Review and special article
Screening for high blood pressure: A review of the evidence for the U.S. Preventive Services Task Force

https://doi.org/10.1016/S0749-3797(03)00121-1Get rights and content

Abstract

Context

In 1996, the U.S. Preventive Services Task Force (USPSTF) recommended screening adults for hypertension. Since that time, the published literature on hypertension has expanded rapidly, necessitating a new examination of the evidence supporting screening.

Objective

Update the 1996 evidence review on screening for hypertension.

Data sources

The 1996 Guide to Clinical Preventive Services, recent systematic reviews, and focused searches of MEDLINE were used to identify new evidence relevant to detecting and treating hypertension.

Study selection

When a good quality, recent systematic review was available, it was used to summarize previous research; MEDLINE was searched only for more recent articles. Two authors reviewed abstracts (and full texts, if necessary) of potentially relevant articles to determine if they should be included.

Data extraction

One author extracted data from included studies into evidence tables.

Data synthesis

Hypertension can be effectively detected through office measurement of blood pressure. Treatment of elevated blood pressure in adults can reduce cardiovascular events. The magnitude of risk reduction depends on the degree of hypertension and the presence of other cardiovascular risk factors. Available studies have found no important adverse effects on psychological well-being and mixed effects on the absenteeism rates of adults who are screened and labeled as being hypertensive.

Conclusions

Substantial indirect evidence supports the effectiveness of screening adults to detect hypertension and treating them to reduce cardiovascular disease.

Introduction

I n the United States, hypertension is responsible for 35% of all cardiovascular events (myocardial infarction and stroke), 49% of all episodes of heart failure, and 24% of all premature deaths.1 Patients with hypertension have 2 to 4 times more risk for stroke, myocardial infarction, heart failure, and peripheral vascular disease than patients without hypertension.2 Additionally, they have an increased risk for end-stage renal disease, retinopathy, and aortic aneurysm.1, 3, 4 This substantial burden of suffering from hypertension, in combination with a feasible and accurate means of detection, and a clear benefit from treatment,5 have led to a widespread recommendation for screening for hypertension.

In 1996, the U.S. Preventive Services Task Force (USPSTF) reviewed the evidence regarding screening for hypertension.5 Based on that review, the USPSTF strongly recommended screening adults aged 21 years and older using standard office sphygmomanometry. Although the USPSTF did not recommend a specific interval for screening, they noted that measurement every 2 years for patients with previously normal blood pressures and every year in people with borderline levels may be prudent.

In this report, newer evidence relevant to screening for hypertension in adults has been systematically examined to assist the USPSTF in updating its recommendations and the Guide to Clinical Preventive Services.5

Section snippets

Analytic framework and key questions

To examine the role of outpatient clinical screening for hypertension in adults, an analytic framework depicting key questions of interest to the USPSTF was developed (Figure 1). The arrows in the analytic framework represent steps in the chain of logic connecting screening with defined outcomes: cardiovascular disease (CVD), renal failure, and reduction of mortality.

Four key questions guided the literature searches and synthesis of the evidence:

  • Key Question No. 1: Does screening and early

Key question 1: does screening for hypertension reduce cardiovascular disease and mortality?

RCTs of screening (versus no screening) would provide the best evidence about the effects of screening for hypertension on CVD and mortality. No such studies were identified. Many trials of hypertension treatment that compared pharmacologic and behavioral intervention to usual care, however, showed a beneficial effect of treatment in patients who were enrolled on the basis of elevated blood pressures detected on screening examinations. These findings suggest that screening may be beneficial,

Discussion

Strong indirect evidence supports screening adults for hypertension. Hypertension is an important contributor to CVD morbidity and mortality. It is predictive of CVD events and reliably detected through screening blood pressure measurements using a standard arm blood pressure cuff and sphygmomanometer. Additionally, treatment of adult hypertensive patients with drug therapy and possibly nonpharmacologic interventions can reduce blood pressure and the incidence of cardiovascular events,

Acknowledgements

This study was developed by the RTI International–University of North Carolina at Chapel Hill (RTI-UNC) Evidence-Based Practice Center under contract to the Agency for Healthcare Research and Quality (AHRQ) (contract # 290-97-0011), Rockville MD. We acknowledge at AHRQ the continuing support of David Atkins, MD, MPH, Chief Medical Officer of the AHRQ Center for Practice and Technology Assessment; and Jean Slutsky, PA, MSPH, Task Order Officer for the USPSTF project.

We are also indebted to our

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