Evidence-based guidelines are needed to determine appropriate follow-up intervals for chronic medical conditions to maximize the quality of patient care and minimize unnecessary costs.

Although there are nearly 1 billion outpatient follow-up visits annually in the United States, few data exist documenting evidence-based follow-up intervals for the most common and costly chronic conditions.

Evidence-based follow-up intervals must be established based on healthcare outcomes.
Evidence-based follow-up intervals have the potential to reduce healthcare costs per person and improve access without compromising or restricting care.

Public concern regarding access to care combined with increasing pressure to curtail healthcare costs has prompted physicians to think critically about how best to manage chronic disease. Perhaps surprisingly, Americans face long wait times compared with other industrialized nations. A 2010 Commonwealth Fund study of 11 industrialized countries found waiting times were longer in the United States than in all the other countries except Canada, Norway, and Sweden. 1 Moreover, the study showed that only 57% of patients were able to access a same-day or next-day appointment when they were sick or needed care, compared with top-ranking Switzerland, where 93% of patients described being able to secure an appointment under these conditions. Similarly, 19% of patients in the United States waited 6 or more days for an appointment compared with only 2% of patients in Switzerland. 1 Several specialties face a shortage of providers, and geographic inequities also exist in almost all areas. 2 This problem is confounded by increasing patient demand in an aging population and slow growth in physician supply, which lags behind other countries on a per capita basis, and is further exacerbated by economic disparities. 3

Where might there be more room for patients in this system? Notably, a substantial portion of outpatient office visits are follow-up visits. According to the National Health Statistics Report for 2009, there were nearly 1 billion office visits in 2009, 30% of which were for routine follow-up of a chronic problem and an additional 26% of which were for preventive care or follow-up of an acute condition. The remaining 42% were for the evaluation of a new problem or an exacerbation of a chronic condition. 4

There are 3 obvious questions. (1) Are these follow- up visits and their timing determined scientifically or by convenience and habit? (2) Is there an evidence base to support physicians’ practice patterns? (3) If there is evidence to support physicians’ practice patterns, are physicians adhering to those guidelines? If not, scheduling habits may be unnecessarily contributing to the problems f limited access, excessive utilization, and excessive costs, without improvement in healthcare outcomes.

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for performing a systematic review, we used the PubMed database to search for studies discussing evidence-based guidelines for follow-up intervals for the top 5 chronic conditions accounting for the greatest number of outpatient visits in 2010 (mental disorders, back problems, arthritis, chronic obstructive pulmonary disease/asthma, hypertension). 5 These 5 conditions accounted for approximately $281 billion in healthcare expenditures in 2010. 6

This search yielded 330 studies. Abstracts of these studies were reviewed, and guidelines with recommendations for follow-up interval timing were included. Eight studies recommended specific follow-up times ( 7-15 ).

Some guidelines attempted to recommend specific followup intervals, but the vast majority were not evidence based. Determining the appropriate intervals and modeling their impact are important. For example, patients being medically managed for hypertension are typically seen every 6 months. However, a recent randomized controlled trial determined 6 months to be too short an interval to reflect accurate therapy-induced changes in blood pressure. 8 Extending the follow-up interval in this case may not only result in cost savings but also improve patient care, as patients appear to be better managed with more accurate assessment of blood pressure and more appropriate adjustments to therapy. Similarly, recent research into optimizing follow-up intervals for melanoma patients demonstrated that frequency of followup intervals did not impact outcomes. 16

The next task was to determine the impact on healthcare utilization and expenditures of curtailing inappropriate follow-up visits. With a model that examines the diagnosis of hypertension, the profound effect of small reforms in followup practice becomes substantially clear. Essential hypertension accounted for $47.4 billion in healthcare expenditures in 2008, with outpatient visits accounting for $13.03 billion. 17 There were 79.1 million outpatient visits for hypertension in 2008.18 About 88%, or 69.6 million, of those visits were established patients.16 Using the Medicare national allowable billing amount of $65.30 for a Current Procedural Terminology code 99213 visit, we can estimate the cost savings as a function of the number of visits omitted. If follow-up visits were extended by just 1 month, from 6 to 7 months, there would be a 15% decrease in the number of visits in 1 year. This reduction could correspond to a cost savings of nearly $682 million. If the follow-up interval were extended to 9 months, there would be a 34% reduction in follow-up visits for 1 year and a potential cost savings of $1.5 billion. Decreasing follow-up visits to a yearly interval would result in a 50% reduction in follow-up visit volume and a possible cost savings of about $2.3 billion ( ). Additionally, patients may be better managed with more accurate assessment of blood pressure and more appropriate adjustments to therapy.

In this era of healthcare reform, managing follow-up visits and intervals is an evidence-based approach that has the potential to reduce costs per person and improve access without compromising or restricting care. In order to implement this plan, appropriate follow-up intervals must first be established based on healthcare outcomes. Physicians should tackle this first step by focusing research efforts and funding on the development of evidence-based follow-up guidelines for common chronic diagnoses. The same scientific rigor that guides therapeutic decision making should be used to optimize chronic disease management. Rational choice of follow-up intervals is a crucial step in adjusting current utilization patterns to maximize the quality of patient care while minimizing unnecessary costs. It’s a win for everyone. Author Affiliations: From University of Massachusetts (EJ, AR), Boston, MA; Harvard Medical School (ABK), Boston, MA.

Funding Source: None.

Author Disclosures: The authors (ABK, EJ, AR) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (ABK); acquisition of data (AR, EJ); analysis and interpretation of data (ABK, EJ, AR); drafting of the manuscript (ABK, EJ, AR); critical revision of the manuscript for important intellectual content (ABK, EJ, AR); administrative, technical, or logistic support (ABK); and supervision (ABK).

Address correspondence to: Alexa Boer Kimball, MD, MPH, Department of Dermatology, Harvard University School of Medicine, 50 Staniford St, #240, Boston, MA 02114. E-mail: [email protected]. 1. Schoen C, Osborn R; for the Commonwealth Fund. 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries. http://www.commonwealthfund.org/Surveys/2010/Nov/2010-International-Survey.aspx. Published November 2010. Accessed October 30,2012.

2. US General Accounting Office. Physician Workforce: Physician Supply Increased in Metropolitan and Nonmetropolitan Areas but Geographic Disparities Persisted. http://www.gao.gov/new.items/d04124.pdf. Published October 2003. Accessed June 11, 2012.

3. Simoens S, Hurst J. The Supply of Physician Services in OECD Countries. OECD Health Working Papers No. 21. http://www.oecd.org/dataoecd/27/22/35987490.pdf. Published January 2006. Accessed June 11, 2012.

4. Centers for Disease Control and Prevention. National AmbulatoryMedical Care Survey: 2009 Summary Tables. Fact Sheet: Physician Office Visits. http://www.cdc.gov/nchs/data/ahcd/NAMCS_Factsheet_All_2009.pdf. Accessed June 11, 2012.

5. Agency for Healthcare Research and Quality. Table 2: Number of events for selected conditions by type of service: United States, 2010. Medical Expenditure Panel Survey Household Component Data. Rockville, MD: Agency for Healthcare Research and Quality; 2010. Accessed June 11, 2012.

6. Agency for Healthcare Research and Quality. Total expenses and percent distribution for selected conditions by type of service: United States, 2010. Medical Expenditure Panel Survey Household Component Data. Rockville, MD: Agency for Healthcare Research and Quality; 2010. Accessed June 11, 2012.

7. Quinn RR, Hemmelgarn BR, Padwal RS, et al; Canadian Hypertension Education Program. The 2010 Canadian Hypertension Education Program recommendations for the management of hypertension: part I—blood pressure measurement, diagnosis and assessment of risk. Can J Cardiol. 2010;26(5):241-248.

8. Keenan K, Hayen A, Neal BC, Irwig L. Long term monitoring in patients receiving treatment to lower blood pressure: analysis of data from placebo controlled randomised controlled trial. BMJ. 2009;338:b1492.

9. British Thoracic Society Standards of Care Committee. BTS statement on criteria for specialist referral, admission, discharge and follow-up for adults with respiratory disease. Thorax. 2008;63(suppl1):i1-i16.

10. van den Bemt L, Schermer T, Smeele I, et al. Monitoring of patients with COPD: a review of current guidelines’ recommendations. Respir Med. 2008;102(5):633-641.

11. Schulberg HC, Katon W, Simon GE, Rush AJ. Treating major depression in primary care practice: an update of the Agency for Health Care Policy and Research Practice Guidelines. Arch Gen Psychiatry. 1998;55(12):1121-1127.

12. Francken AB, Hoekstra HJ. Follow-up of melanoma patients: the need for evidence-based protocols. Ann Surg Oncol. 2009;16(4): 804-805.

13. Francken AB, Thompson JF, Bastiaannet E, Hoekstra HJ. Detection of the first recurrence in patients with melanoma: three quarters by the patient, one quarter during outpatient follow-up [in Dutch]. Ned Tijdschr Geneeskd. 2008;152(10):557-562.

14. Francken AB, Shaw HM, Accortt NA, Soong SJ, Hoekstra HJ, Thompson JF. Detection of first relapse in cutaneous melanoma patients: implications for the formulation of evidence-based follow-up guidelines. Ann Surg Oncol. 2007;14(6):1924-1933.

15. Einwachter-Thompson J, MacKie RM. An evidence base for reconsidering current follow-up guidelines for patients with cutaneous melanoma less than 0.5mm thick at diagnosis. Br J Dermatol. 2008; 159(2):337-341.

16. Turner RM, Bell KJ, Morton RL, et al. Optimizing the frequency of follow-up visits for patients treated for localized primary cutaneous melanoma. J Clin Oncol. 2011;29(35):4641-4646.

17. Agency for Healthcare Research and Quality. Total expenses and percent distribution for selected conditions by type of service & number of events for selected conditions by type of service: United States, 2008. Medical Expenditure Panel Survey Household Component Data.Rockville, MD: Agency for Healthcare Research and Quality; 2008. AccessedJune 11, 2012.

18. Centers for Disease Control and Prevention. National Ambulatory Medical Care Survey: 2008 Summary Tables: Table 8: Continuity-of- Care Office Visit Characteristics, by Specialty Type: United States, 2008.

Office Procedures for Older Adults by Physician Associates and Nurse Practitioners

The authors probed Medicare Part B data to explore outpatient clinical procedures performed by physician associates and nurse practitioners and report the trends from 2014 through 2021.

Institutional Practices for Charitable Medication Access for Uninsured Patients

Analysis of a patient sample enrolled in charitable care at an academic medical center revealed that chronic medications were variably filled at a significant cost.

High-Need Beneficiary Enrollment Patterns in Medicare Advantage and Traditional Medicare

Accounting for 32% of all Medicare enrollees in 2019, high-need beneficiaries were more likely to be in traditional Medicare than Medicare Advantage.

Trends in Low-Value Cancer Care During the COVID-19 Pandemic

Among adults with newly diagnosed cancer, rates of low-value cancer services persisted throughout the COVID-19 pandemic in areas ranging from peridiagnosis imaging to end-of-life care.

Impact of Care Coordination on 30-Day Readmission, Mortality, and Costs for Heart Failure

Enhancing coordination of care has the potential to increase the value of heart failure care.

Prices and Complications in Hospital-Based and Freestanding Surgery Centers

Average prices are substantially higher but rates of complications are similar in hospital-based vs freestanding surgery centers for colonoscopy, arthroscopy, and cataract removal surgery.

2 Commerce Drive Cranbury, NJ 08512

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The impact of hypertension follow-up management on the choices of signing up family doctor contract services: does socioeconomic status matter?

Affiliations.

1 Centre for Health Management and Policy Research, School of Public Health Cheeloo College of Medicine, Shandong University, Jinan, 250012, China.
2 Institute of Health and Elderly Care, Shandong University, Jinan, 250012, China.
3 Shandong Center for Disease Control and Prevention, Jinan, 250012, China. [email protected].
4 Shandong Health Commission Medical Management Service Center, Jinan, 250012, China.
5 NHC Key Lab of Health Economics and Policy Research, Shandong University, Jinan, 250012, China.
PMID: 38658816
PMCID: PMC11040762
DOI: 10.1186/s12875-024-02383-8

Background: This study aimed to explore the association between hypertension follow-up management and family doctor contract services, as well as to examine whether socioeconomic status (SES) had an interaction effect on this relationship among older adults in China.

Methods: We used data from the sixth National Health Service Survey of Shandong Province, China, including 3,112 older adults (age ≥ 60 years) with hypertension in 2018. Logistic regression models and a margins plot were used to analyze the role of SES in the relationship between hypertension follow-up management and family doctor contract services.

Results: The regular hypertension follow-up management rate and family doctor contracting rate were 81.8% and 70.9%, respectively, among older adults with hypertension. We found that participants with regular hypertension follow-up management were more likely to sign family doctor contract services (OR=1.28, 95%CI: 1.04, 1.58, P=0.018). The interaction effect occurred in the groups who lived in rural areas (OR=1.55, 95%CI: 1.02, 2.35), with high education level (OR=0.53, 95%CI: 0.32, 0.88) and had high incomes (OR=0.53, 95%CI: 0.35, 0.81).

Conclusions: Our findings suggested that regular hypertension follow-up management was associated with family doctor contract services and SES influenced this relationship. Primary health care should improve the contracting rate of family doctors by strengthening follow-up management of chronic diseases. Family doctors should focus on improving services quality and enriching the content of service packages especially for older adults with higher income and education level.

Keywords: Family doctor contract services; Hypertension follow-up management; Socioeconomic status.

Publication types

Research Support, Non-U.S. Gov't
Aged, 80 and over
Contract Services*
Hypertension* / epidemiology
Hypertension* / therapy
Middle Aged
Physicians, Family
Social Class*

Grants and funding

71974117/National Natural Science Foundation of China

Open access
Published: 01 May 2024

Endothelial dysfunction in breast cancer survivors on aromatase inhibitors: changes over time

Adnan Shaaban 1 ,
Ashley Petersen 3 ,
Heather Beckwith 4 ,
Natalia Florea 5 ,
David A. Potter 4 ,
Douglas Yee 4 ,
Rachel I. Vogel 6 ,
Daniel Duprez 7 &
Anne H. Blaes 2 , 4

Cardio-Oncology volume 10 , Article number: 27 ( 2024 ) Cite this article

Metrics details

Breast cancer is estimated to comprise about 290,560 new cases in 2022. Aromatase inhibitors (AIs) are recommended as adjuvant treatment for estrogen-receptor positive (ER+) breast carcinoma in postmenopausal women, which includes approximately two-thirds of all women with breast cancer. AIs inhibit the peripheral conversion of androgens to estrogen by deactivation of the aromatase enzyme, leading to a reduction in serum estrogen level in postmenopausal women with ER+ breast carcinoma. Estrogen is known for its cardiovascular (CV) protective properties through a variety of mechanisms including vasodilation of blood vessels and inhibition of vascular injury resulting in the prevention of atherosclerosis. In clinical trials and prospective cohorts, the long-term use of AIs can increase the risk for hypertension and hyperlipidemia. Studies demonstrate mixed results as to the impact of AIs on actual CV events and overall survival.

A single arm longitudinal study of 14 postmenopausal women with ER+ breast cancer prescribed adjuvant AIs at the University of Minnesota (UMN). Subjects with a history of known tobacco use, hypertension, hyperlipidemia, and diabetes were excluded to eliminate potential confounding factors. Participants underwent routine labs, blood pressure assessments, and vascular testing at baseline (prior to starting AIs) and at six months. Vascular assessment was performed using the EndoPAT 2000 and HDI/PulseWave CR-2000 Cardiovascular Profiling System and pulse contour analysis on two occasions as previously described. Vascular measurements were conducted by one trained vascular technician. Assessments were performed in triplicate, and the mean indices were used for analyses. All subjects were on an AI at the follow-up visit. The protocol was approved by the UMN Institutional Review Board and all participants were provided written informed consent. Baseline and follow-up characteristics were compared using Wilcoxon signed-rank tests. Analyses were performed using R version 3.6.1 (R Foundation for Statistical Computing, Vienna, Austria).

After six months of AI treatment, EndoPAT® ratio declined to a median 1.12 (Q1: 0.85, Q3: 1.86; p = 0.045; Figure 1) and median estradiol levels decreased to 2 pg/mL (Q1: 2, Q3: 3; p=0.052). There was no evidence of association between change in EndoPAT® and change in estradiol level (p = 0.91). There were no statistically significant changes in small or large arterial elasticity.

Conclusions

We hypothesize that long-term use of AI can lead to persistent endothelial dysfunction, and further investigation is necessary. In our study, patients were on AI for approximately 5-10 years. As a result, we do not have data on whether these changes, such as EndoPAT® ratio and the elasticity of small and large arterial, are reversible with discontinuation of AI. These findings set the stage for a larger study to more conclusively determine the association between AI exposure and cardiovascular outcomes. Further studies should evaluate for multivariate associations withmodifiable risk factors for CV disease.

Breast cancer is estimated to comprise about 290,560 new cases in 2022 [ 1 ]. Aromatase inhibitors (AIs) are recommended as adjuvant treatment for estrogen-receptor positive (ER+) breast carcinoma in postmenopausal women, which includes approximately two-thirds of all women with breast cancer [ 2 ].

AIs inhibit the peripheral conversion of androgens to estrogen by deactivation of the aromatase enzyme, leading to a reduction in serum estrogen level in postmenopausal women with ER + breast carcinoma [ 3 , 4 , 5 ]. Estrogen is known for its cardiovascular (CV) protective properties through a variety of mechanisms including vasodilation of blood vessels and inhibition of vascular injury resulting in the prevention of atherosclerosis [ 6 ]. In clinical trials and prospective cohorts, the long-term use of AIs can increase the risk for hypertension and hyperlipidemia. Studies demonstrate mixed results as to the impact of AIs on actual CV events and overall survival [ 7 , 8 ].

We hypothesized that the use of AIs and the associated reduction in estrogen would result in endothelial dysfunction, a predictor of early CV disease in women with breast cancer. Endothelial dysfunction, identified by reactive hyperemia using Endo-PAT, a non-invasive device that measures arterial vasoreactivity by assessing the peripheral arterial tone (Zoll Itamar), has been associated with an increased risk of CV events, independent of the Framingham risk score [ 9 ]. With the rising number of pre- and postmenopausal women on AIs for five to ten years, understanding the long-term impact of AIs on blood vessels and CV risk in cancer survivors is vital.

EndoPAT 2000

EndoPAT 2000, developed by Zoll Itamar, is a U.S. Food & Drug Administration approved non-invasive device that utilizes peripheral arterial tonometry (PAT) to measure pulse wave amplitude (PWA) abnormalities in response to hyperemia vasoreactivity [ 10 , 11 ]. PWA abnormalities have been previously studied and found to be associated with endothelial dysfunction and CV disease [ 10 , 12 , 13 ].

We conducted a single arm longitudinal study of 14 postmenopausal women with ER + breast cancer prescribed adjuvant AI at the University of Minnesota (UMN). Subjects with a history of known tobacco use, hypertension, hyperlipidemia, and diabetes were excluded to eliminate potential confounding factors. Participants underwent routine labs, blood pressure assessments, and vascular testing at baseline (prior to starting AIs) and at six months. Vascular assessment was performed using the EndoPAT 2000 and HDI/PulseWave CR-2000 Cardiovascular Profiling System (Hypertension Diagnostic Inc., Eagan, MN) and pulse contour analysis on two occasions as previously described [ 14 ]. Vascular measurements were conducted by one trained vascular technician (NF). Assessments were performed in triplicate, and the mean indices were used for analyses. Biomarkers were obtained using a fasting blood draw to evaluate lipids, total cholesterol (TC), low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL), triglycerides (TG), high sensitivity CRP (hsCRP), serum glucose, 17-betaestradiol (estradiol), von Willebrand factor, tissue plasminogen activator, and plasminogen activator inhibitor-1. All subjects were on an AI at the follow-up visit. The protocol was approved by the UMN Institutional Review Board and all participants were provided written informed consent. Baseline and follow-up characteristics were compared using Wilcoxon signed-rank tests. Analyses were performed using R version 3.6.1 (R Foundation for Statistical Computing, Vienna, Austria).

Nine (64.3%) of the 14 participants had stage I breast cancer, four (28.6%) had stage II disease, and one (7.1%) had stage III disease. All fourteen received neoadjuvant or adjuvant chemotherapy. Ten (71.4%) participants received radiation therapy (four left-sided, six right-sided). Anastrozole was the most commonly used AI (6; 42.9%) followed by letrozole (5; 35.7%) and exemestane (3; 21.4%). None of the participants were on tamoxifen.

Patient characteristics and outcomes are outlined in Table 1 . All patients were postmenopausal women. A total of 20 patients met inclusion criteria; however, only 14 patients who had follow-up visits were included in the analyses. Median baseline age of participants was 58 years (1st quartile [Q1]: 56, 3rd quartile [Q3]: 60) and median baseline body mass index was 26.5 kg/m 2 (Q1: 24.4, Q3: 31.6). Median systolic and diastolic blood pressure was 120 (Q1: 115, Q3: 124) and 70 (Q1: 61, Q3: 73) mm/Hg, respectively, and total cholesterol 228 mg/dL (Q1: 202, Q3: 244). Median baseline ultrasensitive estradiol level was 7 pg/mL (Q1: 4, Q3: 15) and hsCRP was 2.45 mg/L (Q1: 1.14, Q3: 6.07). Prior to AI therapy, EndoPAT ratio was 2.18 (Q1: 1.19, Q3: 2.43). Median baseline small arterial elasticity and large arterial elasticity was 4.1 mL/mmHg x100 (Q1: 3.2, Q3: 6.1) and 12.4 mL/mmHg x10 (Q1: 10.4, Q3: 14.2), respectively.

After six months of AI treatment, EndoPAT® ratio declined to a median 1.12 (Q1: 0.85, Q3: 1.86; p = 0.045; Fig. 1 ) and median estradiol levels decreased to 2 pg/mL (Q1: 2, Q3: 3; p = 0.052). There was no evidence of an association between change in EndoPAT® and change in estradiol level ( p = 0.91). There were no statistically significant changes in small arterial elasticity, which at 6 months was 4.3 mL/mmHg x100 (Q1: 4.0, Q3: 5.7) or large arterial elasticity, which at 6 months was 14.1 mL/mmHg x 10 (Q1: 11.0, Q3: 17.2). There were no statistically significant differences in serum glucose, TC, LDL, HDL, nor hsCRP at 6 months compared to baseline. hsCRP remained elevated at median 2.98 mg/L. Biomarkers of von Willebrand factor, tissue plasminogen activator, and plasminogen activator inhibitor-1 did not change over time.

EndoPAT ratio measurements at baseline and 6 months with those from the same woman connected. Figure 1 : Of the 14 women, one did not have EndoPAT ratios measured and one was missing the EndoPAT ratio at 6-month follow-up

Endovascular dysfunction is an early sign for atherosclerosis and vascular impairment; therefore, measuring endovascular dysfunction using flow-mediated dilation or EndoPAT helps identify patients who may be at risk for CV events [ 9 , 14 ]. Our EndoPAT pilot study suggests that postmenopausal breast cancer survivors on AIs therapy develop endothelial dysfunction, a predictor of adverse CV disease. These changes develop while on AIs, correlating with a decline in estradiol levels.

Large clinical studies report higher rates of hypertension, hypercholesterolemia, and ischemic CV disease in postmenopausal breast cancer survivors receiving AIs [ 7 , 8 , 15 ]. The Long Island Breast Cancer study demonstrated increased CV deaths and decreased survival after seven years of treatment with AI [ 15 ]; this study, however, did not differentiate whether findings were related to secondary causes such as the development of hypertension, hypercholesterolemia, or directly related to AI therapy. A more recent retrospective cohort of 15,815 breast cancer patients diagnosed 2006–2012 demonstrated an increase in heart failure in those treated over the age of 75 years when treated with an AI compared to tamoxifen. The risk of ischemic heart disease increased in those who took AIs for at least four years (hazard ratio (HR): 2.12; 95% CI: 1.40–3.25) compared to those who took no or had short term exposure to AI [ 8 ]. In the study cohort of the UK Clinical Practice Research Datalink of 17,922 breast cancer patients treated with AI, there was an increase in heart failure risk (HR: 1.86; 95% CI: 1.14–3.03) and CV mortality (HR: 1.50; 95% CI: 1.11–2.04) in those treated with AI compared to tamoxifen [ 7 ]. Contrarily, a randomized double blinded study compared anastrozole to placebo did not show an increase risk for CV events [ 16 ].

CV disease development is multifactorial due to risk factors such as aging, hypertension, hyperlipidemia and tobacco use. This development often begins with endothelial dysfunction and which ultimately leads to atherosclerosis and ischemic events. Inflammation, fibrosis, and estrogen depletion can lead to changes in the endothelium [ 6 , 17 , 18 ]. In this study, treatment of postmenopausal breast cancer with AI was associated with increased endothelial dysfunction, which coincided within six months of starting the medication and declines in estrogen. This finding is significantly lower than the 1.67 EndoPAT level which was previously linked to higher CV events by Shechter et al. [ 19 ]. Our prior work also demonstrated higher rates of impaired endothelial function compared with healthy postmenopausal controls [ 14 ]. There was a suggestion endothelial changes were associated with a decline in estrogen levels; however, this did not meet statistical significance [ 14 ]. Markers of inflammation (hsCRP) remained persistent; other biomarker work did not suggest the etiology of these changes [ 14 ].

Given the high prevalence of breast cancer and recommendations for extended use of AIs in postmenopausal women, it is important to investigate further the risk of CV disease development due to AI use as prior studies have been inconclusive. Additionally, with further reductions in estrogen in premenopausal women, where ovarian suppression plus AI is often recommended, understanding the long-term implications of this treatment regimen on overall cardiac health is imperative. In the current literature, few studies have shown the correlation between estrogen levels and endothelial dysfunction. Luca et al. reported study results of ten premenopausal women who showed that estradiol serum levels were inversely proportional to endothelial dysfunction and subsequent CV events by measuring flow-mediated dilation [ 16 ]. Given our work, and prior published work, we hypothesize that long-term use of AI can lead to persistent endothelial dysfunction, and further investigation is necessary. In our study, patients were on AI for approximately 5–10 years. As a result, we do not have data on whether these changes, such as EndoPAT® ratio and the elasticity of small and large arterial, are reversible with discontinuation of AI.

Conclusion and limitations

This study has a few limitations. It is a pilot study, and as such, has a small sample size. Additionally, the population was predominantly Caucasian, limiting the generalizability. This study was designed to detect AI-specific risk because subjects with a known major risk factors such as tobacco use, hypertension, or hyperlipidemia were excluded. These findings set the stage for a larger study to more conclusively determine the association between AI exposure and cardiovascular outcomes. Further studies should evaluate for multivariate associations with modifiable risk factors for CV disease.

Postmenopausal breast cancer survivors prescribed AIs develop endothelial dysfunction, a predictor of adverse CV disease. Understanding the exact mechanisms through further detailed biomarker research long-term, along with potential interventions, such as modifications of CV risk factors, to mitigate these effects is necessary and warrants further investigation.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on request.

Abbreviations

Aromatase inhibitors

Estrogen-receptor positive

Cardiovascular

C-reactive protein

High-density lipoprotein cholesterol

Hazard Ratio

Low-density lipoprotein cholesterol

Total cholesterol

Triglycerides

Tissue-type plasminogen activator

Plasminogen-activator 1

Peripheral arterial tonometry

Pulse wave amplitude

University of Minnesota

Miller KD, Nogueira L, Mariotto AB et al. Cancer treatment and survivorship statistics, 2019. CA Cancer J Clin. 2019.

Cuzick J, Sestak I, Baum M, et al. Effect of anastrozole and tamoxifen as adjuvant treatment for early-stage breast cancer: 10-year analysis of the ATAC trial. Lancet Oncol. 2010;11(12):1135–41.

Article CAS PubMed Google Scholar

Brueggemeier RW, et al. Aromatase inhibitors in the treatment of breast cancer. Endocr Reviews vol. 2005;26(3):331–45. https://doi.org/10.1210/er.2004-0015 .

Article CAS Google Scholar

Adhikari N, et al. Combating breast cancer with non-steroidal aromatase inhibitors (NSAIs): understanding the chemico-biological interactions through comparative SAR/QSAR study. Eur J Med Chem. 2017;137:365–438. https://doi.org/10.1016/j.ejmech.2017.05.041 .

Smith IE, Dowsett M. Aromatase inhibitors in breast cancer. New Engl J Med vol. 2003;348:2431–42. https://doi.org/10.1056/NEJMra023246 .

Meyer MR, Barton M. Estrogens and Coronary Artery Disease: New Clinical perspectives. Adv Pharmacol. 2016;77:307–60.

Khosrow-Khavar F, Filion KB, Bouganim N, Suissa S, Azoulay L. Aromatase inhibitors and the risk of Cardiovascular outcomes in women with breast Cancer: a Population-based Cohort Study. Circulation. 2020;141(7):549–59.

Article PubMed Google Scholar

Sund M, Garcia-Argibay M, Garmo H, et al. Aromatase inhibitors use and risk for cardiovascular disease in breast cancer patients: a population-based cohort study. Breast. 2021;59:157–64.

Article PubMed PubMed Central Google Scholar

Rubinshtein R, Kuvin JT, Soffler M, et al. Assessment of endothelial function by non-invasive peripheral arterial tonometry predicts late cardiovascular adverse events. Eur Heart J. 2010;31(9):1142–8.

Axtell AL, et al. Assessing endothelial vasodilator function with the Endo-PAT 2000. J Visualized Experiments: JoVE. 2010;44. https://doi.org/10.3791/2167 . 2167. 15 Oct.

Zoll. itamar. https://www.itamar-medical.com/professionals/endopat/ . Accessed on 3/28/2024.

Kuvin JT, et al. Assessment of peripheral vascular endothelial function with finger arterial pulse wave amplitude. Am Heart J vol. 2003;146(1):168–74. https://doi.org/10.1016/S0002-8703(03)00094-2 .

Article Google Scholar

Hedblad B, et al. Low pulse-wave amplitude during reactive leg hyperaemia: an independent, early marker for ischaemic heart disease and death. Results from the 21-year follow-up of the prospective cohort study ‘Men born in 1914’, Malmö, Sweden. J Intern Med vol. 1994;236(2):161–8. https://doi.org/10.1111/j.1365-2796.1994.tb01278.x .

Blaes A, Beckwith H, Florea N et al. Vascular function in breast cancer survivors on aromatase inhibitors: a pilot study. Breast Cancer Res Treat. 2017.

Bradshaw PT, Stevens J, Khankari N, Teitelbaum SL, Neugut AI, Gammon MD. Cardiovascular Disease Mortality among breast Cancer survivors. Epidemiology. 2016;27(1):6–13.

Luca MC, Liuni A, Harvey P, Mak S, Parker JD. Effects of estradiol on measurements of conduit artery endothelial function after ischemia and reperfusion in premenopausal women. Can J Physiol Pharmacol. 2016;94(12):1304–8.

Lew R, Komesaroff P, Williams M, Dawood T, Sudhir K. Endogenous estrogens influence endothelial function in young men. Circul Res. 2003;93(11):1127–33.

Shechter M, Matetzky S, Prasad M, Goitein O, Goldkorn R, Naroditsky M, Koren-Morag N, Lerman A. Endothelial function predicts 1-year adverse clinical outcome in patients hospitalized in the emergency department chest pain unit. Int J Cardiol. 2017;240:14–9. Epub 2017 May 1. PMID: 28477961.

Cuzick J, Sestak I, Forbes JF, Dowsett M, Cawthorn S, Mansel RE, Loibl S, Bonanni B, Evans DG, Howell A. IBIS-II investigators. Use of anastrozole for breast cancer prevention (IBIS-II): long-term results of a randomised controlled trial. Lancet. 2020;395(10218):117–122. doi: 10.1016/S0140-6736(19)32955-1. Epub 2019 Dec 12. Erratum in: Lancet. 2020;395(10223):496. Erratum in: Lancet. 2021;397(10276):796. PMID: 31839281; PMCID: PMC6961114.

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Adnan Shaaban

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Anne H. Blaes

Division of Biostatistics and Health Data Science, University of Minnesota, Minneapolis, MN, USA

Ashley Petersen

Department of Internal Medicine, Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA

Heather Beckwith, David A. Potter, Douglas Yee & Anne H. Blaes

Department on Internal Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, USA

Natalia Florea

Department of Obstetrics, Gynecology and Women’s Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, USA

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AS served as primary investigator and wrote majority of the manuscript. AP: Study statistician, helped in interpretation of data and generation of tables and figures. HB: All other co-authors helped the primary investigator in editing and writing the final draft for the manuscript. AB: Corresponding author had a major role in interpreting data and writing manuscript. All authors read and approved the final manuscript.

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Shaaban, A., Petersen, A., Beckwith, H. et al. Endothelial dysfunction in breast cancer survivors on aromatase inhibitors: changes over time. Cardio-Oncology 10 , 27 (2024). https://doi.org/10.1186/s40959-024-00227-z

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During follow-up visits, the following topics will be addressed Adherence with therapy (medication, diet, exercise, stress management) Efficacy of therapy and need for adjustment HTN education reinforcement Follow-up visits will be scheduled at 2 weeks to 6 months depending on patients' responses to and adherence with treatment.
2017 Guideline for High Blood Pressure in Adults
Follow-up: In low-risk adults with elevated BP or stage 1 hypertension with low ASCVD risk, BP should be repeated after 3-6 months of nonpharmacologic therapy. Adults with stage 1 hypertension and high ASCVD risk (≥10% 10-year ASCVD risk) should be managed with both nonpharmacologic and antihypertensive drug therapy with repeat BP in 1 month.
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Hypertension, or abnormally high blood pressure, is a leading risk factor for cardiovascular disease. In the United States, there are approximately 67 million adults who have hypertension, ... Depending upon whether this is a first visit or a follow-up visit, ask appropriate and simple questions to help you determine patients goals and concerns ...
2020 International Society of Hypertension Global Hypertension Practice
The measurement of BP in the office or clinic is most commonly the basis for hypertension diagnosis and follow-up. Office BP should be measured according to recommendations shown in Table 3 and Figure 1. 1,2,17,18. Whenever possible, the diagnosis should not be made on a single office visit.
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