Hypertension Treatment: Key Differences Between the US and Other Regions
Medication Selection Patterns
The most prescribed antihypertensive medications differ substantially between the US, UK, and European Union, with only 5 drugs representing over 50% of prescriptions in each region, though the specific drugs vary by location. 1
Regional Prescription Patterns
United States: The top 5 medications (ranks 1-5) account for over half of all hypertension prescriptions, with a panel of medications needed to cover 95% of treatments 1
United Kingdom: Just 4 medications span over half of prescriptions, with 20 drugs describing 95% of dispensed treatments 1
European Union: The pattern is more diverse, requiring 5 drugs to represent over 50% of prescribed antihypertensives, with greater variation in prescribing habits 1
Common medications across all three regions include: amlodipine, enalapril, furosemide, lisinopril, losartan, propranolol, ramipril, and spironolactone 1
Treatment Guidelines and Blood Pressure Targets
US guidelines are more aggressive than many international recommendations, defining hypertension at ≥130/80 mm Hg, while international guidelines typically use ≥140/90 mm Hg as the threshold. 1
Blood Pressure Thresholds
US (2017 ACC/AHA): Hypertension defined as ≥130/80 mm Hg, with treatment targets <130/80 mm Hg for most adults <65 years 1, 2
International Society of Hypertension (2020): Office BP ≥140/90 mm Hg defines hypertension, with more flexible targets based on resource availability 1
Out-of-office measurements: US guidelines emphasize ambulatory and home BP monitoring more heavily, though international guidelines acknowledge these may not be feasible in low-resource settings 1
First-Line Medication Recommendations
US Approach for Different Populations
In Black adults without heart failure or CKD, US guidelines specifically recommend starting with thiazide-type diuretics or calcium channel blockers rather than ACE inhibitors or ARBs. 1
Black adults show less BP reduction with ACE inhibitors or ARBs as monotherapy compared to thiazide diuretics or CCBs 1
In the ALLHAT trial with >15,000 Black participants, ACE inhibitors were associated with 40% greater stroke risk, 32% greater heart failure risk, and 19% greater CVD risk compared to thiazide diuretics 1
Most patients, especially Black adults, require ≥2 antihypertensive medications to achieve BP targets 1
International Approach
International guidelines recommend a more uniform approach across populations, with single-pill combination therapy emphasized from the start in many regions. 1
The 2020 ISH guidelines advocate for single-pill combinations as essential standard of care globally, though acknowledge implementation challenges in low-resource settings 1
Four drug classes (thiazide diuretic, CCB, ACE inhibitor, or ARB) are considered equally appropriate first-line options internationally 1
Healthcare System and Access Differences
Treatment and Control Rates
The US achieves higher hypertension awareness, treatment, and control rates than most low- and middle-income countries, but still lags behind top-performing nations like Canada and South Korea. 1
US control rates: Approximately 44% of adults with hypertension have BP controlled to <140/90 mm Hg; <25% controlled to the newer <130/80 mm Hg target 1, 2
Low- and middle-income countries: Only 30% of people with hypertension receive treatment, and only 10% have controlled BP 1
Best-performing countries (Canada, Germany, South Korea): Treatment coverage reaches 80% with control rates approaching 70% 1
Racial and Ethnic Disparities
Hypertension control rates in the US are significantly lower for Black, Hispanic, and Asian Americans compared to non-Hispanic whites, with Black adults experiencing 1.8 times greater risk of fatal stroke. 1
Non-Hispanic white men: 53.8% controlled; women: 59.1% controlled 1
Non-Hispanic Black men: 43.8% controlled; women: 52.3% controlled 1
Hispanic Americans: Lower control rates primarily due to lack of awareness and treatment rather than medication effectiveness 1
Age-adjusted hypertension mortality rates per 1,000 persons: Non-Hispanic Black men (50.1) and women (35.6) versus non-Hispanic white men (19.3) and women (15.8) 1
Implementation Challenges
Resource Availability
Low- and middle-income regions face substantial barriers including lack of trained healthcare professionals, unreliable electricity, limited access to BP devices, and poor availability of affordable medications—challenges largely absent in the US healthcare system. 1
Only 25% of African countries have hypertension guidelines, often adopting high-income region guidelines that may be impractical 1
Universal health coverage, out-of-pocket spending, and medication supply chains significantly influence treatment access globally 1
Therapeutic Inertia
Therapeutic inertia—failure to initiate or intensify therapy when goals are not met—is a major barrier in the US, with antihypertensive therapy intensified at only 13% of visits with uncontrolled BP. 1
Patients with lowest therapeutic inertia rates are 33 times more likely to achieve BP control 1
US guidelines emphasize team-based care, real-time audit and feedback, and system-wide quality improvement to address this problem 1
Adherence Testing Approaches
Chemical adherence testing using LC-MS/MS is being developed and standardized differently across regions, with the US, UK, and EU each requiring different medication panels based on local prescribing patterns. 1
Verbal informed consent on the day of sampling is recommended, with consent recorded in medical notes 1
Screening panels should include the top 95% of locally prescribed medications, with a minimum of the 5 most prescribed drugs 1
Hydrochlorothiazide should be included in all panels due to its common use in combination pills and rapid elimination, which helps detect intermittent dosing 1