A CLOSER LOOK AT

Nearly one in four

Americans has high
blood pressure.

A JOINT PROJECT BETWEEN

T H E A M E R I C A N H E A R T A S S O C I AT I O N A N D
T H E N AT I O N A L P H A R M AC E U T I C A L C O U N C I L
H
igh blood pressure is a silent killer responsible for the
deaths of more than 44,000 Americans in 1998. Data
indicate that the death rate associated with high blood
pressure is rising. Two types of blood
pressure—systolic and diastolic—are
measured. High blood pressure, or
hypertension, is defined in an adult as a
systolic pressure of 140 millimeters of
mercury (mm Hg) or higher and/or a
diastolic pressure of 90 mm Hg or higher
(see box on next page).1
High blood pressure can occur in
children or adults, but is particularly
prevalent in African-Americans,
middle-aged and elderly people, obese
people, heavy drinkers, and women
taking oral contraceptives. People with
diabetes, gout, or kidney disease have a
higher frequency of high blood
pressure.2 Roughly 50 million
Americans age six and older have high
blood pressure.3 Left untreated, high
blood pressure can lead to heart
disease, kidney disease, and stroke.3 In
2001, the estimated total direct costs of
treating high blood pressure are
estimated at $29.6 billion, in addition to
$10.8 billion in indirect costs from lost
productivity.3
Many people have undiagnosed high blood pressure
because the symptoms are not always obvious. It is
estimated that only 68 percent of Americans with high
blood pressure are aware of their condition. While four-
fifths of those diagnosed with high blood pressure take
medication for it, only half of those patients actually control
their blood pressure adequately. This failure to control high
blood pressure may be due to improper treatment,
noncompliance with prescribed medications and lifestyle
changes, or other reasons.1
High blood pressure is primarily treated through lifestyle
modification and drug therapy. Patients may be advised to
stop smoking, lose weight, exercise regularly, and limit their
intake of salt, fats, and alcohol.1 Studies have found that body
weight, changes in body weight over time, and skinfold
thickness are related to changes in blood pressure levels.
These factors have been linked to the later rise and
development of high blood pressure. People who are
overweight are more likely to have high-normal to mild-high
blood pressure. Most Americans also consume far more salt
than their bodies need. Heavy sodium consumption
increases blood pressure in some people, leading to high
blood pressure. The American Heart Association Nutrition
Committee recommends a diet low in salt and fat, and rich in
potassium, calcium, magnesium and protein.4
The Sixth Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of
Hypertension (JNC), published in 1997, contains practice
guidelines for treatment of high blood pressure.1 The
guidelines state that patients with mild or moderate high
blood pressure should begin treatment with long-acting, once-
daily drug therapy. Patients with severe high blood pressure
may require a more aggressive medication regimen. If the
initial therapy fails, a drug from a different therapeutic class or
combination therapy should be prescribed.
There are several classes of medications used to treat high
blood pressure and each reduces blood pressure through a
different mechanism. Diuretics rid the body of excess fluids
and salt; beta blockers reduce heart rate and the heart’s
output of blood; sympathetic nerve inhibitors prevent
nerves from constricting blood vessels; vasodilators relax
the muscles in the walls of blood vessels; ACE inhibitors and
angiotensin II receptor blockers affect the body’s
production and absorption of angiotensin, a chemical that
causes arteries to constrict; and calcium channel blockers
reduce heart rate and relax blood vessels.5 These drugs are
also used to treat people with heart problems, glaucoma,
kidney disease, and other conditions. Currently no class of
drugs is accepted to be most effective for treating high
blood pressure. Combinations of existing drugs are often
more effective than single-drug therapy.6, 7 Studies have
shown that among patients with high blood pressure,
maintaining a healthy blood pressure requires the use of
multiple drugs in most cases.8, 9
A number of studies have highlighted the health benefits of
lowering high blood pressure even by small amounts.
Analyses of recent clinical trials indicate a 38 percent decrease
in strokes among patients who lowered their blood pressure
only slightly.10 More recent studies point to a 16 percent
reduction in heart disease-related deaths for individuals
undergoing long-term drug therapy for high blood pressure.10
Treating high blood pressure long-term has been shown to
lower health care costs and to reduce rates of related diseases
and death. According to one study, when the number of
patients controlling high blood pressure increased from 44 to
68 percent, annual health care costs dropped by 40 percent.11
 T
here is some concern that the prescription of drugs may not always follow the JNC
guidelines. This could, in some cases, be due to poor compliance and other
medical conditions. High blood pressure treatment compliance appears to be
closely tied to the side-effect profiles of drugs and cost concerns. In general, as the
side-effect profile of a medication worsens, so does treatment compliance.12 Physicians
may also deviate from standard guidelines to accommodate other medical conditions.
Certain drugs, for instance, can aid people with Type I diabetes by decreasing their
resistance to insulin.13

In the face of rising prevalence, meeting national treatment goals may require
coordinated efforts to raise awareness, encourage treatment, and achieve control of
high blood pressure. Education programs can alert the public to the need for blood
pressure testing and highlight the health benefits of controlling hypertension. New
medications can also play a role. Together, new therapies and better practice
patterns are the keys to improving high blood pressure control.

T
OTAL DIRECT COSTS OF TREATING HYPERTENSION ARE
ESTIMATED TO BE $29.6 BILLION IN 2001.

BLOOD PRESSURE DEFINED

Blood pressure Optimal Normal High Normal Hypertension
(mm Hg)

Systolic Less than 120 Less than 130 130-139 140 or higher
(top number)

Diastolic Less than 80 Less than 85 85-89 90 or higher

(bottom number)

FACTORS THAT INCREASE YOUR RISK OF DEVELOPING

HIGH BLOOD PRESSURE:
• Family history of high blood pressure
• Race (African-Americans are more likely to have high blood pressure than Caucasians.)
• Male gender (Men have a greater risk of high blood pressure than women until age 55, when their respective risks are
similar. At age 75 and older, women are more likely to develop high blood pressure than men.)
• Age (Blood pressure tends to increase with age.)
• Sensitivity to salt
• Obesity and excess weight
• Heavy alcohol consumption
• Use of oral contraceptives and some other medications
• Sedentary or inactive lifestyle

Source: American Heart Association. (2001) Heart and Stroke A-Z Guide: High Blood Pressure, Factors that Contribute to.
[Online]. Available: http://www.americanheart.org/Heart_and_Stroke_A_Z_Guide/hbpf.html [10/18/01].
 FACTORS INFLUENCING DRUG SPENDING FOR
HIGH BLOOD PRESSURE 1994-1997
METHODOLOGY Spending on pharmaceuticals was analyzed for individuals who received health benefit
coverage from large employers in 1994 and 1997. The sample included individuals who
This study separately
received drug treatment for high blood pressure and those who were diagnosed with a
analyzed prescription drug
condition other than high blood pressure for which these drugs are often prescribed.
spending growth for two
large national claims
databases, one representing 20
managed care plan enrollees Volume Factors
and the other representing
15
those covered by large
employer-provided health
benefit plans. The study 10
defined and assessed
several factors affecting the 5
price per day of therapy and
the volume of therapy — 0
the number of days of
therapy received and the -5
number of patients receiving
drug therapy. The analysis -10 Price Factors
also examined the effects of
price and volume changes
for established drugs on the Spending for high blood pressure drugs rose 10 percent from 1994 to 1997. Volume factors
market during the entire (increased numbers of people with high cholesterol receiving cholesterol lowering
period of analysis and for prescriptions, and increased intensity and duration of drug therapy) far outweighed price
new drugs that were first factors, which had a negative impact on spending growth.
marketed during this period.

Factors Influencing Growth in Rx Expenditures: % Positive Impact % Negative Impact

Total Growth in Expenditures +10
Growth Due to Volume Factors +18
Changes in the Number of Prescriptions per Person for Established Drugs -5
Changes in the Number of Prescriptions per Person for New Entrants +18
Changes in Days of Therapy for Established Drugs +9
Changes in Days of Therapy for New Entrants 0
Patients per 1000 Health Care Enrollees -3
Growth Due to Price Factors -8
Inflation +1
Changes in Mix of Established Drugs -7
Price of New Entrants -2
Source: MEDSTAT’s Marketscan database
SPENDING PER CAPITA FOR HIGH BLOOD PRESSURE MEDICATIONS
1994
250
1997
Avg. $ Per Capita

200
150
100
50
0
All ACE Inhibitors Alpha-Beta Beta Blockers Calcium Hypotensive Vasodilating
Blockers Channel Agents Agents
Blockers

Drug spending per capita decreased from 1994 to 1997 across most classes of high blood pressure drugs. Per capita spending on ACE
inhibitors, calcium channel blockers, alpha-beta blockers and beta blockers each fell roughly 20 percent from 1994 to 1997, while
spending on vasodilating agents dropped 6 percent. The only increase in per capita spending was for hypotensive agents. Spending
for these drugs grew 7 percent in three years.

Source: MEDSTAT’s Marketscan database

INDIVIDUALIZED CARE FOR

AFRICAN-AMERICANS
High blood pressure can occur in people of all ages, genders and races, but it is particularly
common in African-Americans. In fact, the prevalence of high blood pressure in African-
Americans is among the highest in the world. Compared with Caucasians, African-Americans
develop high blood pressure at an earlier age and their average blood pressures are much
higher. African-Americans have moderate high blood pressure twice as often as Caucasians and
severe high blood pressure three times as often. As a result, African-Americans have a 2- to 3-
fold greater risk of stroke and are more likely to die of stroke than Caucasians.

It is not surprising then that the treatment for high blood pressure affects African-Americans
and Caucasians differently. In general, ACE inhibitors are less effective for African-American
patients than they are for Caucasian patients – although they are often the first choice
treatment. Beta-blockers also exhibit different levels of effectiveness among ethnic groups.
While all medications used to treat high blood pressure can be effective for African-Americans,
different dosages are often necessary. Drug therapy should be tailored to the individual patient
in order to achieve optimal results.

Source: American Heart Association. (2001) Biostatistical Fact Sheet-Populations,

African-Americans and Cardiovascular Diseases. [Online].
Available: http://www.americanheart.org/statistics/biostats/bioafr.htm [10/18/01].
 FOR MORE INFORMATION ABOUT
ABOUT THIS
PUBLICATION:
HIGH BLOOD PRESSURE, PLEASE CONTACT:
The American Heart Association (AHA)
“A Closer Look at High Blood Pressure” is www.americanheart.org
a joint publication of the American Heart 1-800-AHA-USA1
Association and the National
Pharmaceutical Council. The National Institutes of Health (NIH)
www.nih.gov
The American Heart Association spent 301-496-4000
about $337 million during fiscal year
1999-2000 on research support, public The National Heart, Lung and Blood Institute (NHLBI)
and professional education, and www.nhlbi.nih.gov
community programs. Nationwide, our 1-800-575-9355
organization has grown to include more
than 22.5 million volunteers and The National Institute of Neurological Disorders and Stroke (NINDS)
supporters who carry out our mission in www.ninds.nih.gov
communities across the country. The 1-800-352-9424
association is the largest voluntary
health organization fighting heart American College of Cardiology (ACC)
disease, stroke and other cardiovascular www.acc.org
diseases, which annually kill about
1-800-253-4636
950,000 Americans.

Since 1953, the National Pharmaceutical

Council (NPC) has sponsored and
conducted scientific, evidence-based
analyses of the appropriate use of
pharmaceuticals and the clinical and
economic value of pharmaceutical
innovation. NPC provides educational
resources to a variety of health care
stakeholders, including patients,
clinicians, payers and policy makers.
More than 20 research-based
pharmaceutical companies are members
of the NPC.
1
Joint National Committee. The Sixth Report of The
Joint National Committee on Detection, Evaluation
and Treatment of High Blood Pressure (JNC-VI). NIH
Pub. No. 98-4080. Rockville, MD: National Heart,
Lung, and Blood Institute, National Institutes of
Health, 1997.
2
American Heart Association. (2001) Heart and Stroke
A-Z Guide: High Blood Pressure. [Online]. Available:
http://www.americanheart.org/Heart_and_Stroke_
A_Z_Guide/hbp.html [10/18/01].
3
American Heart Association. (2001) Heart and Stroke
Statistical Update. Dallas, TX: AHA, 2000.
4
American Heart Association. (2001) Heart and Stroke
A-Z Guide: High Blood Pressure, Factors that
Contribute to. [Online]. Available: http://www.
americanheart.org/Heart_and_Stroke_A_Z_Guide/
hbpf.html [10/18/01].
5
American Heart Association. (2001) Heart and Stroke
A-Z Guide: High Blood Pressure, What Can Be Done.
[Online]. Available: http://www.americanheart.org/
8
Hansson L, Zanchetti A, Carruthers SG et al. Effects
of intensive blood-pressure lowering and low-dose
aspirin in patients with hypertension: principal
results of the Hypertension Optimal Treatment (HOT)
randomised trial. Lancet 1998;351:1755-1762.
9
Moser M. National recommendations for the
pharmacological treatment of hypertension: Should
they be revised? Arch Intern Med 1999;159:1403-1406.
10
Moser M. Hypertension can be treated effectively
without increasing the cost of care. Journal of Human
Hypertension 1996;10(Suppl. 2):S33-S38.
11
Moser M. The cost of treating hypertension: can we
keep it under control without compromising the level
of care? Am J Hypertens 1998;11(8, pt. 2):120S-127S.
12
Hansson L. Medical and cost-economy aspects of
modern antihypertensive therapy—with special
reference to 2 years of clinical experience with
losartan. Blood Pressure 1997;6(Suppl 1):52-55.
Barrie W. Cost-effective therapy for hypertension.
13

Heart_and_Stroke_A_Z_Guide/hbpwhat.html West J Med 1996;164:303-309.

For more information about NPC or for
additional resources, please contact:
The National Pharmaceutical Council
1894 Preston White Drive
Reston, VA 20191-5433
Phone: 703-620-6390
Fax: 703-476-0904
www.npcnow.org
[10/18/01].
6
Moser M, Black H. The role of combination therapy
in the treatment of hypertension. Am J Hypertens
1998;11(6, pt. 2):73S-78S.
7
Gradman AH, Cutler NR, Davis PD, et al. Combined
enalapril and felodipine extended release (ER) for
systemic hypertension. Am J Cardiol 1997;79:431-435.
Cited in Moser and Black, 1998.