Delays in diagnosing hypertension were associated with reduced treatment rates and increased cardiovascular risk over 5 years, according to a retrospective study of 311,743 adults. Patients who were diagnosed with hypertension following two elevated blood pressure readings were significantly less likely to receive antihypertensive medications and more likely to experience heart failure, stroke, or myocardial infarction.
The study included adults aged 18 to 85 with at least two outpatient blood pressure (BP) readings of 140/90 mm Hg or higher that were recorded at least 30 days apart between 2010 and 2021. These patients met criteria for a “computed” hypertension diagnosis based on blood pressure records, though not all received a timely clinical diagnosis. Among the study population, 45,454 patients (15%) were diagnosed after the second elevated reading. In this group, 31% received a prescription for antihypertensive medication within 30 days of diagnosis, compared with 75% of those who were diagnosed between the first and second elevated readings.
The likelihood of receiving treatment declined as delays increased. Of those who were diagnosed 1 to 90 days after the second elevated reading, 55% received medication. That rate dropped to 32% for those who were diagnosed between 91 and 365 days, and to 26% for diagnoses made more than 365 days after the second elevated reading.
Delayed diagnosis was also associated with higher risk of adverse cardiovascular events over 5 years. Adjusted hazard ratios (HRs) for the composite outcome of myocardial infarction, ischemic stroke, or heart failure hospitalization after the second elevated BP reading were 1.04 for diagnosis 1 to 90 days, 1.11 for 91 to 365 days, and 1.29 for more than 365 days. Heart failure hospitalization showed the strongest association, with an HR of 1.31 for diagnosis after more than 365 days.
Health care engagement remained high among patients with delayed diagnosis. Between the second elevated BP reading and diagnosis, these patients had a median of 14 outpatient visits, which indicated missed clinical opportunities rather than lack of access to care. "However, alternative explanations should also be considered," wrote lead author Yuan Lu, ScD, of the Center for Outcomes Research and Evaluation at Yale New Haven Hospital in Connecticut, with colleagues. "Clinicians may hesitate to diagnose hypertension based on a single elevated BP measurement, particularly when concerned about white-coat hypertension (ie, uncontrolled clinic-measured BP, with either home or ambulatory readings at goal) or transient BP elevations." The authors added that current guidelines suggest elevated, sustained hypertension should be confirmed and lifestyle modifications be recommended to patients prior to initiating medication.
They also found that delays were more common among specific demographic groups. Patients aged 45 to 64 had a median delay of 17.5 months, compared with 13.4 months among those aged 75 or older. Women had a median delay of 16.6 months vs 16.1 months for men. Non-Hispanic Asian and non-Hispanic Black patients experienced delays of 18.5 and 17.2 months, respectively, compared with 16.3 months in non-Hispanic White patients. The authors noted that implicit biases, differences in symptom presentation, or variability in patient interactions could contribute to delays in diagnosis and prescribing as well.
They suggested that primary care physicians, pharmacists, and nurses, as well as electronic health record support tools, can help address more timely evaluation, diagnosis, and treatment. However, the potential for overdiagnosis and overtreatment are essential considerations as well, they added. The researchers proposed more frequent BP reassessment and ambulatory BP monitoring while keeping efficiency in mind with interdisciplinary care teams to "improve the accuracy, timeliness, and overall quality of hypertension diagnosis and management."
Limitations included generalizability and the need to address home BP monitoring or ambulatory BP data, social determinants of health, and other confounders. The lower BP threshold for high-risk patients was also recently updated in US guidelines, which may increase the number of undiagnosed hypertension cases in future studies that apply the new guidelines.
Full disclosures can be found in the published study.
Source: JAMA Network Open