November 23rd, 2012
Undiagnosed Hypertension in Younger Adults
Heather M Johnson, MD, MS
Dr. Johnson answers CardioExchange editors’ questions about her research group’s retrospective study of undiagnosed hypertension in younger adults. It was presented at the American Heart Association conference earlier this month.
THE STUDY
The cohort comprised 30,000 adults who met guideline criteria for hypertension and regularly received primary care. Patients were excluded if they had a previous diagnosis of hypertension or had been prescribed antihypertensive medication. Emergency room blood pressure readings were not counted.
After at least 2 years of follow-up, patients age 18 to 39 were less likely to receive a diagnosis for their hypertension than were patients age 60 or older. After adjustment for patient demographics, comorbidities, and provider factors, hazard ratios for a hypertension diagnosis were as follows:
18- to 24-year-olds: HR, 0.35; 95% CI, 0.29-0.42
25- to 31-year-olds: HR, 0.39; 95% 0.35-0.43
32- to 39-year-olds: HR 0.51; 95% CI, 0.47-0.55
The likelihood of receiving a hypertension diagnosis was especially low among young adults whose primary spoken language was not English, but also (surprisingly) among young adults of white race. Female providers were more likely than male providers to diagnose hypertension in young adults.
THE AUTHOR RESPONDS
How do you know that these diagnoses of hypertension were truly “missed” versus ignored? That distinction would change how clinicians address the problem.
I agree – that distinction does change how the problem is addressed. Our research does not answer the question of “missed” versus ignored elevated blood pressure. Additional research that includes qualitative methodology is needed to determine whether elevated blood pressures were missed or ignored.
Why do you suspect that having a male healthcare provider was associated with a missed diagnosis?
One possible reason that having a male healthcare provider was associated with a missed hypertension diagnosis among young adults comes from previously published studies showing that male and female providers differ in patient-provider communication. Further research is needed to understand how this difference may affect young adults’ awareness, understanding, and diagnosis of hypertension.
Were providers just as likely to miss all grades of hypertension severity?
Providers were less likely to diagnose milder levels of hypertension.
How do you suggest that we decrease these rates of missed diagnoses? Would you tackle it on a patient/public level or on a physician/provider level?
The primary implication of our study is that it emphasizes the need for interventions to be tailored to young adults with elevated blood pressure, in order to improve hypertension diagnosis rates. In addition, our research demonstrates that multiple factors contribute to low hypertension diagnosis rates in this age group. The most effective interventions are likely to be system-level interventions that address multiple components and not just focus on providers.
Offer your thoughts about this study by Dr. Johnson and her colleagues.
3 Responses to “Undiagnosed Hypertension in Younger Adults”
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Perhaps those who failed to diagnose ‘hypertension’ did so with the awareness that the diagnosis does not have a sound scientific basis. Pickering showed some 60 years ago that blood pressure has a unitary distribution and any division drawn is entirely arbitrary. JNC7 set some arbitrary thresholds but these are well below the line where there is clear evidence of universal benefit from treatment, especially in those at low absolute risk of cardiovascular events. This is reputedly one reason why the JNC8 committee is having such trouble reconciling traditional practice based solely or largely on BP levels with the evidence base. Other national and international guidelines have moved a variable way into accepting the complexity of assessing risk (and consequent benefit of risk reduction) on the basis of multiple risk factors and away from the simplistic dichotomising of the population on the basis of a single risk factor.
In my workplace, the staff often come to measure their blood pressure on our monitors because they are feeling a little dizzy, or have a headache etc. or because they have been told to follow their blood pressure readings. Sometimes the readings are a little alarming. However, I find myself reluctant to lable young people “hypertensive” and instead give them lifestyle advice (somethimes with a severe look so the message gets through), and to keep track of their readings in a regular and controlled way. Perhaps I am not the only one who feels that something is wrong if a large portion of the young and healthy population goes on medication, with all the side effects and cost, when simple common sense could be a better solution. Is this a “guy” way of thinking? Awaiting studies on that…
Many of these patients may have white coat hypertension – get them to check their BP at home or prescribe a 24 hour ambulatory BP monitor. Many have very poor lifestyle habits (alcohol, smoking, NSAIDs, carbs). Many are obese – a few even have sleep apnea. No I would not jump to a medication right off “the bat”. Typically what we are seeing is anxiety in a health care setting combined with poor lifestyle (if your lifestyle is excellent, even an anxious health care setting is unlikely to give you much of a sustained boost in BP). If they are a bit older, I start screening for secondary causes of hypertension (fibromuscular dysplasia, primary hyperaldosteronism, obstructive sleep apnea, hypercortisolism, pheochromocytoma, hyperparathyroidism, hypothyroidism, etc).