Published Online
on February 11, 2008

A more recent version of this article appeared on February 19, 2008

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Submitted on October 1, 2007
Accepted on November 20, 2007

Trends and Cardiovascular Mortality Effects of State-Level Blood Pressure and Uncontrolled Hypertension in the United States

Majid Ezzati PhD^*, Shefali Oza SB, Goodarz Danaei MD, and Christopher J.L. Murray MD, DPhil

From the Harvard School of Public Health, Boston (M.E., G.D., C.J.L.M.), and Initiative for Global Health, Harvard University, Cambridge (M.E., S.O., G.D., C.J.L.M.), Mass, and Institute for Health Metrics and Evaluation, University of Washington (C.J.L.M.), Seattle.

^* To whom correspondence should be addressed. E-mail: majid_ezzati{at}harvard.edu.

Background—Blood pressure is an important risk factor for cardiovascular disease and mortality and has lifestyle and healthcare determinants that vary across states. Only self-reported hypertension status is measured at the state level in the United States. Our aim was to estimate levels and trends in state-level mean systolic blood pressure (SBP), the prevalence of uncontrolled systolic hypertension, and cardiovascular mortality attributable to all levels of higher-than-optimal SBP.

Methods and Results—We estimated the relationship between actual SBP/uncontrolled hypertension and self-reported hypertension, use of blood pressure medication, and a set of health system and sociodemographic variables in the nationally representative National Health and Nutrition Examination Survey. We applied this relationship to identical variables from the Behavioral Risk Factor Surveillance System to estimate state-specific mean SBP and uncontrolled hypertension. We used the comparative risk assessment methods to estimate cardiovascular mortality attributable to higher-than-optimal SBP. In 2001–2003, age-standardized uncontrolled hypertension prevalence was highest in the District of Columbia, Mississippi, Louisiana, Alabama, Texas, Georgia, and South Carolina (18% to 21% for men and 24% to 26% for women) and lowest in Vermont, Minnesota, Connecticut, New Hampshire, Iowa, and Colorado (15% to 16% for men and 21% for women). Women had a higher prevalence of uncontrolled hypertension than men in every state by 4 (Arizona) to 7 (Kansas) percentage points. In the 1990s, uncontrolled hypertension in women increased the most in Idaho and Oregon (by 6 percentage points) and the least in the District of Columbia and Mississippi (by 3 percentage points). For men, the worst-performing states were New Mexico and Louisiana (decrease of 0.6 and 1.3 percentage points), and the best-performing states were Vermont and Indiana (decrease of 4 and 3 percentage points). Age-standardized cardiovascular mortality attributable to higher-than-optimal SBP ranged from 200 to 220 per 100 000 (Minnesota and Massachusetts) to 360 to 370 per 100 000 (District of Columbia and Mississippi) for women and from 210 per 100 000 (Colorado and Utah) to 370 per 100 000 (Mississippi) and 410 per 100 000 (District of Columbia) for men.

Conclusions—Lifestyle and pharmacological interventions for lowering blood pressure are particularly needed in the South and Appalachia, and with emphasis on control among women. Self-reported data on hypertension diagnosis from the Behavioral Risk Factor Surveillance System can be used to obtain unbiased state-level estimates of blood pressure and uncontrolled hypertension as benchmarks for priority setting and for designing and evaluating intervention programs.

Key words: blood pressure • cardiovascular diseases • hypertension • models, statistical • mortality • risk factors • United States

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