Four in Five US Adults With Hypertension Have Uncontrolled BP

Roughly 80% of US adults with hypertension do not have their blood pressure controlled to less than 130/80 mm Hg, according to a look at National Health and Nutrition Examination Survey (NHANES) data.

In addition, most individuals with uncontrolled BP (61.3%) were not taking any antihypertensive medications, lead author Shakia Hardy, PhD, MPH (University of North Carolina at Chapel Hill), and colleagues report in a research letter published this week in JAMA.

Hardy told TCTMD that the motivation behind the analysis was to see how well the US population was faring in the context of new treatment goals found in the 2025 hypertension guideline published by the American Heart Association, American College of Cardiology, and several other professional organizations. The guidance calls for treatment of BP to less than 130/80 mm Hg using lifestyle measures and antihypertensive medications, broadening the pool of patients covered by that recommendation compared with the earlier 2017 document.

As such, Hardy said her team expected to find a large proportion of the population with hypertension left untreated, but what they observed was a bit surprising.

These latest findings “highlight a large gap in hypertension control,” the authors write.

The analysis, which relied on NHANES data from 2021 to 2023, included 3,216 individuals ages 20 years and older who were not pregnant and had hypertension defined as a systolic BP ≥ 130 mm Hg, a diastolic BP ≥ 80 mm Hg, or self-reported use of antihypertensive medications. BP was measured using an oscillometric device, with mean readings calculated from three measurements.

During the study period, 79.1% of those with hypertension had uncontrolled BP (mean age 54.3 years; 46.3% women), defined as having a systolic reading above 130 mm Hg and/or a diastolic reading above 80 mm Hg.

Only an estimated 38.7% of participants with uncontrolled BP were taking antihypertensive medications. Compared with those on treatment, those who were not taking BP-lowering drugs were younger (estimated mean age 49.2 vs 62.4 years) and less likely to have health insurance (estimated 88.8% vs 95.1%), a routine source for healthcare (estimated 83.0% vs 95.9%), or high CVD risk (estimated 33.7% vs 71.9%; P < 0.001 for all).

Individuals who were not receiving treatment for their hypertension were more likely than their treated counterparts to have a systolic or diastolic BP above goal by at least 10 mm Hg (estimated 52.6% vs 34.6%), 20 mm Hg (estimated 24.7% vs 12.8%), and 30 mm Hg (estimated 10.8% vs 5.7%; P < 0.001 for all).

For the untreated individuals who are within 10 mm Hg of treatment goals, control might be attainable through lifestyle modification and initiation of antihypertensive medications, the investigators say. But for those patients with uncontrolled BP despite use of antihypertensive drugs, they add, getting to BP goals might require more-intensive treatment involving combination therapy.

Access to the healthcare system does not appear to be the main problem when it comes to BP control, Hardy said, noting that most patients in this study—irrespective of whether they were receiving treatment—had health insurance and a source for routine healthcare. Rather, clinical inertia needs to be overcome.

“I don’t think access was necessarily the issue. I think it’s management within care—initiating antihypertensive medication earlier and then titrating medication more quickly when people are not reaching goal,” Hardy said. “Changes in the way in which we manage people would help bring people closer to goal or below goal.”