Outcomes July 2013 epidemiology and trends over time in the diagnosis and management of hypertension across a variety of patient populations . Trends in Antihypertensive Medication Use and Blood Pressure Control Among United States

ssential or primary hypertension, the world's leading risk factor for global disease burden, is expected to cause more than half of the estimated 17 million deaths per year resulting from car-diovascular disease (CVD) worldwide. 1 Defined as an elevation of blood pressure (BP) beyond 140/90 mm Hg, hypertension is strongly correlated with adverse outcomes such as stroke, ischemic heart disease, heart failure, and end stage renal disease. The challenges of managing hypertension and preventing the development of these latter outcomes are unlikely to relent; the global burden of hyper-tension is projected to increase by 60% to affect approximately 1.6 billion adults worldwide by 2025. 2 In this month's topic review in Circulation: Cardiovascular Quality and Outcomes, we concentrate on this highly prevalent condition. Considerable hurdles remain in overcoming the burden of hyper-tension. First, the insidious nature in which hypertension develops means that hypertension is frequently undiagnosed, and early detection prior to the development of end-organ damage remains a challenge. Second, many patients appropriately diagnosed with hypertension fail to achieve the treatment targets recommended by guidelines. This highlights the considerable challenges in implementing risk factor modification and appropriate adherence to antihy-pertensive therapies long term. Third, uncertainty remains as to the appropriate BP treatment target for high-risk patients. While a target BP <140/90 mm Hg is generally recommended, a lower threshold of <130/80 mm Hg is recommended for patients at high risk of CVD, such as patients with diabetes. 3 Whether such intensive BP lowering leads to improved outcomes remains uncertain. 4 Fourth, even among patients who receive appropriate care, a proportion of patients remains resistant to treatment despite multiple medications. These patients with resistant hypertension carry substantial risk of adverse events. 5 The emergence of renal artery de-innervation may herald a novel and effective procedural option to treat these patients. 6 The challenges highlighted are pertinent to many populations. Many low-and middle-income countries, most of which are in the midst of the epidemiological transition, face rapidly increasing prevalence of hypertension in the context of limited healthcare resources. In these countries, diagnosis and appropriate management of hyperten-sion remains disconcertingly low. 7 Developing innovative and cost-effective solutions to improve hypertension diagnosis and control thus remains a key priority. 8 These issues are not limited to developing countries alone; less than 50% of the US patients have appropriate BP control 9 despite good access to care, a wealth of evidence surrounding lifestyle modification, and …