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Hypertension-Related Deaths Rise in US, Especially in Rural South, Data Show

Mary Caffrey
Research highlighting these trends, based on 10 million death records pulled from a CDC database, will be presented at the American College of Cardiology’s Annual Scientific Session together with World Congress of Cardiology (ACC.20/WCC), which is taking place as a virtual meeting March 28-30.
Deaths linked to hypertension have climbed over the past 7 years, especially in the rural South, where more people have related conditions like diabetes and obesity but more working poor have been left out of Medicaid expansion.

Research highlighting these trends, based on 10 million death records pulled from a CDC database, will be presented at the American College of Cardiology’s Annual Scientific Session together with World Congress of Cardiology (ACC.20/WCC), which is taking place as a virtual meeting March 28-30. Results are also published in the Journal of the American College of Cardiology.

Overall, death rates due to hypertension increased by 72% among rural populations and 20% among those in urban areas, researchers said in their abstract.

“This is a public health emergency that has not been fully recognized,” said lead author Lakshmi Nambiar, MD, a cardiovascular disease fellow at the University of Vermont Larner College of Medicine, in a statement. She said poor diets, rising rates of obesity and diabetes, and “a lack of access to healthcare” could account for regional differences, and targeted interventions would be needed to reverse the tide.

Notably, the findings conflict with studies that point to an overall decline in death rates from coronary artery disease, a common form of heart disease caused by narrowing arteries that has been successfully treated with statins.

“Hypertension-related cardiovascular deaths are rising in the [United States] across all age groups, all regions, and in both urban and rural populations,” she said. “These findings are alarming and warrant further investigation, as well as preventative efforts.”

Data for the current study cover 2007 to 2017, when high blood pressure (BP) was defined as systolic BP of at least 140 mm Hg and diastolic BP of at least 90 mm Hg. In 2017, the ACC and the American Heart Association adopted stricter guidelines for defining hypertension, saying it begins when systolic BP reaches 130 mm Hg and diastolic BP hits 80 mm Hg. A 2018 study found the changing standard could mean another 31 million US adults would have high blood pressure, bringing the total to 105 million.

For their study, the Vermont researchers examined death certificates for those listing cardiovascular disease as the cause of death, with hypertension as a contributing factor. Deaths linked to hypertension rose across the board, but they rose fastest in the rural South, where data showed a 2.5-fold higher hypertension-related death rate compared with other parts of the country.

Age-adjusted death rates in the rural South rose from 23.9 deaths per 100,000 people in 2007 to 39.5 deaths per 100,000 people in 2017. Most areas of the country, including urban areas in the South, saw death rates linked to hypertension decline through 2011-2012 before this trend reversed. In the rural South, the researchers found death rates related to hypertension have climbed at an ever-increasing pace since 2007.

During the study period, Congress passed the Affordable Care Act (ACA), which formally marks its 10th anniversary on Monday. Some provisions, such as those allowing adult children to stay on family insurance plans through age 26, took effect quickly. A centerpiece of the plan, which allowed working class Americans earning up to 133% of the federal poverty level (FPL) to enroll in Medicaid, did not take effect until January 1, 2014.

Although Democrats in Congress planned for states to be required to add to their Medicaid rolls, conservative states successfully challenged this mandate. Today, 14 states still have not expanded Medicaid, and these include states with some of the highest obesity and diabetes rates in the country, such as Alabama, Mississippi, and Georgia.

During a press briefing on consumer-related research, The American Journal of Managed Care® asked Nambiar if the trend could be linked to the decision by many Deep South states to decline Medicaid expansion—or, in the case of Louisiana, to delay it some years after it was permitted under the ACA.

“I definitely think that could be a contributing factor,” Nambiar said. Management of hypertension occurs in the primary care office, she noted, where patients are regularly assessed and placed on treatment as needed. “If there is a lack of access to healthcare and proper treatment of high blood pressure, that could definitely be related” to some state-level decisions to forego Medicaid expansion.

Of the 14 states that have not expanded Medicaid to those earning up to 133% of the FPL, 7 are in the Southeast, and Texas is in the Southwest.

ACC.20/WCC will take place March 28-30, 2020, as a virtual meeting due to COVID-19, which forced the cancellation of the in-person Chciago, Illinois, meeting. Visit here for full coverage.


Nambiar L, Dauerman H, Vanburen P, LeWinter M. Decade-long temporal trends in hypertension-related deaths. Presented at ACC.20/WCC March 28-30, 2020. Abstract 20-A-14942.

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