Uncontrolled Blood Pressure, HbA1c Common Among Hospitalized Heart Failure Patients

An analysis of NHANES surveys from 2001-2018 describes the overall prevalence of uncontrolled hypertension and HbA1c in adults with heart failure and provides insight into racial/ethnic disparities in prevalence.

New research describes the prevalence of uncontrolled blood pressure and HbA1c among patients hospitalized with heart failure in the US in the last 2 decades.

An analysis of data from the National Health and Nutrition Examination Survey (NHANES) from 2001 through 2018, results of the study suggest uncontrolled blood pressure was present in nearly half of all patients hospitalized with heart failure during the study period and uncontrolled HbA1c was observed among nearly 1-in-10, with results also pointing to disparities in the prevalence of both based on racial/ethnic background of a patient.

“This analysis of nationally representative data of ambulatory adults with heart failure demonstrates a high prevalence of uncontrolled blood pressure and uncontrolled HbA1c and documents a significant gap between the recommended blood pressure and HbA1c targets outlined by the AHA/ACC/HFSA and levels of risk factor control frequently achieved by patients with heart failure. These findings highlight the importance of implementation science research to design and inform interventions that can effectively improve risk factor control for patients with heart failure,” wrote investigators.

Although blood pressure and HbA1c represent modifiable risk factors, investigators noted a lack of studies evaluating these factors among ambulatory patients with heart failure and what racial and ethnic disparities in care might exist in this subset of patients. With this in mind, investigators launched the current study with the intent of assessing prevalence of uncontrolled blood pressure and HbA1c among non-Hispanic Black, non-Hispanic White, and Mexican American adults aged 20 years and older with self-reported heart failure in the US across NHANES survey cycles from 2001 to 2002 and 2017 to 2018.

From NHANES, investigators obtained information related to a cohort of 91,315 participants for potential inclusion in their analyses. Of these, 1423 participants answered “Yes” to the question “Has a doctor or other health professional ever told you that you had congestive heart failure”. This cohort had a mean age of 67±0.4 years, 48.8±1.6% were female, and 93.8±0.8% were insured. Of the 1423 included in the investigators' analyses, which was representative of 4,825,667 US patients, 866 were non-Hispanic White patients, 402 were non-Hispanic Black patients, and 155 were Mexican American patients.

For the purpose of analysis, uncontrolled blood pressure was defined as a systolic blood pressure of 130 mmHg or greater and uncontrolled HbA1c was defined as an HbA1c of 8% or greater. The primary outcome of interest for the analyses was the prevalence of uncontrolled HbA1c and blood pressure, which was calculated by race and ethnicity and adjusted for sex, age, treatment, and socioeconomic status. Investigators assessed trends in prevalence for both risk factors as secondary outcomes of interest.

Overall, 48% (95% CI, 49-56) of adult patients with heart failure had uncontrolled blood pressure, with uncontrolled hypertension observed among 51% (95% CI, 47-55) of those receiving treatment for hypertension. For HbA1c, 8% (95% CI, 6-10) of the study cohort had uncontrolled HbA1c. Investigators noted prevalence of uncontrolled HbA1c was higher in participants who also reported current treatment for diabetes, with 21% (95% CI, 17–37) of these patients having uncontrolled HbA1c.

In unadjusted analyses, results suggested non-Hispanic Black participants had a higher prevalence ratio of uncontrolled BP compared with non-Hispanic White participants (53% [95% CI, 48–58] vs 47% [95% CI, 43–51]; P <.05). In adjusted analyses, results indicated non-Hispanic Black participants were at a 1.19-fold greater risk of having uncontrolled blood pressure than their non-Hispanic White counterparts (1.19 [95% CI, 1.02-1.39]). When assessing differences in the prevalence of uncontrolled HbA1c among patients with heart failure, results suggested there were no significant differences in prevalence according to race and ethnicity. Investigators also pointed out the prevalence of uncontrolled blood pressure improved during the study period, but prevalence remained high, with 41% (95% CI, 36-47) reporting uncontrolled blood pressure and 7% (95% CI, 5-12) uncontrolled HbA1c in the most recent NHANES survey cycle.

In an editorial penned by Madeline Sterling, MD, MPH, MS, and Utibe R. Essie, MD, MPH, the pair commend investigators for their efforts and underline the importance of addressing these gaps in implementation science to improve population-level health for those with heart failure and other cardiovascular conditions.

“Irrespective of the underlying reasons, these findings, and particularly the fact that they remained largely stable over an 18-year study period, are troubling. To mitigate poor risk factor control and achieve health equity in HF care, there is a dire need to increase the uptake of evidence-based guidelines, particularly for blood pressure and glycemic control,” Sterling and Essie wrote. “Building on health equity and implementation science frameworks, improving equitable guideline uptake will likely require that interventions account for the complex and multilayered social determinants of health that patients with HF experience, especially those of marginalized groups.”

This study, “Blood Pressure and Glycemic Control Among Ambulatory US Adults With Heart Failure: National Health and Nutrition Examination Survey 2001 to 2018,” was published in Circulation: Heart Failure.