By the Healthy People 2020 Heart Disease and Stroke Federal Partnership
High blood pressure, or hypertension, has detrimental effects on health, particularly if left uncontrolled for sustained periods of time. High pressure in blood vessels damages major organs, especially the heart, brain, kidneys, and eyes, and is a leading risk factor for heart attacks and strokes. Hypertension in middle age has been linked to steeper rates of cognitive decline later in life. It is often called a “silent killer” because its effects can go unnoticed for years until significant damage has occurred. A recent CDC analysis suggests that hypertension contributed to 360,000 deaths in the U.S. in 2013, representing a significant increase since 2000.
Approximately 30 percent of Americans have hypertension. Although lifestyle changes and medications are effective and affordable, overall rates of control remain suboptimal. Some racial and ethnic minorities have higher rates of hypertension and lower rates of control, which may contribute to the disproportionate burden of cardiovascular disease in these populations and patients. More work is needed to understand barriers to achieving better control and to develop evidence-based interventions. Community and health systems interventions tailored to the populations they serve are recommended as important strategies for attaining better blood pressure control among more people.
Dramatic improvements in public health could be gained from enhanced hypertension control. One analysis estimated that a 10% increase in the number of people whose hypertension is successfully treated would prevent 14,000 deaths, which was greater than any other clinical preventive service tested in the model. The Healthy People 2020 Heart Disease and Stroke (HDS) Topic Area includes an objective to increase the proportion of adults with hypertension whose blood pressure is under control to 61.2 percent by 2020, a significant improvement from the 2005-2008 baseline estimate of 43.7 percent. The importance of this Healthy People objective is evident in its designation as a Leading Health Indicator, one of 26 Healthy People objectives selected as significant measures of public health. Leading Health Indicators represent a call for cross-sector collaboration in areas where there is momentous opportunity for positive public health impact.
Sixteen objectives in the HDS Topic Area focus on blood pressure. The federal partners who oversee these HDS objectives support research, data analysis, public health initiatives, and public education activities that will facilitate use of evidence-based strategies to prevent and control hypertension.
The Centers for Disease Control and Prevention (CDC) has several synergistic activities supportive of Healthy People 2020 HDS objectives. For example, Million Hearts®, a U.S. Department of Health and Human Services initiative co-led by CDC and the Centers for Medicare and Medicaid Services, has a goal of preventing 1 million heart attacks and strokes over a 5-year period. The initiative aligns, coordinates, and advances activities within and among communities through diverse collaboration. The focus of efforts of Million Hearts® in the clinical setting is on the ABCs of heart health (aspirin use when appropriate, blood pressure control, cholesterol management, and smoking cessation) with improving hypertension control as a key priority. Million Hearts® promotes the use of advanced models of care such as electronic health record systems to assess and improve performance, the adoption of evidence-based tools (e.g., hypertension treatment protocols and patient registries), and the use of electronic health data to target patients and improve outcomes (e.g., identification of hypertensive patients Hiding in Plain Sight). A wealth of information to improve hypertension control is available through the Million Hearts® website, including success stories from high-functioning health systems (i.e., Hypertension Control Champions) and patient, practice- and community-level tools and resources (e.g., Self-Measured Blood Pressure Monitoring: Action Steps for Clinicians). In addition to Million Hearts®, CDC provides funding across all 50 states and the District of Columbia to implement strategies and activities to promote awareness of hypertension and other related disorders or strategies to prevent disease onset. Additional information can be reviewed on the Division of Heart Disease and Stroke Prevention’s Grantee Information website and the National Center for Chronic Disease Prevention and Health Promotion website.
The National Institutes of Health (NIH) also supports research and programs that align with the Healthy People 2020 HDS objectives. In recent news, a groundbreaking trial co-sponsored by the National Heart, Lung, and Blood Institute (NHLBI), the National Institute of Neurological Disorders and Stroke (NINDS), the National Institute on Aging and the National Institute of Diabetes and Digestive and Kidney Diseases, Systolic Blood Pressure Intervention Trial (SPRINT), was stopped early based on preliminary findings that aiming for a lower blood pressure target can save lives and reduce the risk of cardiovascular disease in adults 50 years and older with hypertension and without diabetes. The study found that compared with standard treatment of blood pressure (to below 140 millimeters of mercury [mm Hg] systolic), treating to below 120 mm Hg reduced the rate of heart attack, heart failure, and stroke–by 25 percent, and the risk of death by 27 percent. These institutes also co-sponsored the SPRINT- Memory and Cognition in Decreased Hypertension (MIND), which is assessing the effects of aggressive blood pressure control on cognition.
Effectiveness and implementation trials also provide key information. The goal of these trials is to determine effective strategies for delivering proven effective interventions in routine clinical settings. An example of this type of NHLBI sponsored research include the Home Blood Pressure Telemonitoring and Case Management to Control Hypertension study which promotes community efforts to achieve blood pressure control through in-home blood pressure monitoring with the collaboration of pharmacists and primary care physicians. This study plans to evaluate the long term feasibility, and critical factors for translating this intervention into practice.
NINDS and NHLBI are partnering with the Patient Centered Outcomes Research Institute to improve hypertension control among high risk racial and ethnic minority populations by sponsoring two comparative effectiveness trials to evaluate hypertension control strategies at the health system and/or community level. Several regional partnerships supported through the NINDS Stroke Prevention Intervention Research Program are also testing innovative health system and community-based hypertension control strategies among minority communities.
In addition to research efforts, the NHLBI collaboratively supports programs such as the Heart Truth and the Million Hearts initiative to promote the dissemination of knowledge and good practices among health care providers and patients. The NHLBI has also conducted a systematic review on hypertension which was completed in 2014 and is available for NHLBI partners to guide development of clinical practice guidelines using the collaborative model.
NINDS is launching a public health education campaign called Mind Your Risks. Many people are unaware that hypertension in midlife can raise the risk for cognitive impairment in later life, and the campaign aims to address this knowledge gap. The campaign will begin in the Stroke Belt states, a region that is most severely affected by hypertension, and spread nationwide in late spring. Key messages emphasize that hypertension in middle age has been associated with brain tissue damage and poorer cognition later in life, and managing hypertension in midlife may help protect the brain from later cognitive impairment and dementia.
Collectively, these activities symbolize significant momentum toward the Healthy People 2020 HDS goal of improved hypertension control, which will translate into dramatic improvements in health and longevity of the U.S. population.
Healthy People 2020 Heart Disease and Stroke Federal Partnership Workgroup Members
Centers for Disease Control and Prevention: Yuling Hong, MD, PhD, National Center for Chronic Disease Prevention and Health Promotion, Division for Heart Disease and Stroke Prevention; Fleetwood Loustalot, PhD, FNP, National Center for Chronic Disease Prevention and Health Promotion, Division for Heart Disease and Stroke Prevention; Angela Thompson-Paul, PhD, MSPH, National Center for Chronic Disease Prevention and Health Promotion, Division for Heart Disease and Stroke Prevention
National Institutes of Health: Joylene John-Sowah, MD, MPH, National Heart, Lung, and Blood Institute, Center for Translation Research and Implementation Science; Katherine Pahigiannis, PhD, National Institute of Neurological Disorders and Stroke, Office of Science Policy and Planning
The workgroup would like to thank their Heart Disease and Stroke topic area liaisons for the excellent guidance and technical support they have provided for the workgroup’s activities:Emmeline Ochiai, MPH, Department of Health and Human Services Office of Disease Prevention and Health Promotion; Kimberly Hurvitz, MHS, Centers for Disease Control and Prevention National Center for Health Statistics
The workgroup would also like to thank their colleagues who contributed to this blog post: Marian Emr, Director, National Institute of Neurological Disorders and Stroke Office of Communications and Public Liaison; Lawrence J Fine, MD, DrPh, National Heart, Lung, and Blood Institute Division of Cardiovascular Sciences; Lawton S. Cooper, MD, MPH National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences; Booker Daniels, MPH, National Center for Chronic Disease Prevention and Health Promotion, Division for Heart Disease and Stroke Prevention; Barbara Bowman, PhD, National Center for Chronic Disease Prevention and Health Promotion, Division for Heart Disease and Stroke Prevention