case study of hypertension

• Search Menu
• Sign in through your institution
• Advance articles
• Editor's Choice
• Graphical Abstracts and Tidbit
• Author Guidelines
• Submission Site
• Open Access
• About American Journal of Hypertension
• Editorial Board
• Board of Directors
• Advertising and Corporate Services
• Journals Career Network
• Self-Archiving Policy
• Dispatch Dates
• AJH Summer School
• Journals on Oxford Academic
• Books on Oxford Academic

Article Contents

Clinical management and treatment decisions, hypertension in black americans, pharmacologic treatment of hypertension in black americans.

• < Previous
• Article contents
• Figures & tables
• Supplementary Data

Suzanne Oparil, Case study, American Journal of Hypertension , Volume 11, Issue S8, November 1998, Pages 192S–194S, https://doi.org/10.1016/S0895-7061(98)00195-2

• Permissions Icon Permissions

Ms. C is a 42-year-old black American woman with a 7-year history of hypertension first diagnosed during her last pregnancy. Her family history is positive for hypertension, with her mother dying at 56 years of age from hypertension-related cardiovascular disease (CVD). In addition, both her maternal and paternal grandparents had CVD.

At physician visit one, Ms. C presented with complaints of headache and general weakness. She reported that she has been taking many medications for her hypertension in the past, but stopped taking them because of the side effects. She could not recall the names of the medications. Currently she is taking 100 mg/day atenolol and 12.5 mg/day hydrochlorothiazide (HCTZ), which she admits to taking irregularly because “... they bother me, and I forget to renew my prescription.” Despite this antihypertensive regimen, her blood pressure remains elevated, ranging from 150 to 155/110 to 114 mm Hg. In addition, Ms. C admits that she has found it difficult to exercise, stop smoking, and change her eating habits. Findings from a complete history and physical assessment are unremarkable except for the presence of moderate obesity (5 ft 6 in., 150 lbs), minimal retinopathy, and a 25-year history of smoking approximately one pack of cigarettes per day. Initial laboratory data revealed serum sodium 138 mEq/L (135 to 147 mEq/L); potassium 3.4 mEq/L (3.5 to 5 mEq/L); blood urea nitrogen (BUN) 19 mg/dL (10 to 20 mg/dL); creatinine 0.9 mg/dL (0.35 to 0.93 mg/dL); calcium 9.8 mg/dL (8.8 to 10 mg/dL); total cholesterol 268 mg/dL (< 245 mg/dL); triglycerides 230 mg/dL (< 160 mg/dL); and fasting glucose 105 mg/dL (70 to 110 mg/dL). The patient refused a 24-h urine test.

Taking into account the past history of compliance irregularities and the need to take immediate action to lower this patient’s blood pressure, Ms. C’s pharmacologic regimen was changed to a trial of the angiotensin-converting enzyme (ACE) inhibitor enalapril, 5 mg/day; her HCTZ was discontinued. In addition, recommendations for smoking cessation, weight reduction, and diet modification were reviewed as recommended by the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI). 1

After a 3-month trial of this treatment plan with escalation of the enalapril dose to 20 mg/day, the patient’s blood pressure remained uncontrolled. The patient’s medical status was reviewed, without notation of significant changes, and her antihypertensive therapy was modified. The ACE inhibitor was discontinued, and the patient was started on the angiotensin-II receptor blocker (ARB) losartan, 50 mg/day.

After 2 months of therapy with the ARB the patient experienced a modest, yet encouraging, reduction in blood pressure (140/100 mm Hg). Serum electrolyte laboratory values were within normal limits, and the physical assessment remained unchanged. The treatment plan was to continue the ARB and reevaluate the patient in 1 month. At that time, if blood pressure control remained marginal, low-dose HCTZ (12.5 mg/day) was to be added to the regimen.

Hypertension remains a significant health problem in the United States (US) despite recent advances in antihypertensive therapy. The role of hypertension as a risk factor for cardiovascular morbidity and mortality is well established. 2–7 The age-adjusted prevalence of hypertension in non-Hispanic black Americans is approximately 40% higher than in non-Hispanic whites. 8 Black Americans have an earlier onset of hypertension and greater incidence of stage 3 hypertension than whites, thereby raising the risk for hypertension-related target organ damage. 1 , 8 For example, hypertensive black Americans have a 320% greater incidence of hypertension-related end-stage renal disease (ESRD), 80% higher stroke mortality rate, and 50% higher CVD mortality rate, compared with that of the general population. 1 , 9 In addition, aging is associated with increases in the prevalence and severity of hypertension. 8

Research findings suggest that risk factors for coronary heart disease (CHD) and stroke, particularly the role of blood pressure, may be different for black American and white individuals. 10–12 Some studies indicate that effective treatment of hypertension in black Americans results in a decrease in the incidence of CVD to a level that is similar to that of nonblack American hypertensives. 13 , 14

Data also reveal differences between black American and white individuals in responsiveness to antihypertensive therapy. For instance, studies have shown that diuretics 15 , 16 and the calcium channel blocker diltiazem 16 , 17 are effective in lowering blood pressure in black American patients, whereas β-adrenergic receptor blockers and ACE inhibitors appear less effective. 15 , 16 In addition, recent studies indicate that ARB may also be effective in this patient population.

Angiotensin-II receptor blockers are a relatively new class of agents that are approved for the treatment of hypertension. Currently, four ARB have been approved by the US Food and Drug Administration (FDA): eprosartan, irbesartan, losartan, and valsartan. Recently, a 528-patient, 26-week study compared the efficacy of eprosartan (200 to 300 mg/twice daily) versus enalapril (5 to 20 mg/daily) in patients with essential hypertension (baseline sitting diastolic blood pressure [DBP] 95 to 114 mm Hg). After 3 to 5 weeks of placebo, patients were randomized to receive either eprosartan or enalapril. After 12 weeks of therapy within the titration phase, patients were supplemented with HCTZ as needed. In a prospectively defined subset analysis, black American patients in the eprosartan group (n = 21) achieved comparable reductions in DBP (−13.3 mm Hg with eprosartan; −12.4 mm Hg with enalapril) and greater reductions in systolic blood pressure (SBP) (−23.1 with eprosartan; −13.2 with enalapril), compared with black American patients in the enalapril group (n = 19) ( Fig. 1 ). 18 Additional trials enrolling more patients are clearly necessary, but this early experience with an ARB in black American patients is encouraging.

Efficacy of the angiotensin II receptor blocker eprosartan in black American with mild to moderate hypertension (baseline sitting DBP 95 to 114 mm Hg) in a 26-week study. Eprosartan, 200 to 300 mg twice daily (n = 21, solid bar), enalapril 5 to 20 mg daily (n = 19, diagonal bar). †10 of 21 eprosartan patients and seven of 19 enalapril patients also received HCTZ. Adapted from data in Levine: Subgroup analysis of black hypertensive patients treated with eprosartan or enalapril: results of a 26-week study, in Programs and abstracts from the 1st International Symposium on Angiotensin-II Antagonism, September 28–October 1, 1997, London, UK.

Approximately 30% of all deaths in hypertensive black American men and 20% of all deaths in hypertensive black American women are attributable to high blood pressure. Black Americans develop high blood pressure at an earlier age, and hypertension is more severe in every decade of life, compared with whites. As a result, black Americans have a 1.3 times greater rate of nonfatal stroke, a 1.8 times greater rate of fatal stroke, a 1.5 times greater rate of heart disease deaths, and a 5 times greater rate of ESRD when compared with whites. 19 Therefore, there is a need for aggressive antihypertensive treatment in this group. Newer, better tolerated antihypertensive drugs, which have the advantages of fewer adverse effects combined with greater antihypertensive efficacy, may be of great benefit to this patient population.

1. Joint National Committee : The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure . Arch Intern Med 1997 ; 24 157 : 2413 – 2446 .

Google Scholar

2. Veterans Administration Cooperative Study Group on Antihypertensive Agents : Effects of treatment on morbidity in hypertension: Results in patients with diastolic blood pressures averaging 115 through 129 mm Hg . JAMA 1967 ; 202 : 116 – 122 .

3. Veterans Administration Cooperative Study Group on Antihypertensive Agents : Effects of treatment on morbidity in hypertension: II. Results in patients with diastolic blood pressures averaging 90 through 114 mm Hg . JAMA 1970 ; 213 : 1143 – 1152 .

4. Pooling Project Research Group : Relationship of blood pressure, serum cholesterol, smoking habit, relative weight and ECG abnormalities to the incidence of major coronary events: Final report of the pooling project . J Chronic Dis 1978 ; 31 : 201 – 306 .

5. Hypertension Detection and Follow-Up Program Cooperative Group : Five-year findings of the hypertension detection and follow-up program: I. Reduction in mortality of persons with high blood pressure, including mild hypertension . JAMA 1979 ; 242 : 2562 – 2577 .

6. Kannel WB , Dawber TR , McGee DL : Perspectives on systolic hypertension: The Framingham Study . Circulation 1980 ; 61 : 1179 – 1182 .

7. Hypertension Detection and Follow-Up Program Cooperative Group : The effect of treatment on mortality in “mild” hypertension: Results of the Hypertension Detection and Follow-Up Program . N Engl J Med 1982 ; 307 : 976 – 980 .

8. Burt VL , Whelton P , Roccella EJ et al.  : Prevalence of hypertension in the US adult population: Results from the third National Health and Nutrition Examination Survey, 1988–1991 . Hypertension 1995 ; 25 : 305 – 313 .

9. Klag MJ , Whelton PK , Randall BL et al.  : End-stage renal disease in African-American and white men: 16-year MRFIT findings . JAMA 1997 ; 277 : 1293 – 1298 .

10. Neaton JD , Kuller LH , Wentworth D et al.  : Total and cardiovascular mortality in relation to cigarette smoking, serum cholesterol concentration, and diastolic blood pressure among black and white males followed up for five years . Am Heart J 1984 ; 3 : 759 – 769 .

11. Gillum RF , Grant CT : Coronary heart disease in black populations II: Risk factors . Heart J 1982 ; 104 : 852 – 864 .

12. M’Buyamba-Kabangu JR , Amery A , Lijnen P : Differences between black and white persons in blood pressure and related biological variables . J Hum Hypertens 1994 ; 8 : 163 – 170 .

13. Hypertension Detection and Follow-up Program Cooperative Group : Five-year findings of the Hypertension Detection and Follow-up Program: mortality by race-sex and blood pressure level: a further analysis . J Community Health 1984 ; 9 : 314 – 327 .

14. Ooi WL , Budner NS , Cohen H et al.  : Impact of race on treatment response and cardiovascular disease among hypertensives . Hypertension 1989 ; 14 : 227 – 234 .

15. Weinberger MH : Racial differences in antihypertensive therapy: evidence and implications . Cardiovasc Drugs Ther 1990 ; 4 ( suppl 2 ): 379 – 392 .

16. Materson BJ , Reda DJ , Cushman WC et al.  : Single-drug therapy for hypertension in men: A comparison of six antihypertensive agents with placebo . N Engl J Med 1993 ; 328 : 914 – 921 .

17. Materson BJ , Reda DJ , Cushman WC for the Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents : Department of Veterans Affairs single-drug therapy of hypertension study: Revised figures and new data . Am J Hypertens 1995 ; 8 : 189 – 192 .

18. Levine B : Subgroup analysis of black hypertensive patients treated with eprosartan or enalapril: results of a 26-week study , in Programs and abstracts from the first International Symposium on Angiotensin-II Antagonism , September 28 – October 1 , 1997 , London, UK .

19. American Heart Association: 1997 Heart and Stroke Statistical Update . American Heart Association , Dallas , 1997 .

• hypertension
• blood pressure
• african american

Email alerts

Citing articles via.

• Recommend to your Library

Affiliations

• Online ISSN 1941-7225
• Copyright © 2024 American Journal of Hypertension, Ltd.
• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Institutional account management
• Rights and permissions
• Get help with access
• Accessibility
• Advertising
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

Book series

Practical Case Studies in Hypertension Management

About this book series.

• Giuliano Tocci

Book titles in this series

Hypertension and 24-hour ambulatory blood pressure monitoring.

• Julian Segura
• Copyright: 2019

Available Renditions

Hypertension and Renal Organ Damage

• Roberto Pontremoli
• Copyright: 2018

Hypertension and Cardiac Organ Damage

• Raffaele Izzo
• Copyright: 2017

Hypertension and Metabolic Cardiovascular Risk Factors

• Arrigo F. G. Cicero
• Copyright: 2016

Hypertension and Comorbidities

• Agostino Virdis

Publish with us

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• BMC Res Notes

A teenager with uncontrolled hypertension: a case report

Abdul wadud chowdhury.

1 Department of Cardiology, Dhaka Medical College Hospital, Dhaka, Bangladesh

ATM Hasibul Hasan

2 Department of Medicine (Outdoor Patient Department), Dhaka Medical College Hospital, Dhaka, Bangladesh

SME Jahan Kabir

Km nurus sabah.

Takayasu Arteritis is a vasculitis occurring mostly in young females which may present in diverse ways. Here we report a teenager with Takayasu Arteritis who presented with uncontrolled hypertension. This case depicts an atypical presentation of this disease where the girl visited many physicians for controlling the level of hypertension and put a diagnostic dilemma about the underlying etiology of young hypertension.

Case presentation

A 13 year old girl presented with epistaxis, persistent headache and uncontrolled hypertension. Her clinical examination revealed normal radial, very feeble femoral and absent other lower limb pulses. There was a blood pressure discrepancy of 50/40 mm of Hg between two arms. There were bruits over multiple areas including the abdominal aorta. She had features of left ventricular hypertrophy. Her Arch aortogram showed hugely dilated arch of aorta which became abruptly normal just after origin of left subclavian artery. There was ostio-proximal stenosis of right bracheocephalic artery, left common carotid and left subclavian artery with post stenotic dilatation of all the vessels. Abdominal aortogram revealed critical stenosis of abdominal aorta above the origin of renal arteries with a pressure gradient of 80/11 mm of Hg.

Takayasu’s Arteritis should also be kept in mind while searching for the cause of uncontrolled hypertension in the young age group.

The estimated prevalence of hypertension in pediatric age group is between 2%–5% [ 1 ]. The usual form of hypertension in young is attributable to secondary causes. The most common cause is the renovascular one (60–70%) [ 2 , 3 ]. Cushing syndrome, hyperthyroidism, pheochromocytoma, essential hypertension, coarctation of aorta, SLE are also found less commonly with hypertension in children and adeloscent [ 4 ]. With the growing knowledge and awareness of hypertension, the rate of diagnosis is increasing in children [ 1 ]. Evidences are increasing regarding early development of atherosclerosis in child and their possible relation to hypertension and coronary artery disease [ 5 ]. Several studies have reported the correlation between pediatric hypertension and family H/O hypertension, low birth weight, excess body weight [ 6 , 7 ]. Here we describe a 13 year old girl presenting with epistaxis, headache and uncontrolled hypertension despite poly drug therapy, abnormal peripheral pulses and unequal blood pressure in upper limbs. Further investigations were done to determine the cause of hypertension. The arch and abdominal aortography further correlated the uncontrolled hypertension with Takayasu’s disease according to American College Rheumatology (ACR) criteria. KS Chugh et al. described Takayasu Arteritis as the most common cause of renovascular hypertension in India [ 8 ]. Takayasu Arteritis is a large vessel vasculitis of unknown origin characterized by granulomatous inflammation of aorta and its major branches, leading to stenosis, thrombosis and aneurysm formation.

A 13 year old girl presented with three episodes of spontaneous profuse nasal bleeding within last three years which had remission without specific therapy. She had diffuse persistent headache without nausea or vomiting and uncontrolled hypertension, despite taking amlodipine and atenolol. She gave no H/O chest pain, shortness of breath, fever, prolonged cough, pulsatile tinnitus, light headedness, arthralgia, skin rash, weight loss, claudication or colour changes on cold exposure. There was no history of contact with TB patient. She did not give any H/O dizziness or syncope. On examination, both radial pulses were 80 beats/min, regular, high volume and surprisingly apparently symmetrical on both sides. There was no radio-femoral delay. Both the femoral pulses were feeble. All other lower limb pulses were absent. BP on right arm was 120/80 mmHg and on left arm was 170/120mmHg. There were bruits over both carotids, suprasternal, supraclavicular areas and over abdominal aorta. On precordial examination-apex beat was palpable at left 5th intercostal space just lateral to the midclavicular line. It was heaving in nature. A 2 was loud, there was no added sound. All other systemic examinations including optic fundi were normal. On investigation, Hemoglobin was 11.2 gm/dl, Total Count-5100/mm [ 3 ], Neutrophil- 51%, Lymphocyte- 35%, Monocyte- 03%, Eosinophil-07%, Erythrocyte sedimentation rate (ESR)- 30 mm in 1st hour. Mantoux test (MT) and C-reactive protein (CRP) were negative. Blood glucose, Serum creatinine, urine analysis were normal. Chest X-ray showed cardiomegaly with LV type apex (Figure ​ (Figure1 1 A).

A: CXR P-A view. Cardiomegaly with LV type apex. B ECG. Left ventricular hypertrophy.

ECG fulfilled the voltage criteria of left ventricular hypertrophy (Figure ​ (Figure1B). 1 B). 2D, M-mode and Doppler echocardiography revealed concentric left ventricular hypertrophy, aneurysmal dilatation of aortic arch, proximal stenosis and post stenotic dilatation of brachiocephalic, left common carotid and left subclavian artery and narrowing of descending thoracic aorta beyond the origin of left subclavian artery. Arch Aortogram showed hugely dilated (70 mm) arch of aorta which became abruptly normal (35 mm) just after origin of left subclavian artery. Right bracheocephalic artery had ostio-proximal stenosis with marked post stenotic dilatation (Figure ​ (Figure2A: 2 A: white arrow). There was also ostio-proximal stenosis of left common carotid and left subclavian artery with post stenotic dilatation (Figure ​ (Figure2B: 2 B: white arrow). Abdominal aortogram revealed critical stenosis of abdominal aorta (8.9 mm) above the origin of renal arteries (Figure ​ (Figure2C: 2 C: white arrow). Renal arteries were however normal. Pressure study in abdominal aorta showed a pressure tracing of 200/106 mm of Hg above and 120/95 mm of Hg below the stenosis (Figure ​ (Figure3 3 ).

A: Arch Aortogram. Hugely dilated (70 mm) arch of aorta which became abruptly normal (35 mm) just after origin of left subclavian artery. Right bracheocephalic artery had ostio-proximal stenosis with marked post stenotic dilatation (white arrow). B : Arch Aortogram. Ostio-proximal stenosis of left common carotid and left subclavian artery with post stenotic dilatation (white arrow). C : Abdominal Aortogram critical stenosis of abdominal aorta (8.9 mm) above the origin of renal arteries (white arrow).

Pressure tracing in abdominal aorta.

She fulfilled four of the six major ACR (American College of Rheumatology) criteria for Takayasu’s disease eg, onset of age is 13 years (<40years), 50 mm of Hg pressure difference between systolic BP between arms (>10mm of Hg pressure difference), subclavian and aortic bruit and narrowing of major branches of aorta. She was prescribed Amlodipine 10 mg, Atenolol 100mg, Prazosin 6mg, Hydrochlorthiazide 50mg and Amiloride 5mg. Methotrexate 5mg weekly with Folinic acid supplementation were given too. Plan for Angioplasty and Stenting of abdominal aortic stenosis was provided to the patient.

Takayasu’s Arteritis (TA) is a chronic inflammatory large vessel vasculitis of unknown origin, predominantly affecting aorta and its major branches. It is also called Aortic arch syndrome, Pulse less disease, Occlusive thromboaortopathy, Martorell syndrome [ 9 ]. The first scientific description of Takayasu’s Arteritis was given by Mikito Takaysu, Professor of Opthalmology at Kanazawa University, Japan, in 1905 at 12th Annual conference of Japanese Ophthalmology Society [ 10 ]. He presented a 21year old woman with a peculiar form of arteriovenus anastomoses at optic fundi. K Onishi and T Kagosha also contributed with their patients of absent radial pulse in the same conference [ 10 ]. But the first ever documented description of this arteritis dates back to 1830. Rokushu Yamamoto who practiced Japanese oriental medicine, described a case of 45 years old man presenting with absent pulse in one upper limb and feeble pulse in another one following a year long history of high grade fever. During the period of follow up the patient subsequently became emaciated, dyspnoeic and died suddenly after 11 years [ 10 ]. The world wide prevalence of Takayasu’s disease is 3.3/million. The disease is more common in East Asia and in Asian descendants in other countries [ 11 ]. TA commonly presents in 2nd or 3rd decade of life, with a high female preponderance. But the female to male ratio declines from Eastern Asia to the West [ 12 ]. TA may manifest as asymptomatic pulseless disease to catastrophic neurological impairements. The disease may present in two phase, a prepulseless phase of nonspecific inflammatory signs, followed by a chronic phase of vascular insufficiency [ 13 - 15 ]. Presentation of TA varies among the races. Japanese patients are predominantly female, presents with pulslessness, dizziness, vertigo, aortic regurgitation, inflammatory process commonly affecting the arch and its major branches, whereas Indian patients are male dominant. Indian cases present with more hypertension, headache, LV hypertrophy and vasculitic involvement of abdominal aorta and renal arteries [ 15 ]. Diminished or absent pulse along with upper limb claudication and blood pressure difference is found in 84–96% of cases [ 16 ]. Vascular bruits involving carotid, subclavian and abdominal vessels are also common (80–94%) [ 17 ]. Hypertension is associated with 33–83% patients of TA [ 15 , 17 ]. Our index case was also a young girl with feeble femoral pulse and absent other peripheral pulses in lower limb, blood pressure discrepancy between arms, bruits over multiple areas of chest and neck and hypertension. The blood pressure discrepancy of 50/40 mm of Hg is probably due to the difference in percentage of stenosis among the brachiocephalic (70–80% stenosis) and left subclavian vessels (50–60% stenosis). Retinopathy, aortic regurgitation, congestive heart failure, cardiomyopathy, myocardial ischemia, headache, dizziness, seizure are less common association of TA. From common findings of TA, American College of Rheumatology has devised some diagnostic criteria for TA in 1990. Angiography remains the gold standard investigation for diagnosis. The main differential diagnosis include other causes of large vessel vasculitis eg inflammatory vasculitis (Syphilis, Tuberculosis, Behchets, SLE); development abnormalities (Coarctation of aorta, Marfans syndrome) and neurofibromatosis. TA has been classified on the basis of angiographic findings. The new classification was described at Takayasu Arteritis Conference in 1994 based on vessel involvement. Type-I involving branches from aortic arch, Type-IIa denoting ascending aorta, aortic arch and its branches, Type-IIb including Type-Ia plus descending thoracic aorta. Type-III means descending thoracic aorta, abdominal aorta and/ or renal arteries. Type-IV involves abdominal aorta and/ or renal arteries. Type-V is combined features of Type-IIb and Type-IV [ 15 ]. Ishikawa classified different clinical groups based on natural history and complications. He described Group-I as uncomplicated disease with or without pulmonary artery involvement, Group-IIA as mild/moderate single complication together with uncomplicated disease, Group-IIB as severe single complication together with uncomplicated disease, Group-III as two or more complications together with uncomplicated disease [ 17 ]. Ishikawa defined Takayasu retinopathy, Secondary hypertension, Aortic regurgitation, Aneurysm formation as four most important complications. Our index case met the angiographic criteria of Type-IV Takayasu Arteritis class and Group-III of Ishikawa class [ 17 ]. Ishikawa class caries a prognostic significance not only for the Japanese patients but also for the Indians. The overall five year survival rate is 83%. The survival rate is 100% in Group-I and 70% in Group-IIb and Group-III. The most common cause of mortality is cerebrovascular disease and cardiac failure. Regarding treatment strategy steroid had been the mainstay of treatment. Shelhamer et al. showed half of the TA patients on steroid won’t respond [ 18 ]. Kerr et al. showed overall remission rate of 33% with immunosuppressive drugs in steroid unresponsive patients [ 16 ]. Methotrexate though not more efficacious than others, became popular due to its well tolerability [ 19 , 20 ]. The combination of steroid and methotrexate demonstrated a remission rate of 81% in steroid unresponsive patients [ 21 ]. Treatment of hypertension and prevention of thrombosis are also important aspects of therapy. Treatment of hypertension with ACE inhibitors requires careful monitoring for renal artery stenosis. Surgery may be needed in patients with critical renal artery stenoses, limb claudication limiting the daily activities, stenosis of three or more cerebral vessels, moderate aortic regurgitation. Stenoses of renal artery are best treated by Percutaneous Transluminal Angioplasty [ 21 ]. Stent placement following angioplasty is a safe and effective procedure [ 22 ]. Takayasu’s Arteritis is a chronic progressive vasculopathy. So long term follow up is recommended. Markers of acute phase response are unreliable during follow up. Doppler studies and MRA are can help to determine the vessel wall thickness and lumen configuration.

Takaysu’s Arteritis can have varied presentation. So a young female patient presenting with absent pulse, unequal blood pressure between arms and hypertension should be suspected clinically for Takayasu’s disease.

Written informed consent was obtained from the patient’s guardian for publication of this case report and for all the accompanying images.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

AWC is the first author and was involved in diagnosis by performing the angiography and writing a part of the manuscript. ATMHH is the communicating author and was involved in writing the manuscript. SMEJK and KMNS were responsible for the management of the patient. All the authors read and approved the final manuscript.

Acknowledgement

We acknowledge Professor H I Lutfur Rahman Khan for providing the overall support to us.

• Sorof JM, Lai D, Turner J, Poffenbarger T, Portman RJ. Overweight, ethnicity, and the prevalence of hypertension in school-aged children. Pediatrics. 2004; 113 (3 pt 1):475–482. [ PubMed ] [ Google Scholar ]
• Ooi BS, Chen BTM, Toh CCS, Khoo OT. “Cause of Hypertension in Young” Br Med J. 1970; 3 :744–746. doi: 10.1136/bmj.3.5725.744. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Flynn JT. Evaluation and management of hypertension in childhood. Prog Pediatr Cardiol. 2001; 12 :177–188. doi: 10.1016/S1058-9813(00)00071-0. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004; 114 (2 suppl 4th report):555–576. [ PubMed ] [ Google Scholar ]
• Luma GB, Spoitta RT. “Hypertension in Children and Adeloscent” Am Fam Physician. 2006; 73 (9):1558–1566. [ PubMed ] [ Google Scholar ]
• Franco MC, Christofalo DM, Sawaya AL, Ajzen SA, Sesso R. Effects of low birth weight in 8- to 13-yearold children: implications in endothelial function and uric acid levels. Hypertension. 2006; 48 (1):45–50. doi: 10.1161/01.HYP.0000223446.49596.3a. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Moore WE, Stephens A, Wilson T, Wilson W, Eichner JE. Body mass index and blood pressure screening in a rural public school system: the Healthy Kids Project. Prev Chronic Dis. 2006; 3 (4):A114. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Chugh KS, Jain S, Sakhuja V. Renovascular hypertension due to Takayasu’s Arteritis among Indian patients. QJM. 1992; 85 :833–843. [ PubMed ] [ Google Scholar ]
• Lupi-Herrera E, Sánchez-Torres G, Marcushamer J. Takayasu Arteritis. Clinical study of 107 cases. Am Heart J. 1977; 93 :94–103. doi: 10.1016/S0002-8703(77)80178-6. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Numano F, Okawara M, Inomata H. Takayasu’s Arteritis. Lancet. 2000; 356 :1023–1025. doi: 10.1016/S0140-6736(00)02701-X. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Watts R, Al Taiar A, Mooney J, Scott D, MacGregor A. The Epidemiology of Takayasu Arteritis in the UK. Rheumatology. 2009; 48 :1008–1011. doi: 10.1093/rheumatology/kep153. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Johnston SL, Lock RJ, Gompels MM. Takayasu Arteritis: a review. J Clin Pathol. 2002; 55 :481–486. doi: 10.1136/jcp.55.7.481. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Moriwaki R, Noda M, Yajima M. Clinical manifestations of Takayasu Arteritis in India and Japan—new classification of angiographic findings. Angiology. 1997; 48 :369–379. [ PubMed ] [ Google Scholar ]
• Jain S, Sharma N, Singh S. Takayasu Arteritis in children and young Indians. Int J Cardiol. 2000; 75 :S153–S157. [ PubMed ] [ Google Scholar ]
• Subramanyan R, Joy J, Balakrishnan KG. Natural history of aortoarteritis (Takayasu’s disease) Circulation. 1989; 80 :429–437. doi: 10.1161/01.CIR.80.3.429. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kerr GS, Hallahan CW, Giordano J. Takayasu Arteritis. Ann Intern Med. 1994; 120 :919–929. [ PubMed ] [ Google Scholar ]
• Ishikawa K. Natural history and classification of occlusive thromboaortopathy (Takayasu’s disease) Circulation. 1978; 57 :27–35. doi: 10.1161/01.CIR.57.1.27. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Shelhamer JH, Volkman DJ, Parrillo JE. Takayasu’s Arteritis and its therapy. Ann Intern Med. 1985; 103 :121–126. [ PubMed ] [ Google Scholar ]
• Hoffman GS, Leavitt RY, Kerr GS. Treatment of Takayasu’s Arteritis (TA) with methotrexate (MTX) Arthritis Rheum. 1991; 34 :S74. [ PubMed ] [ Google Scholar ]
• Hoffmann GS, Leavitt RY, Kerr GS. Treatment of glucocorticoid-resistant or relapsing Takayasu Arteritis with methotrexate. Arthritis Rheum. 1994; 37 :578–582. doi: 10.1002/art.1780370420. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Giordano JM. Surgical treatment of Takayasu’s Arteritis. Int J Cardiol. 2000; 75 :S123–S128. [ PubMed ] [ Google Scholar ]
• Sharma BK, Jain S, Bali HK. A follow-up study of balloon angioplasty and de-novo stenting in Takayasu Arteritis. Int J Cardiol. 2000; 75 :S147–S152. [ PubMed ] [ Google Scholar ]

• Remote Access
• Save figures into PowerPoint
• Download tables as PDFs

Chapter 6:  10 Real Cases on Hypertensive Emergency and Pericardial Disease: Diagnosis, Management, and Follow-Up

Niel Shah; Fareeha S. Alavi; Muhammad Saad

• Download Chapter PDF

Disclaimer: These citations have been automatically generated based on the information we have and it may not be 100% accurate. Please consult the latest official manual style if you have any questions regarding the format accuracy.

Download citation file:

• Search Book

Jump to a Section

Case review, case discussion.

• Clinical Symptoms
• Diagnostic Evaluation
• Full Chapter
• Supplementary Content

Case 1: Management of Hypertensive Encephalopathy

A 45-year-old man with a 2-month history of progressive headache presented to the emergency department with nausea, vomiting, visual disturbance, and confusion for 1 day. He denied fever, weakness, numbness, shortness of breath, and flulike symptoms. He had significant medical history of hypertension and was on a β-blocker in the past, but a year ago, he stopped taking medication due to an unspecified reason. The patient denied any history of tobacco smoking, alcoholism, and recreational drug use. The patient had a significant family history of hypertension in both his father and mother. Physical examination was unremarkable, and at the time of triage, his blood pressure (BP) was noted as 195/123 mm Hg, equal in both arms. The patient was promptly started on intravenous labetalol with the goal to reduce BP by 15% to 20% in the first hour. The BP was rechecked after an hour of starting labetalol and was 165/100 mm Hg. MRI of the brain was performed in the emergency department and demonstrated multiple scattered areas of increased signal intensity on T2-weighted and fluid-attenuated inversion recovery (FLAIR) images in both the occipital and posterior parietal lobes. There were also similar lesions in both hemispheres of the cerebellum (especially the cerebellar white matter on the left) as well as in the medulla oblongata. The lesions were not associated with mass effect, and after contrast administration, there was no evidence of abnormal enhancement. In the emergency department, his BP decreased to 160/95 mm Hg, and he was transitioned from drip to oral medications and transferred to the telemetry floor. How would you manage this case?

The patient initially presented with headache, nausea, vomiting, blurred vision, and confusion. The patient’s BP was found to be 195/123 mm Hg, and MRI of the brain demonstrated scattered lesions with increased intensity in the occipital and posterior parietal lobes, as well as in cerebellum and medulla oblongata. The clinical presentation, elevated BP, and brain MRI findings were suggestive of hypertensive emergency, more specifically hypertensive encephalopathy. These MRI changes can be seen particularly in posterior reversible encephalopathy syndrome (PRES), a sequela of hypertensive encephalopathy. BP was initially controlled by labetalol, and after satisfactory control of BP, the patient was switched to oral antihypertensive medications.

Hypertensive emergency refers to the elevation of systolic BP >180 mm Hg and/or diastolic BP >120 mm Hg that is associated with end-organ damage; however, in some conditions such as pregnancy, more modest BP elevation can constitute an emergency. An equal degree of hypertension but without end-organ damage constitutes a hypertensive urgency, the treatment of which requires gradual BP reduction over several hours. Patients with hypertensive emergency require rapid, tightly controlled reductions in BP that avoid overcorrection. Management typically occurs in an intensive care setting with continuous arterial BP monitoring and continuous infusion of antihypertensive agents.

Get Free Access Through Your Institution

Pop-up div successfully displayed.

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

Please Wait

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• Open access
• Published: 14 August 2024

Effectiveness of biofeedback on blood pressure in patients with hypertension: systematic review and meta-analysis

• Sian Jenkins   ORCID: orcid.org/0000-0003-1963-4495 1 , 2 ,
• Ainslea Cross 3 ,
• Hanad Osman   ORCID: orcid.org/0000-0001-7404-1276 1 , 2 ,
• Farah Salim 4 ,
• Dan Lane 4 ,
• Dennis Bernieh 4 ,
• Kamlesh Khunti 2 &
• Pankaj Gupta   ORCID: orcid.org/0000-0001-9481-6067 4 , 5  

Journal of Human Hypertension ( 2024 ) Cite this article

147 Accesses

9 Altmetric

Metrics details

• Health care
• Hypertension

Hypertension is the leading modifiable risk factor for cardiovascular disease, but less than 50% have their blood pressure controlled. A possible avenue to support hypertension management is a holistic approach, using non-pharmacological interventions. Since hypertension is mediated in part by dysregulation of the autonomic nervous system (ANS), biofeedback may help improve hypertension management by targeted self-regulation and self-awareness of parameters that regulate the ANS. This systematic review aimed to assess the effectiveness of biofeedback on blood pressure in hypertensive patients. The review was pre-registered on PROSPERO and followed the PICO strategy. A total of 1782 articles were retrieved, 20 met the inclusion criteria. Sample sizes ranged from 15 to 301 participants; with a median age of 49.3 (43.3–55.0) years and 45% were female. There was a significant effect of biofeedback on systolic (−4.52, Z = 2.31, P  = 0.02, CI [−8.35, −0.69]) and diastolic blood pressure (−5.19, Z = 3.54, P  = 0.0004, CI [−8.07, −2.32]). Six different biofeedback modalities were used, with biofeedback delivered by psychologists, trained therapists and research assistants. There was no publication bias, heterogeneity was rated as substantial and data quality was rated to be poor. This review demonstrated that biofeedback had a significant effect on blood pressure. However, this should be viewed in the context of included studies being limited by heterogeneity and dated literature, meaning the research does not reflect the current biofeedback technology such as wearable devices. Future research should incorporate these technologies with robust methodology to fully understand the effect of biofeedback on hypertension.

Similar content being viewed by others

Short- to long-term blood pressure variability: Current evidence and new evaluations

A systematic review and meta-analysis of mindfulness-based stress reduction for arterial hypertension

High versus low measurement frequency during 24-h ambulatory blood pressure monitoring - a randomized crossover study

Introduction.

Hypertension is the leading modifiable risk factor for cardiovascular disease, stroke and premature death [ 1 ]. Globally, 1.2 billion people have hypertension, a figure that doubled between 1990 and 2019 [ 1 ]. Worldwide hypertension control remains poor with only 21% of men and 18% of women achieving blood pressure targets [ 1 ]. This is despite the availability of cheap and effective medications. Hence it would be useful to consider non-pharmacological therapies that, in conjunction with medications, may help improve blood pressure in a more holistic manner.

It is accepted that hypertension is in part due to a derangement in the regulation of the autonomic nervous system (ANS). The sympathetic nervous system leads to increase in heart rate and blood pressure, whereas the parasympathetic nervous system relaxes the body and decreases blood pressure [ 2 ]. Hypertension is also linked to impaired baroreceptor regulation with interrelationships between baroreflex sensitivity and autonomic dysfunction [ 3 ]. There is evidence that non-pharmacological treatments such as lifestyle interventions and weight loss have a positive impact on the ANS [ 2 ]. Therefore, improved regulation in the ANS, especially an increase in parasympathetic activity, can improve blood pressure and biofeedback may help to achieve this [ 4 ].

Biofeedback improves ANS control as it promotes self-regulation, induces a ‘relaxation response’ and reduces cognitive avoidance (i.e., avoiding thoughts of undesirable situations through distraction, thought suppression or worry [ 5 ]) through increasing awareness of physiological processes [ 6 ]. Biofeedback uses instruments to measure physiological responses such as heart rate variability, sharing this with the user in real time with the aim to increase awareness and health [ 7 ]. Biofeedback is often paired with interventions that address behaviour, emotion and thoughts, which can benefit physiological processes [ 7 ]. Frank et al. [ 8 ] described biofeedback as “training not treatment” highlighting the level of motivation and practice required by the user to achieve the benefits of biofeedback. Ultimately, the goal is that these learned processes become automatic and individuals do not require device feedback to achieve the desired outcomes.

Over the years, the field of biofeedback has progressed with advances in technology. Available devices are user friendly and wearable [ 9 , 10 , 11 , 12 ], making biofeedback a more accessible intervention. Additionally, using a wearable device gives insight into an individual’s physiology and response to stress and daily life on a continuous basis. This is more representative than data provided by a static clinic blood pressure measurement. With the improvement of technology, accessibility to biofeedback and progressions in artificial intelligence (AI), it is important to understand the existing literature and how we can progress knowledge and implementation of biofeedback to improve health and wellbeing. This review aimed to assess the effectiveness of biofeedback in patients with hypertension. The main outcome assessed was a change in blood pressure.

Eligibility criteria

This review was pre-registered on PROSPERO (ID: CRD42021285875) and follows PRISMA 2020 reporting guidelines [ 13 ]. Inclusion criteria were as follows: assessment of biofeedback (all modalities e.g., neurological, cardiovascular, physical) on systolic and/or diastolic blood pressure, randomised control trial, published in English, adult participants aged 18 and over, with a diagnosis of hypertension (office reading of systolic blood pressure (SBP) ≥ 140 and/or diastolic blood pressure (DBP) ≥ 90 mmHg or home blood pressure readings of SBP ≥ 135 and/or DBP ≥ 85 mmHg) [ 14 ]. There was no specification for patients to be on specific types of hypertension treatment. Systematic reviews, editorial letters and conference abstracts were excluded.

Study selection

The following electronic bibliographic databases were searched: PubMed, MEDLINE, PsycINFO, Embase, CINAHL and Cochrane Central Register of Trials. There was no date limit and all sources were last searched on January 16th, 2024. The search strategy followed the PICO criteria and was adjusted according to each database. The MEDLINE search strategy can be viewed in the Supplementary Material. Mendeley Desktop Reference Manager was used to store retrieved results and remove duplicates. Abstracts were reviewed in the first stage screening, which was completed by one review (S.J.), with a random 10% of abstracts screened by a second reviewer (A.C.). Disagreements were resolved after discussion between the two reviewers. The second stage screening reviewed the full text of articles and was completed by one reviewer (S.J.).

Data extraction

Extracted data was retrieved and collated into an Excel spreadsheet by one reviewer (S.J.). Outcomes retrieved included participant characteristics, intervention design, study design, pre/post intervention measurements and conclusions. Please see the Supplementary Material for the list of outcomes and variables retrieved. The effect measure for all main outcomes was mean (±standard deviation).

Synthesis methods

Studies were included in the meta-analysis if the mean and standard deviation was reported for a change in SBP and/or DBP. If reported, raw data and standard errors were converted to standard deviations and included. Authors were emailed for missing data and if there was no response, papers were excluded from the meta-analysis and assessed narratively.

The meta-analysis and forest plot diagrams were completed in Review Manager (version 5.4). A random effects model was used to assess systolic and diastolic blood pressure. Publication bias and Egger’s test was conducted in RStudio (version 2023.12.0 + 369).

A meta-regression was conducted on age and sex to explore possible causes of heterogeneity. However, there was insufficient data to conduct a reliable meta-regression for biofeedback modality. The meta-regression was a mixed effects model conducted in RStudio (version 2023.12.0 + 369).

Data quality assessment

Papers were assessed for bias with the Cochrane Risk of Bias assessment [ 15 ], assessing for selection, reporting, performance, detection, attrition, and other sources of bias. The Risk of Bias 2 Tool [ 16 ] was used to input assessment, calculate summary data and figures, and to check inter-rater agreement.

The overall quality of evidence from reviewed studies was assessed with the GRADE assessment [ 17 ], which reviewed individual study limitations, inconsistency of results, indirectness of evidence, imprecision, and publication bias. The quality of evidence was rated from high to very low.

Figure  1 details the PRISMA flowchart. The search generated 1782 articles, with 244 potentially eligible articles identified during the title and abstract screening. The full text screen identified 20 articles that met the inclusion criteria for the review. Of these articles, 18 were from peer-reviewed journals and two were PhD theses. The main reasons for exclusion were study design not meeting the inclusion criteria (31%), articles not in English (18%), or outcomes outside of the inclusion criteria (14%).

Flowchart in line with PRISMA guidelines indicating the number of articles originally identified, screened, excluded and included within the systematic review.

Participant characteristics

The overall characteristics of the 20 included studies are summarised in Table  1 . The mean demographics are reported in Table  2 . The studies were published between 1975 and 2013, from 10 different countries. There was a total of 988 participants and sample sizes ranged from 15 to 301 participants. The age ranged from 28 to 70 years, with 45% female participants. Ethnicity was reported in 3 articles, of these, 96% were Caucasian. The mean baseline SBP was 149.3 ± 7.8 mmHg and the mean DBP 93.0 ± 6.9 mmHg. Five studies [ 18 , 19 , 20 , 21 , 22 ] did not report data such as sex or age and were omitted from the above summary but were included in the main analysis as they reported key outcomes.

Types of biofeedback modalities

There were six different biofeedback modalities used across the 20 studies (Table  3 ). The type of biofeedback device used varied across studies and modalities, including finger or forehead electrodes [ 22 , 23 , 24 , 25 ], sphygmomanometer [ 18 , 26 , 27 ], finger blood pressure machines [ 28 , 29 ] and compact disk (CD) players [ 30 , 31 ]. No studies used a wearable device.

Blood pressure biofeedback was used by six studies and was measured with either a non-invasive beat to beat finger arterial pressure measurement [ 29 ] or an automated blood pressure device [ 18 , 20 , 26 , 27 , 32 ]. Blood pressure biofeedback was typically received by the participant visually (e.g., a screen) [ 18 , 26 , 28 , 29 , 32 ] and/or auditorily (e.g., a beep) [ 22 , 23 ]. For example, participants in the study by Tsai et al. [ 29 ] performed self-regulation techniques, such as deep breathing, and observed their blood pressure on a display.

Electromyographic (EMG) biofeedback detects changes or contractions in muscle. All six studies using EMG biofeedback gave auditory feedback, with some using the tone pitch and frequency to indicate EMG changes [ 19 , 20 , 22 , 24 , 33 ].

Galvanic skin response (GSR) biofeedback focuses on sweat gland activity and was used by five studies. As an example: Patel et al. [ 25 ] delivered the GSR feedback tone in one headphone and played a relaxation tape through the other headphone. The tone grew fainter as the participant relaxed and GSR activity reduced.

Thermal biofeedback was used in four studies. The intervention by Blanchard et al. [ 34 ] aimed to teach participants to increase temperature of their hands or feet, therefore strengthening deep-muscle relaxation.

RESPeRATE, a branded auditory based biofeedback device, was used in two studies [ 30 , 31 ]. It involves listening and breathing in time with a melody to guide slow breathing [ 30 ].

Achmon et al. [ 35 ] was the only study to use heart rate biofeedback. It used ear lobe capillary pulsations to guide heart rate reductions in normal and tension-provoking situations.

Intervention characteristics

Table  3 details the biofeedback intervention characteristics of the included studies. Biofeedback was mostly delivered one-to-one, with four studies delivering biofeedback to groups of 3–13 participants [ 19 , 28 , 33 , 34 ]. Studies varied in the biofeedback session length (12–75 min) and number of sessions (4–48 sessions). The post-study follow up ranged from 2 weeks to 12 months, with ten studies not reporting any follow up. Biofeedback training was delivered by psychologists in four studies [ 27 , 34 , 36 , 37 ] and by a trained nurse or therapist in two studies [ 32 , 35 ]. Three studies used an experimenter or research assistant to deliver biofeedback [ 18 , 20 , 24 ], with the remaining eleven not detailing who delivered biofeedback training.

There were eight different control conditions used across studies, the most common were self-recorded blood pressure measurements and placebo. Six studies [ 22 , 24 , 26 , 34 , 35 , 38 ] had multiple comparison groups (i.e., biofeedback and treatment as usual, placebo biofeedback, normotensive comparators). For data extraction, the treatment as usual group was prioritised as a comparator, followed by placebo biofeedback.

There was large variation across intervention design making it difficult to compare different designs and understand the most effective biofeedback intervention.

In terms of measuring how intervention delivery corresponded to the protocol, only two studies [ 29 , 34 ] detailed methods that suggested fidelity checks, including a therapist remaining with the group throughout the intervention and a trained nurse implementing biofeedback under supervision of a qualified biofeedback practitioner. Only five studies [ 18 , 25 , 28 , 31 , 36 ] reported the use of power calculations to inform the sample size.

The methods used for blood pressure measurements varied across studies; seventeen [ 18 , 19 , 20 , 22 , 23 , 24 , 25 , 27 , 28 , 29 , 30 , 31 , 33 , 35 , 36 , 37 , 38 ] used clinic readings, and three [ 26 , 32 , 34 ] used home measurements. In the ten studies [ 19 , 20 , 23 , 24 , 27 , 30 , 31 , 32 , 35 , 36 ] reporting medication use, 55% of participants were on anti-hypertensive medications. Medication status was not reported in three studies [ 25 , 33 , 37 ], whilst seven [ 18 , 22 , 26 , 28 , 29 , 34 , 38 ] studies reported participants were not taking any medications.

A total of seventeen studies detailed information regarding participant withdrawal or exclusion, with the remaining three studies [ 22 , 26 , 38 ] not reporting if any participants withdrew from the study. Overall, 111 participants withdrew, 44 were excluded and 2 participants died during the study time period. Reasons or details of participant withdrawal was limited, with 4 studies [ 19 , 27 , 33 , 36 ] detailing if participants withdrew from the control or biofeedback group, and six studies detailing the specific stage participants withdrew at i.e., before or after baseline measurements [ 27 , 37 ], after randomisation [ 30 , 33 , 35 ] or “within 2 weeks” [ 32 ]. Nine studies [ 18 , 19 , 20 , 23 , 24 , 28 , 29 , 34 , 36 ] did not detail at what stage participants withdrew. Reasons for participant exclusion included overly high blood pressure [ 28 , 34 ], medication changes [ 23 , 36 ], hypertrophy [ 18 ], failure in randomisation [ 25 ] and Olsson et al. [ 37 ] reported issues with biofeedback installation, commuting for the study and blood pressure not meeting hypertension criteria.

Meta-analysis of suitable studies

A meta-analysis was conducted for SBP with twelve studies and DBP with eleven studies, since the remainder did not have adequate data as detailed in the methods section. The studies included in the meta-analysis had six different control conditions (please see Table  3 ).

The meta-analysis showed that biofeedback had a significant effect on SBP −4.52 (Z = 2.31, P  = 0.02, CI [−8.35, −0.69]) and a significant effect on DBP −5.19 (Z = 3.54, P  = 0.0004, CI [−8.07, −2.32] (Fig.  2 ). The forest plot shows heterogeneity was high for SBP I 2  = 75% (Tau 2  = 27.80; Chi 2  = 43.15; P  < 0.0001). The DBP forest plot can be seen in Fig.  3 , also highlighting the high heterogeneity I 2  = 76% (Tau 2  = 15.46; Chi 2  = 41.46; P  < 0.00001).

The forest plot demonstrates a significant effect of biofeedback on systolic blood pressure.

The forest plot demonstrates a significant effect of biofeedback on diastolic blood pressure.

Notably, Nakao et al. [ 32 ] and Achmon et al. [ 35 ] had substantial mean differences between the biofeedback and control group, with a mean difference in SBP of −23.00 mmHg in Nakao et al. [ 32 ] and −23.93 mmHg in Achmon et al. [ 35 ] studies. Within the papers there were limited reasons for the large decreases. Despite the large mean difference, neither paper was given a heavier weighting within the forest plot compared to other studies, with Nakao et al. [ 32 ] allocated 5.6% and 9.4% and Achmon et al. [ 35 ] allocated 6.7% and 10.0% for systolic and diastolic blood pressure respectively.

Additionally, it is noticeable that Pandic et al. [ 30 ] had a SBP mean difference of 7.68 mmHg in favour of the control group. The control group had a larger reduction in blood pressure compared to the RESPeRATE intervention group. The authors reflected on previous literature that showed relaxing music played to the control group can decrease blood pressure. Publication bias was assessed with Egger’s test and was non-significant for both SBP (−0.34, 95% CI [−2.22–1.54], P  = 0.73) and DBP (−1.1, 95% CI [−3–0.75], P  = 0.27). Corresponding funnel plots can be found in the Supplementary Material (Supplementary Figs.  S1 and S2 ).

Of the eight studies excluded from the meta-analysis, only two showed significant findings in favour of biofeedback [ 19 , 33 ] (Supplementary Tables  S1 and S2 ). Across the 20 included studies, the pooled blood pressure difference in biofeedback groups was −9.5 mmHg SBP and −6.7 mmHg DBP, compared to −3.4 mmHg SBP and −1.9 mmHg DBP in control groups (Supplementary Table  S3 ).

Meta-regression

A meta-regression was conducted for age and sex on systolic and diastolic blood pressure. There was no significant association between participant age and effect of biofeedback on systolic (β = 0.49, SE = 0.40, 95% CI [−0.29, 1.26], p  < 0.22) or diastolic (β = 0.44, SE = 0.26, 95% CI [−0.07, 0.96], p  < 0.09) blood pressure (Supplementary Figs.  S3 and S4 ).

There was no significant effect of sex on biofeedback outcomes, with no effect of participants being male on systolic (β = 0.00, SE = 0.05, 95% CI [-0.10, 0.11], p  < 0.97) or diastolic (β = 0.01, SE = 0.04, 95% CI [−0.06, 0.07], p  < 0.87) blood pressure, or being female on systolic (β = 0.01, SE = 0.07, 95% CI [−0.12, 0.15], p  < 0.87) or diastolic (β = 0.01, SE = 0.05, 95% CI [−0.08, 0.10], p  < 0.80) blood pressure (Supplementary Figs.  S5 – 8 ).

Quality assessments

The Cochrane risk of bias assessment identified there were “some concerns” (Supplementary Table  S4 ). This was affected by 65% of papers not specifying randomisation allocation sequences or blinding of researchers or participants. All papers were raised to “some concerns” due to lack of pre-specified analysis plans.

The GRADE assessment showed data to have a “low certainty” of evidence, meaning further research is likely to change the estimate and have an important impact on confidence in the effect estimate. The certainty was downgraded from “high” to “low” due to inconsistency in evidence identified by heterogeneity and the risk of bias score. See Supplementary Material (Supplementary Table  S5 ) for assessment ratings.

This was the first systematic review since 2009 to assess the effect of biofeedback in patients with hypertension (≥140/90 mmHg). The review and meta-analysis demonstrated that biofeedback significantly improved SBP and DBP. However, these results should be interpreted with caution given the limitations of included studies, such as heterogeneity, low study quality and limited details regarding randomisation, blinding and intervention delivery. The meta-regression analyses demonstrated that participant age or sex did not account for the heterogeneity seen within the meta-analysis.

The heterogeneity across biofeedback rendered it difficult to conduct modality specific analysis. Follow up ranged from 2 weeks to 12 months, with 10 studies not reporting if a follow up was conducted. Given the requirement of continued practice to benefit from biofeedback it is important to understand the longevity of the intervention [ 8 ].

Studies included in this review reporting using different instructors to deliver biofeedback to participants, including a psychologist, a trained therapist or nurse, a research assistant or experimenter. Eleven studies did not detail who delivered biofeedback. Although this review was unable to statistically compare delivery personnel and biofeedback outcomes, both studies which used nurse delivered biofeedback demonstrated a significant effect on blood pressure [ 32 , 35 ]. For biofeedback to be a feasible and affordable intervention, the method and personnel delivering the intervention need to be considered. For services such as the NHS in the United Kingdom, it may benefit from biofeedback that is formulated to be delivered by a healthcare assistant or another allied health professional as this would be cheaper and scalable. More innovative solutions for delivery of biofeedback such as the use apps or videos need to be considered.

The results of this review are partly supported by the meta-analysis from Vital et al. [ 39 ] who included nine studies and found a significant reduction in DBP only. The current review differed from Vital et al. [ 39 ] as they included pre-hypertensive patients (SBP measuring 130–139 mmHg). The current review only included patients with SBP ≥ 140/90 mmHg because inclusion of patients with low-mild hypertension can lead to floor effects, with only small reductions possible [ 40 ]. An earlier review by Greenhalgh et al. [ 40 ] found no consistent evidence that demonstrated the benefits of biofeedback. However, they included thirty-six studies, some of which were excluded from the current systematic review based on low blood pressure readings (<140/90 mmHg), and missing or unclear outcomes. The inclusion of more studies, some of which did not meet the criteria for this review, may explain the higher heterogeneity and lack of consistent evidence in comparison to the present review.

This review is limited by heterogeneity and the number of studies included. This made it difficult to identify the most effective intervention design including, number of sessions, intervention length, and biofeedback modality. Despite the meta-analysis demonstrating a significant effect of biofeedback on SBP and DBP, the quality of data was low, especially relating to limited details on randomisation, blinding, missing pre-analysis statistical plans, and whether patients were on antihypertensive medications. The missing details regarding randomisation, blinding and key demographic data is a limitation that if submitted for publication in the current day, papers would not meet research guidelines. Limited details reported about interventions meant it was difficult to understand why some interventions worked, whilst others did not. Additionally, the lack of details regarding at what stage participants withdrew from the study make it difficult to understand if withdrawal was due to the requirements of biofeedback, or for another reason. Similarly, the wide variation in control conditions add difficulty to understanding the effect of biofeedback. This poor quality of data is similar to the findings of by previous reviews, highlighting the need for improved methods and reporting in future studies.

The included studies have several limitations that may affect the reliability of outcomes. These include wide variations in sample size, which may result in findings that do not reflect real patients. In line with representation, the mean age of the included participants was 51.7 ± 8.7 years, which does not reflect the mean age of patients with hypertension, which largely affects patients aged over 65 [ 41 ]. Only 25% of articles reported any power calculations. No studies reported measurements of medication adherence, which can significantly affect blood pressure control [ 42 , 43 ]. Furthermore, ten studies used participant populations that were either partly, or not on any medication. Similarly, intervention adherence was reported in only four studies, and two studies reported the use of fidelity checks. Consequently, it is difficult to ensure the biofeedback intervention was implemented as planned in the majority of studies.

A significant issue in this review is that the dated studies do not represent the availability of current technologies. The majority of studies were published between 1970 and 1999, with only one study published after 2010. Since then, biofeedback technology has improved dramatically and is more user friendly, with the ability to practice independently at home. This has been further supported by the progression with AI, which can further support the development and integration of biofeedback in the healthcare field. It has already been incorporated in biofeedback research in virtual reality exposure therapy for anxiety [ 44 ] and eXtended Reality training scenarios [ 45 ]. The use of machine learning in biofeedback can support tailored feedback and identify scenarios and stimuli that increase physiological responses, which can increase user awareness of their health. Biofeedback devices now include wearables, such as a wristband that continuously records blood pressure and displays results in an app on the user’s phone [ 11 ]. This contrasts with examples from included studies where biofeedback was conducted in the clinic in the presence of researchers [ 29 , 34 ] and using techniques not suitable for home use, such as a researcher manually plotting blood pressure biofeedback on a graph [ 20 ]. The dated technology is reflected in methods of blood pressure measurement.

We believe that biofeedback has a potential role to play in the management of hypertension. New research should incorporate robust methodology, updated biofeedback technology such as wearable devices, and incorporate the use of innovative techniques to support large scale delivery of biofeedback.

To conclude, this meta-analysis showed that biofeedback significantly reduces systolic (-4.52 mmHg, P  = 0.02) and diastolic blood pressure (−5.19 mmHg, P  = 0.0004), with the pooled blood pressure decrease in biofeedback groups reaching clinical significance. However, the low quality of evidence and heterogeneity across studies mean results should be interpreted with caution. Importantly, the dated nature of existing studies means they do not represent the current climate of biofeedback and the availability of current technologies. But future research especially featuring wearable devices using robust methodology are needed to provide evidence of a practical and scalable approach to biofeedback that is clinically deliverable and acceptable to patients.

What is known about the topic

Hypertension is a leading modifiable risk factor for cardiovascular disease. However, despite the availability of medication, hypertension control remains suboptimal in approximately 50% of patients.

Autonomic nervous system dysregulation in part mediates hypertension, highlighting a possible target for interventions aiming to improve blood pressure.

Biofeedback can increase self-regulation and self-awareness of parameters that regulate the autonomic nervous system, suggesting a suitable intervention to support patients with hypertension

What this study adds

The meta-analysis demonstrated that biofeedback had a significant effect on blood pressure, with a reduction in both systolic (−4.52, Z = 2.31, P  = 0.02, CI [−8.35, −0.69]) and diastolic blood pressure (−5.19, Z = 3.54, P  = 0.0004, CI [−8.07, −2.32]).

The weaknesses of the study not only make it difficult to determine the most effective intervention but also affect the ability to draw conclusions about the effect of biofeedback on blood pressure.

Future studies need to incorporate robust methodology and updated technology such as wearable devices, to improve understanding of the role of biofeedback in hypertension.

Data availability

All data generated or analysed during this review are included in this published article [and its supplementary information files].

Zhou B, Perel P, Mensah GA, Ezzati M. Global epidemiology, health burden and effective interventions for elevated blood pressure and hypertension. Nat Rev Cardiol. 2021;18:785–802.

Mancia G, Grassi G. The autonomic nervous system and hypertension. Circulation Res. 2014;114:1804–14.

Article   CAS   PubMed   Google Scholar  

Milic M, Sun P, Liu F, Fainman C, Dimsdale J, Mills PJ, et al. A comparison of pharmacologic and spontaneous baroreflex methods in aging and hypertension. J Hypertens. 2009;27:1243.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Lehrer PM, Vaschillo EG, Vidali V. Heart rate and breathing are not always in phase during resonance frequency breathing. Appl Psychophysiol Biofeedback. 2020;45:145–52.

Article   PubMed   Google Scholar  

Sagui-Henson SJ. Cognitive avoidance. In: Encyclopedia of personality and individual differences. Springer International Publishing. 2017. pp. 1–3.

De Witte NA, Buyck I, Van Daele T. Combining biofeedback with stress management interventions: A systematic review of physiological and psychological effects. Appl Psychophysiol Biofeedback. 2019;44:71–82.

Kondo K, Noonan KM, Freeman M, Ayers C, Morasco BJ, Kansagara D. Efficacy of biofeedback for medical conditions: an evidence map. J Gen Intern Med. 2019;34:2883–93.

Article   PubMed   PubMed Central   Google Scholar  

Frank DL, Khorshid L, Kiffer JF, Moravec CS, McKee MG. Biofeedback in medicine: who, when, why and how? Ment health Fam Med. 2010;7:85.

PubMed   PubMed Central   Google Scholar  

Khazan IZ. The clinical handbook of biofeedback: A step-by-step guide for training and practice with mindfulness. John Wiley & Sons; 2013.

Konstantinidis D, Iliakis P, Tatakis F, Thomopoulos K, Dimitriadis K, Tousoulis D, et al. Wearable blood pressure measurement devices and new approaches in hypertension management: the digital era. J Hum Hypertens. 2022;36:945–51.

Burnier M, Kjeldsen SE, Narkiewicz K, Oparil S. Cuff-less measurements of blood pressure: are we ready for a change? Blood Pressure 2021;30:205–7.

Matsuoka R, Akazawa H, Kodera S, Komuro I. The dawning of the digital era in the management of hypertension. Hypertension Res. 2020;43:1135–40.

Article   Google Scholar  

Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Int J Surg. 2021;88:105906.

Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). Eur Heart J. 2018;39:3021–104.

Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.

Higgins JT, Savović, J., Page, M. J., Sterne, J. A. C. Revised Cochrane risk-of-bias tool for randomized trials (RoB 2). 2019. Available from: https://www.riskofbias.info/welcome/rob-2-0-tool/current-version-of-rob-2 .

Schünemann H, Brożek J, Guyatt G, Oxman A, editors. Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach. 2013. Available from https://gdt.gradepro.org/app/handbook/handbook.html

Hunyor SN, Henderson RJ, Lal SK, Carter NL, Kobler H, Jones M, et al. Placebo-controlled biofeedback blood pressure effect in hypertensive humans. Hypertension. 1997;29:1225–31.

Hafner RJ. Psychological treatment of essential hypertension: a controlled comparison of meditation and meditation plus biofeedback. Biofeedback Self Regul. 1982;7:305–16.

Blanchard EB, Miller ST, Abel GG, Haynes MR, Wicker R. Evaluation of biofeedback in the treatment of borderline essential hypertension 1. J Appl Behav Anal. 1979;12:99–109.

Shoemaker JE, Tasto DL. The effects of muscle relaxation on blood pressure of essential hypertensives. Behav Res Ther. 1975;13:29–43.

Fray JM. Implications of electromyographic feedback for essential hypertensive patients. Lubbock: Texas Tech University; 1975.

McGrady AV, Yonker R, Tan S, Fine TH, Woerner M. The effect of biofeedback-assisted relaxation training on blood pressure and selected biochemical parameters in patients with essential hypertension. Biofeedback Self Regul. 1981;6:343–53.

Billion L. The effect of EMG biofeedback, relaxation, and sham EEG alpha training on blood pressure of essential hypertensives. University of Virginia; ProQuest Dissertations & Theses, 1980.

Patel C. Biofeedback and self-regulation. In: Complementary health therapies: a guide for nurses and the caring professions. Beckenham, Kent: Croom Helm; 1988.

Goldstein IB, Shapiro D, Thananopavarn C, Sambhi MP. Comparison of drug and behavioral treatments of essential hypertension. Health Psychology, 1982;1:7.

Paran E, Amir M, Yaniv N. Evaluating the response of mild hypertensives to biofeedback-assisted relaxation using a mental stress test. J Behav Ther Exp psychiatry. 1996;27:157–67.

Henderson RJ, Hart MG, Lal SK, Hunyor SN. The effect of home training with direct blood pressure biofeedback of hypertensives: a placebo-controlled study. J Hypertens. 1998;16:771–8.

Tsai P-S, Chang N-C, Chang W-Y, Lee P-H, Wang M-Y. Blood pressure biofeedback exerts intermediate-term effects on blood pressure and pressure reactivity in individuals with mild hypertension: a randomized controlled study. J Alternative Complement Med. 2007;13:547–54.

Pandic S, Ekman I, Nord L, Kjellgren KI. Device-guided breathing exercises in the treatment of hypertension–perceptions and effects. CVD Prev Control. 2008;3:163–9.

Google Scholar  

Landman GW, Drion I, van Hateren KJ, van Dijk PR, Logtenberg SJ, Lambert J, et al. Device-guided breathing as treatment for hypertension in type 2 diabetes mellitus: a randomized, double-blind, sham-controlled trial. JAMA Intern Med. 2013;173:1346–50.

Nakao M, Nomura S, Shimosawa T, Yoshiuchi K, Kumano H, Kuboki T, et al. Clinical effects of blood pressure biofeedback treatment on hypertension by auto-shaping. Psychosom Med. 1997;59:331–8.

Patel C. Yoga and biofeedback in the management of hypertension. J Psychosom Res. 1975;19:355–60.

Blanchard EB, Eisele G, Vollmer A, Payne A, Gordon M, Cornish P, et al. Controlled evaluation of thermal biofeedback in treatment of elevated blood pressure in unmedicated mild hypertension. Biofeedback Self Regul. 1996;21:167–90.

Achmon J, Granek M, Golomb M, Hart J. Behavioral treatment of essential hypertension: a comparison between cognitive therapy and biofeedback of heart rate. Psychosom Med. 1989;51:152–64.

Elavally S, Ramamurthy MT, Subash J, Meleveedu R, Venkatasalu MR. Effect of nurse-led home-based biofeedback intervention on the blood pressure levels among patients with hypertension: Pretest–posttest study. J Fam Med Prim care. 2020;9:4833.

Olsson EM, El Alaoui S, Carlberg B, Carlbring P, Ghaderi A. Internet-based biofeedback-assisted relaxation training in the treatment of hypertension: a pilot study. Appl Psychophysiol biofeedback. 2010;35:163–70.

Canino E, Cardona R, Monsalve P, López B, Fragachan F. A behavioral treatment program as a therapy in the control of primary hypertension. Acta Cient Venez. 1994;45:23–30.

CAS   PubMed   Google Scholar  

Vital JEC, de Morais Nunes A, New BSdAC, de Sousa BDA, Nascimento MF, Formiga MF, et al. Biofeedback therapeutic effects on blood pressure levels in hypertensive individuals: a systematic review and meta-analysis. Complement Ther Clin Pract. 2021;44:101420.

Greenhalgh J, Dickson R, Dundar Y. The effects of biofeedback for the treatment of essential hypertension: a systematic review. Health Technol Assess. 2009;13:1–104.

NHS. Health Survey for England, 2021 part 2 2023 [Available from: https://digital.nhs.uk/data-and-information/publications/statistical/health-survey-for-england/2021-part-2/adult-health-hypertension .

Kolandaivelu K, Leiden BB, O’Gara PT, Bhatt DL. Non-adherence to cardiovascular medications. Eur Heart J. 2014;35:3267–76.

Cutler RL, Fernandez-Llimos F, Frommer M, Benrimoj C, Garcia-Cardenas V. Economic impact of medication non-adherence by disease groups: a systematic review. BMJ Open. 2018;8:e016982.

Rahman MA, Brown DJ, Mahmud M, Harris M, Shopland N, Heym N, et al. Enhancing biofeedback-driven self-guided virtual reality exposure therapy through arousal detection from multimodal data using machine learning. Brain Inform. 2023;10:14.

Blackmore KL, Smith SP, Bailey JD, Krynski B. Integrating Biofeedback and Artificial Intelligence into eXtended Reality Training Scenarios: A Systematic Literature Review. Simul Gaming. 2024;55:10468781241236688.

Download references

Acknowledgements

This study is funded by the National Institute for Health Research (NIHR) Applied Research Collaboration East Midlands (ARC EM). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. HO is funded by Servier Affaires Medicale. The views expressed are those of the author(s) and not necessarily those of Servier Affaires Medicale. KK is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration East Midlands (ARC EM) and the NIHR Leicester Biomedical Research Centre (BRC). DL is supported by the John and Lucille van Geest Foundation and the NIHR Leicester Biomedical Research Centre (BRC).

Author information

Authors and affiliations.

Department of Population Health Sciences, University of Leicester, Leicester, UK

Sian Jenkins & Hanad Osman

Diabetes Research Centre, College of Life Sciences, University of Leicester, Leicester, UK

Sian Jenkins, Hanad Osman & Kamlesh Khunti

School of Psychology and Vision Sciences, University of Leicester, Leicester, UK

Ainslea Cross

Department of Cardiovascular Sciences, University of Leicester, Leicester, UK

Farah Salim, Dan Lane, Dennis Bernieh & Pankaj Gupta

Department of Metabolic Medicine & Chemical Pathology, University Hospitals of Leicester NHS Trust, Leicester, UK

Pankaj Gupta

You can also search for this author in PubMed   Google Scholar

Contributions

SJ led the systematic review, analysis and drafted the manuscript; AC screened articles, co-conceived the work that led to the manuscript and reviewed the manuscript; HO conducted data quality assessments and reviewed the manuscript; FS conducted data quality assessments and reviewed the manuscript; DL contributed to data analysis and conception and reviewed the manuscript; DB reviewed the manuscript; KK contributed to data analysis and conception and reviewed the manuscript; PG conceived and designed the work that led to the manuscript, played an important role in data analysis, results interpretation and the manuscript.

Corresponding author

Correspondence to Pankaj Gupta .

Ethics declarations

Competing interests.

The authors declare no competing interests.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Supplementary material, rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Cite this article.

Jenkins, S., Cross, A., Osman, H. et al. Effectiveness of biofeedback on blood pressure in patients with hypertension: systematic review and meta-analysis. J Hum Hypertens (2024). https://doi.org/10.1038/s41371-024-00937-y

Download citation

Received : 23 February 2024

Revised : 25 June 2024

Accepted : 10 July 2024

Published : 14 August 2024

DOI : https://doi.org/10.1038/s41371-024-00937-y

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

• Previous Article
• Next Article

Presentation

Clinical pearls, case study: treating hypertension in patients with diabetes.

• Split-Screen
• Article contents
• Figures & tables
• Supplementary Data
• Peer Review
• Open the PDF for in another window
• Cite Icon Cite
• Get Permissions

Evan M. Benjamin; Case Study: Treating Hypertension in Patients With Diabetes. Clin Diabetes 1 July 2004; 22 (3): 137–138. https://doi.org/10.2337/diaclin.22.3.137

Download citation file:

• Ris (Zotero)
• Reference Manager

L.N. is a 49-year-old white woman with a history of type 2 diabetes,obesity, hypertension, and migraine headaches. The patient was diagnosed with type 2 diabetes 9 years ago when she presented with mild polyuria and polydipsia. L.N. is 5′4″ and has always been on the large side,with her weight fluctuating between 165 and 185 lb.

Initial treatment for her diabetes consisted of an oral sulfonylurea with the rapid addition of metformin. Her diabetes has been under fair control with a most recent hemoglobin A 1c of 7.4%.

Hypertension was diagnosed 5 years ago when blood pressure (BP) measured in the office was noted to be consistently elevated in the range of 160/90 mmHg on three occasions. L.N. was initially treated with lisinopril, starting at 10 mg daily and increasing to 20 mg daily, yet her BP control has fluctuated.

One year ago, microalbuminuria was detected on an annual urine screen, with 1,943 mg/dl of microalbumin identified on a spot urine sample. L.N. comes into the office today for her usual follow-up visit for diabetes. Physical examination reveals an obese woman with a BP of 154/86 mmHg and a pulse of 78 bpm.

What are the effects of controlling BP in people with diabetes?

What is the target BP for patients with diabetes and hypertension?

Which antihypertensive agents are recommended for patients with diabetes?

Diabetes mellitus is a major risk factor for cardiovascular disease (CVD). Approximately two-thirds of people with diabetes die from complications of CVD. Nearly half of middle-aged people with diabetes have evidence of coronary artery disease (CAD), compared with only one-fourth of people without diabetes in similar populations.

Patients with diabetes are prone to a number of cardiovascular risk factors beyond hyperglycemia. These risk factors, including hypertension,dyslipidemia, and a sedentary lifestyle, are particularly prevalent among patients with diabetes. To reduce the mortality and morbidity from CVD among patients with diabetes, aggressive treatment of glycemic control as well as other cardiovascular risk factors must be initiated.

Studies that have compared antihypertensive treatment in patients with diabetes versus placebo have shown reduced cardiovascular events. The United Kingdom Prospective Diabetes Study (UKPDS), which followed patients with diabetes for an average of 8.5 years, found that patients with tight BP control (< 150/< 85 mmHg) versus less tight control (< 180/< 105 mmHg) had lower rates of myocardial infarction (MI), stroke, and peripheral vascular events. In the UKPDS, each 10-mmHg decrease in mean systolic BP was associated with a 12% reduction in risk for any complication related to diabetes, a 15% reduction for death related to diabetes, and an 11% reduction for MI. Another trial followed patients for 2 years and compared calcium-channel blockers and angiotensin-converting enzyme (ACE) inhibitors,with or without hydrochlorothiazide against placebo and found a significant reduction in acute MI, congestive heart failure, and sudden cardiac death in the intervention group compared to placebo.

The Hypertension Optimal Treatment (HOT) trial has shown that patients assigned to lower BP targets have improved outcomes. In the HOT trial,patients who achieved a diastolic BP of < 80 mmHg benefited the most in terms of reduction of cardiovascular events. Other epidemiological studies have shown that BPs > 120/70 mmHg are associated with increased cardiovascular morbidity and mortality in people with diabetes. The American Diabetes Association has recommended a target BP goal of < 130/80 mmHg. Studies have shown that there is no lower threshold value for BP and that the risk of morbidity and mortality will continue to decrease well into the normal range.

Many classes of drugs have been used in numerous trials to treat patients with hypertension. All classes of drugs have been shown to be superior to placebo in terms of reducing morbidity and mortality. Often, numerous agents(three or more) are needed to achieve specific target levels of BP. Use of almost any drug therapy to reduce hypertension in patients with diabetes has been shown to be effective in decreasing cardiovascular risk. Keeping in mind that numerous agents are often required to achieve the target level of BP control, recommending specific agents becomes a not-so-simple task. The literature continues to evolve, and individual patient conditions and preferences also must come into play.

While lowering BP by any means will help to reduce cardiovascular morbidity, there is evidence that may help guide the selection of an antihypertensive regimen. The UKPDS showed no significant differences in outcomes for treatment for hypertension using an ACE inhibitor or aβ-blocker. In addition, both ACE inhibitors and angiotensin II receptor blockers (ARBs) have been shown to slow the development and progression of diabetic nephropathy. In the Heart Outcomes Prevention Evaluation (HOPE)trial, ACE inhibitors were found to have a favorable effect in reducing cardiovascular morbidity and mortality, whereas recent trials have shown a renal protective benefit from both ACE inhibitors and ARBs. ACE inhibitors andβ-blockers seem to be better than dihydropyridine calcium-channel blockers to reduce MI and heart failure. However, trials using dihydropyridine calcium-channel blockers in combination with ACE inhibitors andβ-blockers do not appear to show any increased morbidity or mortality in CVD, as has been implicated in the past for dihydropyridine calcium-channel blockers alone. Recently, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) in high-risk hypertensive patients,including those with diabetes, demonstrated that chlorthalidone, a thiazide-type diuretic, was superior to an ACE inhibitor, lisinopril, in preventing one or more forms of CVD.

L.N. is a typical patient with obesity, diabetes, and hypertension. Her BP control can be improved. To achieve the target BP goal of < 130/80 mmHg, it may be necessary to maximize the dose of the ACE inhibitor and to add a second and perhaps even a third agent.

Diuretics have been shown to have synergistic effects with ACE inhibitors,and one could be added. Because L.N. has migraine headaches as well as diabetic nephropathy, it may be necessary to individualize her treatment. Adding a β-blocker to the ACE inhibitor will certainly help lower her BP and is associated with good evidence to reduce cardiovascular morbidity. Theβ-blocker may also help to reduce the burden caused by her migraine headaches. Because of the presence of microalbuminuria, the combination of ARBs and ACE inhibitors could also be considered to help reduce BP as well as retard the progression of diabetic nephropathy. Overall, more aggressive treatment to control L.N.'s hypertension will be necessary. Information obtained from recent trials and emerging new pharmacological agents now make it easier to achieve BP control targets.

Hypertension is a risk factor for cardiovascular complications of diabetes.

Clinical trials demonstrate that drug therapy versus placebo will reduce cardiovascular events when treating patients with hypertension and diabetes.

A target BP goal of < 130/80 mmHg is recommended.

Pharmacological therapy needs to be individualized to fit patients'needs.

ACE inhibitors, ARBs, diuretics, and β-blockers have all been documented to be effective pharmacological treatment.

Combinations of drugs are often necessary to achieve target levels of BP control.

ACE inhibitors and ARBs are agents best suited to retard progression of nephropathy.

Evan M. Benjamin, MD, FACP, is an assistant professor of medicine and Vice President of Healthcare Quality at Baystate Medical Center in Springfield, Mass.

Email alerts

• Online ISSN 1945-4953
• Print ISSN 0891-8929
• Diabetes Care
• Clinical Diabetes
• Diabetes Spectrum
• Standards of Medical Care in Diabetes
• Scientific Sessions Abstracts
• BMJ Open Diabetes Research & Care
• ShopDiabetes.org
• ADA Professional Books

Clinical Compendia

• Clinical Compendia Home
• Latest News
• DiabetesPro SmartBrief
• Special Collections
• DiabetesPro®
• Diabetes Food Hub™
• Insulin Affordability
• Know Diabetes By Heart™
• About the ADA
• Journal Policies
• For Reviewers
• Advertising in ADA Journals
• Reprints and Permission for Reuse
• Copyright Notice/Public Access Policy
• ADA Professional Membership
• ADA Member Directory
• Diabetes.org
• X (Twitter)
• Cookie Policy
• Accessibility
• Terms & Conditions
• Get Adobe Acrobat Reader
• © Copyright American Diabetes Association

This Feature Is Available To Subscribers Only

Sign In or Create an Account

Case Studies: BP Evaluation and Treatment in Patients with Prediabetes or Diabetes

—the new acc/aha blood pressure guidelines call for a more aggressive diagnostic and treatment approach in most situations..

By Kevin O. Hwang, MD, MPH, Associate Professor, McGovern Medical School, Houston, TX

The following case studies illustrate how the new ACC/AHA guideline specifies a shift in the definition of BP categories and treatment targets.

A 59-year-old man with type 2 diabetes presents with concerns about high blood pressure (BP). At a recent visit to his dentist he was told his BP was high. He was reclining in the dentist’s chair when his BP was taken, but he doesn’t remember the exact reading. He has no symptoms. He has never taken medications for high BP. He takes metformin for type 2 diabetes.

His BP is measured once at 146/95 mm Hg in the left arm while sitting. Physical exam is unremarkable except for obesity. EKG is unremarkable.

BP Measurement

Controlling BP in patients with diabetes reduces the risk of cardiovascular events, but the available data are not sufficient to classify this patient with respect to BP status. The reading taken while reclining in the dentist’s chair was likely inaccurate. A single reading in the medical clinic, even with correct technique, is not adequate for clinical decision-making because individual BP measurements vary in unpredictable or random ways.

The accuracy of BP measurement is affected by patient preparation and positioning, technique, and timing. Before the first reading, the patient should avoid smoking, caffeine, and exercise for at least 30 minutes and should sit quietly in a chair for at least 5 minutes with back supported and feet flat on the floor. An appropriately sized cuff should be placed on the bare upper arm and with the arm supported at heart level. For the first encounter, BP should be recorded in both arms. The arm with the higher reading should be used for subsequent measurements.

It is recommended that one use an average of 2 to 3 readings, separated by 1 to 2 minutes, obtained on 2 to 3 separate visits. Some of those readings should be performed outside of the clinical setting, either with home BP self-monitoring or 24-hour ambulatory BP monitoring, especially when confirming the diagnosis of sustained hypertension. Note that a clinic BP of 140/90 corresponds to home BP values of 135/85. Multiple BP readings in the clinic and at home allow for classification into one of the following categories.

The BP is measured in the office with the correct technique and timing referenced above. The patient is educated on how on to measure BP at home with a validated monitor. He should take at least 2 readings 1 minute apart in the morning and in the evening before supper (4 readings per day). The optimal schedule is to measure BP every day for a week before the next clinic visit, which is set for a month from now. Obtaining multiple clinic and home BP readings on multiple days will support a well-informed assessment of the patient’s BP status and subsequent treatment decisions.

A 62 year old African-American woman with prediabetes presents for her annual physical. She has no complaints. The average of 2 BP readings in her right arm is BP 143/88. Her physical exam is unremarkable except for obesity. She has no history of myocardial infarction, stroke, kidney disease, or heart failure. After the visit, she measures her BP at home and returns 1 month later. The average BP from multiple clinic and home readings is 138/86.

Her total cholesterol is 260 mg/dL, HDL 42 mg/dL, and LDL 165 mg/dL. She does not smoke.

Stage 1 Hypertension

Under the 2017 ACC/AHA guideline, she has stage 1 hypertension (HTN). This guideline uses a uniform BP definition for HTN without regard to patient age or comorbid illnesses, such as diabetes or chronic kidney disease.

In patients with stage 1 HTN and no known atherosclerotic cardiovascular disease (ASCVD) , the new guideline recommends treating with BP-lowering medications if the 10-year risk for ASCVD risk is 10% or greater. With input such as her age, gender, race, lipid profile, and other risk factors, the ACC/AHA Pooled Cohort Equations tool estimates her 10-year risk to be approximately 10.5%.

With stage 1 HTN and 10-year ASCVD risk of 10% or higher, she would benefit from a BP-lowering medication. Thiazide diuretics, angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and calcium channel blockers are first-line agents for HTN because they reduce the risk of clinical events. In African-Americans, thiazide diuretics and calcium channel blockers are more effective for lowering BP and preventing cardiovascular events compared to ACE inhibitors or ARBs.

Patient-specific factors, such as age, comorbidities, concurrent medications, drug adherence, and out-of-pocket costs should be considered. Shared decision making should drive the ultimate choice of antihypertensive medication(s).

Nonpharmacologic strategies for prediabetes and HTN include dietary changes, physical activity, and weight loss. If clinically appropriate, she should also avoid agents which could elevate BP, such as NSAIDs, oral steroids, stimulants, and decongestants.

A goal BP of 130/80 is recommended. After starting the new BP medication, she should monitor BP at home and return to the clinic in 1 month. If the BP goal is not met at that time despite adherence to treatment, consideration should be given to intensifying treatment by increasing the dose of the first medication or adding a second agent.

A 63 year old man with type 2 diabetes has an average BP of 151/92 over the span of several weeks of measuring at home and in the clinic. He also has albuminuria.

Stage 2 Hypertension:

The BP treatment goal patients with diabetes and HTN is less than 130/80. While some patients can be effectively treated with a single agent, serious consideration should be given to starting with 2 drugs of different classes, especially if BP is more than 20/10 mm Hg above their BP target. Giving both medications as a fixed-dose combination may improve adherence.

In this man with diabetes and HTN, any of the first-line classes of antihypertensive agents (diuretics, ACE inhibitors, ARBs, and CCBs) would be reasonable choices. Given the presence of albuminuria, an ACE inhibitor or ARB would be beneficial for slowing progression of kidney disease. However, an ACE inhibitor and ARB should not be used simultaneously due to an increase in cardiovascular and renal risk observed in clinical trials.

He is started on a fixed-dose combination of an ACE-inhibitor and thiazide diuretic. He purchases a validated BP monitor which can transmit BP readings to his provider’s electronic health records system. Direct transmission of BP data to the provider has been shown to help patients achieve greater reductions in BP compared to self-monitoring without transmission of data. One month follow-up is recommended to determine if the treatment goal has been met.

Published: April 30, 2018

• 2. Final Recommendation Statement: High Blood Pressure in Adults: Screening. U.S. Preventive Services Task Force. September 2017.

More On This Topic

Does cabg owe its success more to sag--or to mag, dvt treatment: home versus hospital, perioperative thromboembolic complications predict long-term vte risk, coronary plaque in people with well-controlled hiv and low ascvd risk, poor neighborhood, poor mi outcome, stroke risk at age 66 to 74 years—with atrial fibrillation but without other risk factors, using cardiovascular biomarkers to diagnose type 2 mi: yea or nay, cardiac rehabilitation: outcomes in south asian patients.

Ohio State nav bar

The Ohio State University

• BuckeyeLink
• Find People
• Search Ohio State

Patient Case Presentation

Mr. E.A. is a 40-year-old black male who presented to his Primary Care Provider for a diabetes follow up on October 14th, 2019. The patient complains of a general constant headache that has lasted the past week, with no relieving factors. He also reports an unusual increase in fatigue and general muscle ache without any change in his daily routine. Patient also reports occasional numbness and tingling of face and arms. He is concerned that these symptoms could potentially be a result of his new diabetes medication that he began roughly a week ago. Patient states that he has not had any caffeine or smoked tobacco in the last thirty minutes. During assessment vital signs read BP 165/87, Temp 97.5 , RR 16, O 98%, and HR 86. E.A states he has not lost or gained any weight. After 10 mins, the vital signs were retaken BP 170/90, Temp 97.8, RR 15, O 99% and HR 82. Hg A1c 7.8%, three months prior Hg A1c was 8.0%.  Glucose  180 mg/dL (fasting).  FAST test done; negative for stroke. CT test, Chem 7 and CBC have been ordered.

Past medical history

Diagnosed with diabetes (type 2) at 32 years old

Overweight, BMI of 31

Had a cholecystomy at 38 years old

Diagnosed with dyslipidemia at 32 years old

Past family history

Mother alive, diagnosed diabetic at 42 years old 

Father alive with Hypertension diagnosed at 55 years old

Brother alive and well at 45 years old

Sister alive and obese at 34 years old 

Pertinent social history

Social drinker on occasion

Smokes a pack of cigarettes per day

Works full time as an IT technician and is in graduate school

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Hypertension management: what is the role of case management?

Affiliations.

• 1 Department of Nursing, School of Health, Namık Kemal University, Tekirdag, Turkey.
• 2 Department of Nursing, School of Health, Celal Bayar University, Manisa, Turkey.
• 3 Department of Biostatistic, School of Medicine, Namık Kemal University, Tekirdag, Turkey.
• PMID: 29562041
• DOI: 10.1590/s1980-220x2017016903291

Objective The aim of this study was to determine the effect of case management on hypertension management and on adherence to antihypertensive medication and chronic disease care of patients with hypertension. Method This study was conducted as an experimental and randomized controlled study. The sample of the study consisted of randomly selected patients with hypertension who did not have communication problems, who used antihypertensive medication treatment and whose treatment had been continuing for at least six months. The study group was given individual training (Hypertension causes, the risk factors, significance, unwanted side effects, medication treatment, changes in life style) and was applied case management model in hypertension - joint care protocol but no intervention was offered to the control group. Data was collected using the adherence to antihypertensive medication scale, the patient assessment of chronic illness care in the first and six months later interview. Results There was no significant difference between the study and control group according to adherence to antihypertensive medication and patient assessment of chronic illness care in the first interview. Otherwise, there were significant differences between the study and control group according to blood pressure, adherence to antihypertensive medication and patient assessment of chronic illness care in the six months later interview. The adherence to antihypertensive medication total score and the patient assessment of chronic illness care total score were significantly higher in the study group compared with control group in the six months later interview. Conclusion The case management plays an important role the in control of hypertension, and can improve adherence to antihypertensive medication and chronic illness care.

PubMed Disclaimer

Similar articles

• The (cost-)effectiveness of a patient-tailored intervention programme to enhance adherence to antihypertensive medication in community pharmacies: study protocol of a randomised controlled trial. van der Laan DM, Elders PJ, Boons CC, Bosmans JE, Nijpels G, Hugtenburg JG. van der Laan DM, et al. Trials. 2017 Jan 19;18(1):29. doi: 10.1186/s13063-016-1696-3. Trials. 2017. PMID: 28103948 Free PMC article. Clinical Trial.
• The relationship between hypertensive patients' satisfaction with hypertension care and their antihypertensive medication adherence. Söylemez GK, Aşılar RH. Söylemez GK, et al. J Vasc Nurs. 2023 Sep;41(3):81-88. doi: 10.1016/j.jvn.2023.05.002. Epub 2023 May 25. J Vasc Nurs. 2023. PMID: 37684094
• Impact of a community pharmacists' hypertension-care service on medication adherence. The AFenPA study. Fikri-Benbrahim N, Faus MJ, Martínez-Martínez F, Sabater-Hernández D. Fikri-Benbrahim N, et al. Res Social Adm Pharm. 2013 Nov-Dec;9(6):797-805. doi: 10.1016/j.sapharm.2012.12.006. Epub 2013 Feb 4. Res Social Adm Pharm. 2013. PMID: 23391845 Clinical Trial.
• Behavioral and Pharmacotherapy Weight Loss Interventions to Prevent Obesity-Related Morbidity and Mortality in Adults: An Updated Systematic Review for the U.S. Preventive Services Task Force [Internet]. LeBlanc EL, Patnode CD, Webber EM, Redmond N, Rushkin M, O’Connor EA. LeBlanc EL, et al. Rockville (MD): Agency for Healthcare Research and Quality (US); 2018 Sep. Report No.: 18-05239-EF-1. Rockville (MD): Agency for Healthcare Research and Quality (US); 2018 Sep. Report No.: 18-05239-EF-1. PMID: 30354042 Free Books & Documents. Review.
• Pharmacist interventions to enhance blood pressure control and adherence to antihypertensive therapy: Review and meta-analysis. Morgado MP, Morgado SR, Mendes LC, Pereira LJ, Castelo-Branco M. Morgado MP, et al. Am J Health Syst Pharm. 2011 Feb 1;68(3):241-53. doi: 10.2146/ajhp090656. Am J Health Syst Pharm. 2011. PMID: 21258029 Review.
• Effectiveness of nursing case management versus usual care for blood pressure control in adults with hypertension: a systematic review. Mantovanil MF, Kalinke LP, da Silva ÂTM, Perez Arthur J, Radovanovic CAT, Bortolato-Major C. Mantovanil MF, et al. Invest Educ Enferm. 2021 Feb;39(1):e04. doi: 10.17533/udea.iee.v39n1e04. Invest Educ Enferm. 2021. PMID: 33687808 Free PMC article.
• Results of Nurse Case Management in Primary Heath Care: Bibliographic Review. Doménech-Briz V, Gómez Romero R, de Miguel-Montoya I, Juárez-Vela R, Martínez-Riera JR, Mármol-López MI, Verdeguer-Gómez MV, Sánchez-Rodríguez Á, Gea-Caballero V. Doménech-Briz V, et al. Int J Environ Res Public Health. 2020 Dec 20;17(24):9541. doi: 10.3390/ijerph17249541. Int J Environ Res Public Health. 2020. PMID: 33419267 Free PMC article. Review.
• Nursing case management for people with hypertension: A randomized controlled trial protocol. Song C, Li X, Ning X, Song S. Song C, et al. Medicine (Baltimore). 2020 Dec 24;99(52):e23850. doi: 10.1097/MD.0000000000023850. Medicine (Baltimore). 2020. PMID: 33350776 Free PMC article.

Publication types

• Search in MeSH

LinkOut - more resources

Full text sources.

• Scientific Electronic Library Online

Other Literature Sources

• scite Smart Citations
• MedlinePlus Health Information
• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

Official websites use .gov

A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS

A lock ( ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

Hypertension

Hypertension, or high blood pressure, is a risk factor for cardiovascular disease and stroke—the two leading causes of death in the United States ( 1–3 ).

Featured Chart

Explore data, definitions, key findings, hypertension in adults age 20 and older.

The age-adjusted percentage of adults age 20 and older with hypertension did not change significantly from 2001–2004 to 2017–March 2020. See Featured Chart  for additional analysis.

SOURCE: National Center for Health Statistics, National Health and Nutrition Examination Survey. See Sources and Definitions, National Health and Nutrition Examination Survey (NHANES) and Health, United States , 2022 Table Htn .

• Estimates are based on the U.S. civilian noninstitutionalized population. See Sources and Definitions, Population .
• Age-adjusted estimates are presented to eliminate differences that result from changes in the distribution of age in the population over time. See Sources and Definitions, Age adjustment .
• For information on the methods used to assess trends, see Sources and Definitions, Statistical testing .
• The NHANES program suspended field operations in March 2020 due to the COVID-19 pandemic. As a result, data collection for the 2019–2020 cycle was not completed. Consequently, data collected during 2019–March 2020 were combined with data from the 2017–2018 cycle to create a 2017–March 2020 prepandemic file. This file covers 3.2 years of data collection. For more information, see: “ National Health and Nutrition Examination Survey, 2017–March 2020 Prepandemic File: Sample Design, Estimation, and Analytic Guidelines .”

Hypertension in men age 20 and older

The age-adjusted percentage of men age 20 and older with hypertension did not change significantly from 2001–2004 to 2017–March. See Featured Chart  for additional analysis.

SOURCE: National Center for Health Statistics, National Health and Nutrition Examination Survey. See Sources and Definitions,  National Health and Nutrition Examination Survey (NHANES)  and  Health, United States , 2022 Table Htn .

Hypertension in women age 20 and older

The age-adjusted percentage of women age 20 and older with hypertension did not change significantly from 2001–2004 to 2017–March 2020 (42.1% in 2017–March 2020). See Featured Chart  for additional analysis.

From 2001–2004 to 2017–March 2020, hypertension was stable across all ages and was higher among older adults for both men and women.

NOTE: “Stable” refers to no statistically significant trend during the period.

• From 2001–2004 to 2017–March 2020, the percentage of men and women age 20 and older with hypertension did not change significantly for any age group.
• Throughout the period, the percentage of men and women with hypertension generally increased with increasing age.
• For men in 2017–March 2020, the percentage of those with hypertension ranged from 28.0% for men ages 20–34 to 83.2% for men age 75 and older.
• For women in 2017–March 2020, the percentage of those with hypertension ranged from 13.6% for women ages 20–34 to 84.1% for women age 75 and older.
• In 2017–March 2020, men were more likely to have hypertension than women for those younger than age 55. For those age 55 and older, the prevalence of hypertension was similar for men and women.

From 2001–2004 to 2017–March 2020, the age-adjusted percentage of adults age 20 and older with hypertension did not change significantly for Black, Mexican, and White adults. The percentage for Asian adults increased from 2013–2016 to 2017–March 2020 .

1 Data for the Asian population are available only starting in 2013.

• From 2001–2004 to 2017–March 2020, the age-adjusted percentage of adults age 20 and older with hypertension did not change significantly for Black, Mexican, and White adults.
• For Asian adults, the age-adjusted percentage of hypertension increased from 41.2% in 2013–2016 to 46.2% in 2017–March 2020.
• Throughout the period, hypertension was higher in Black adults compared with Mexican, White, and Asian adults.
• In 2017–March 2020, the age-adjusted percentage of adults with hypertension was 58.9% for Black adults, 46.2% for Asian adults, 44.5% for White adults, and 42.6% for Mexican adults.
• Estimates are Age-adjusted estimates are presented to eliminate differences that result from changes in the distribution of age in the population over time. See Sources and Definitions, Age adjustment .
• Race groups (Asian, Black, and White) are non-Hispanic.
• Data on race and Hispanic origin are presented in the greatest detail possible considering the quality of the data, the amount of missing data, and the number of observations. Although data for Hispanic people are available starting in 2007–2008, to provide estimates for the entire period starting with 2001–2004, estimates for people of Mexican origin are presented in the figure rather than Hispanic. Data for Asian people are available starting in 2011–2012.

Hypertension in adults age 20 and older, by selected characteristics: United States, selected years 1988–1994 to 2017–March 2020

SOURCE: National Center for Health Statistics, National Health and Nutrition Examination Survey.

• NCHS Data Query System
• Data.CDC.gov

Cholesterol in adults age 20 and older, by selected characteristics: United States, selected years 1988–1994 to 2017–March 2020

• Hypertension: Defined as having measured high blood pressure (systolic pressure of at least 130 mm Hg or diastolic pressure of at least 80 mm Hg), taking high blood pressure medication, or both. Those who report taking high blood pressure medication may not have measured high blood pressure but are still classified as having hypertension. See Sources and Definitions, Hypertension .
• Mexican: People of Mexican or Hispanic origin may be of any race. For 1999–2006, the NHANES sample was designed to provide estimates specifically for people of Mexican origin and not for all Hispanic-origin people. Starting with 2007–2008 data, estimates for all Hispanic people are available. To provide the full trend, estimates for people of Mexican origin only are presented in the figure. For data on the Hispanic population, see Health, United States, 2022 Table Htn . Also see Sources and Definitions, Hispanic origin .
• Race: Estimates are presented according to the 1997 Office of Management and Budget’s “Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity” and are for people who reported only one racial group. Starting in 2011, NHANES oversampled the Asian non-Hispanic population. In Health, United States , estimates are presented for Asian non-Hispanic, Black non-Hispanic, and White non-Hispanic people, as well as for people of Hispanic and Mexican origin. Insufficient numbers of observations are available during this period to meet statistical reliability or confidentiality requirements for reporting estimates for additional race categories. See Sources and Definitions, Race .
• Centers for Disease Control and Prevention. High blood pressure . 2023.
• Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Hypertension 71(6):e13-e115. 2018.
• Kochanek KD, Murphy SL, Xu J, Arias E. Deaths: Final data for 2020. NCHS National Vital Statistics Reports; vol 72 no 10. Hyattsville, MD: National Center for Health Statistics. 2023. DOI: https://dx.doi.org/10.15620/cdc:131355 .

Hypertension: A Case Study

• January 2022
• 8(7):379 - 381

• Adesh Medical College and Hospital

• Eternal University

• Akal College of Nursing Eternal University Baru Sahib.

Discover the world's research

• 25+ million members
• 160+ million publication pages
• 2.3+ billion citations
• Muthu Kumaran

• Suzanne Oparil
• Recruit researchers
• Join for free
• Login Email Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google Welcome back! Please log in. Email · Hint Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google No account? Sign up