Hypertensive Crisis in an Era of Escalating Health Care Changes

Theresa P. Yeo; Sherry A. Burrell


Journal for Nurse Practitioners. 2010;6(5):338-346. 

In This Article

Epidemiology of HTN

Primary or essential HTN affects 72 million Americans and contributes to approximately 6% of all cardiovascular deaths.[2] Another 59 million Americans have pre-HTN.[3] The prevalence of HTN is greater among blacks and African Americans compared to other races in the United States, and is the highest rate worldwide.[4,5] In the 1970s, the prevalence of HTN among adults in the United States was 40%.[6] Following a massive public campaign to increase awareness of HTN, the prevalence dropped to 24% between 1980 and 1994. However, the 1999–2000 National Health and Nutrition Examination Survey (NHANES) found that the prevalence of HTN had crept up again to 29%.[6] This trend has continued, with most recent estimates of the prevalence of HTN at 34% in the United States. If this rate of increase persists, it is estimated that by 2025, there will be 104 million Americans suffering from HTN and associated comorbidities.[6]

The main factors driving the increased prevalence of HTN in the United States are obesity, aging of the population, and lack of health insurance for many Americans. Obesity is strongly associated with HTN. According to the most recent estimates by the Centers for Disease Control and Prevention, obesity in the United States has reached epidemic proportions, affecting one third of all adults (72 million persons) and 16% of children.[7] With regard to aging, the U.S. Census Bureau reports that over 37 million persons or 12.4% of the U.S. population are over the age of 65.[8] These numbers are expected to reach 71.5 million (20% of the population) by 2030. It is well documented that systolic BP increases in whites, blacks, and Mexican Americans with aging and to a greater extent in women than men.[3] According to Robinson, the age-adjusted prevalence (of both diagnosed and undiagnosed) HTN between 1999 to 2002 was 78% for women and 64% for men aged 65-years or older based on NHANES data.[9] The number of Americans without access to health care is now estimated at 30 million, plus an additional 17 million undocumented persons.[8] According to NHANES data from 1999 to 2002, a lack of health insurance was associated with higher rates of inadequate blood pressure control among individuals being treated for HTN.[10] As the number of elderly persons grows, the number of obese Americans rises, and more persons are without access to health care, the prevalence of primary HTN is predicted to accelerate. Acute care APNs can expect to see an increase in the number of patients presenting with hypertensive crises.

In general, the earlier HTN develops, the greater the severity of the disease. HTN is also the most common predisposing condition for stroke, acute coronary syndromes, renal failure, and premature cardiovascular disease.[11] A history of HTN is reported among 69% of people with a first myocardial infarction (MI), 77% of those experiencing a first stroke, and 74% of those with heart failure (HF).[1] While the majority of cases of primary HTN are mild (70%), 10% of hypertensive patients are classified as having severe or very serve disease, and 15% of patients with diagnosed HTN receive no treatment.[12–14] Only 38% of men and 23% of women over 80 achieve the JNC-7 recommended level of BP control (< 140/90 or < 130/80 mmHg if co-existing diabetes or renal insufficiency are present).[1]

Failure to increase antihypertensive medication is cited as one of the reasons why the Healthy People 2010 goal of achieving a BP < 140/90 mmHg in 50% of known hypertensive patients has not been achieved.[15] A 2006 study of more than 7000 hypertensive patients uncovered "therapeutic inertia" (defined as failure to add new medications or to increase existing medications in hypertensive patients not meeting their treatment goal of BP < 140/90), in 89% of patients having 4 or more visits.[4]