Self-Reported Antihypertensive Medication Class and Temporal Relationship to Treatment Guidelines

Area of Science:

• Cardiovascular Medicine
• Hypertension Research
• Public Health

Background:

• US hypertension guidelines historically recognized differential responses to antihypertensives in non-Hispanic Black (NHB) adults.
• Recent guidelines (2014 aJNC8, 2017 ACC/AHA) recommend calcium channel blockers (CCBs) or thiazide-type diuretics over renin-angiotensin system blockers for initial hypertension therapy in NHB adults.
• Previous guidelines (1988-2003) also acknowledged better responses to CCBs or thiazides in NHB adults.

Purpose of the Study:

• To assess the temporal impact of updated hypertension treatment guidelines on monotherapy choices in NHB and non-Hispanic White (NHW) adults.
• To evaluate changes in the use of CCB or thiazide-type diuretic monotherapy before and after the 2014 aJNC8 Report.
• To examine the relationship between guideline recommendations, monotherapy patterns, and hypertension control in NHB and NHW populations.

Main Methods:

• Analysis of National Health and Nutrition Examination Surveys (NHANES) data from 2007-2012 (before 2014 aJNC8) and 2015-2018 (after 2014 aJNC8).
• Focused on self-reported monotherapy with CCBs, thiazide-type diuretics, or renin-angiotensin system blockers in adults with hypertension, excluding those with compelling indications for other agents.
• Compared monotherapy rates and hypertension control between the two time periods for NHB and NHW adults.

Main Results:

• CCB or thiazide-type diuretic monotherapy rates remained unchanged in NHW adults (17.1% vs. 18.1%, P=0.711).
• Monotherapy with CCBs or thiazides showed an insignificant increase in NHB adults after 2014 (43.7% vs. 38.2%, P=0.204).
• Within NHB adults, CCB monotherapy significantly increased (29.5% vs. 21.0%, P=0.021), while renin-angiotensin system blocker monotherapy significantly decreased (44.5% vs. 31.0%, P=0.008).
• Despite increased evidence-based CCB use in NHB adults, overall hypertension control declined, with increases in untreated hypertension and monotherapy.
• Therapeutic inertia appears to be worsening, indicating insufficient improvement in hypertension control among NHB adults.

Conclusions:

• A persistent gap exists between guideline recommendations and actual monotherapy practices for hypertension in NHB adults.
• Current evidence-based monotherapy strategies appear insufficient to improve hypertension control in NHB adults.
• Race-neutral strategies, including initiating treatment with single-pill combinations and timely therapeutic intensification, are recommended to improve hypertension control in NHB adults.