Differences in Hypertension and Stage II Hypertension by Demographic and Risk Factors, Obtained by Two Different Protocols in US Adults: National Health and Nutrition Examination Survey, 2017-2018.

BACKGROUND: To compare prevalence of hypertension and stage II hypertension assessed by 2 blood pressure (BP) observation protocols. METHODS: Participants aged 18 years and older (n = 4,689) in the National Health and Nutrition Examination Survey (NHANES 2017-2018) had their BP measured following 2 protocols: the legacy auscultation protocol (AP) and oscillometric protocol (OP). The order of protocols was randomly assigned. Prevalence estimates for hypertension (BP ≥130/80 mm Hg or use of medication for hypertension) and stage II hypertension (BP ≥140/90 mm Hg) were determined overall, by demographics, and by risk factors for each protocol. Ratios (OP% ÷ AP%) and kappa statistics were calculated. RESULTS: Age-adjusted hypertension prevalence was 44.5% (95% confidence interval [CI]: 41.1%-48.0%) using OP and 45.1% (95% CI: 41.5%-48.7%) using AP, prevalence ratio = 0.99 (95% CI = 0.94-1.04). Age-adjusted stage II hypertension prevalence was 15.8% (95% CI: 13.6%-18.2%) using AP and 17.1% (95% CI: 14.7%-19.7%) using OP, prevalence ratio = 0.92 (95% CI = 0.81-1.04). For both hypertension and stage II hypertension, the prevalence ratios by demographics and by risk factors all included unity in their 95% CI, except for stage II hypertension in adults 60+ years (ratio: 0.88 [95% CI: 0.78-0.98]). Kappa for agreement between protocols for hypertension and stage II hypertension was 0.75 (95% CI = 0.71-0.79) and 0.67 (95% CI = 0.61-0.72), respectively. CONCLUSIONS: In adults and for nearly all subcategories there were no significant differences in prevalence of hypertension and stage II hypertension between protocols, indicating that protocol change may not affect the national prevalence estimates of hypertension and stage II hypertension.

Differences in Hypertension Prevalence and Hypertension Control by Urbanization Among Adults in the United States, 2013-2018.

BACKGROUND: To examine the associations between urbanization and hypertension, stage II hypertension, and hypertension control. METHODS: Data on 16,360 US adults aged 18 years or older from the 2013-2018 National Health and Nutrition Examination Survey (NHANES) were used to estimate the prevalence of hypertension (blood pressure (BP) ≥130/80 mm Hg or use of medication for hypertension), stage II hypertension (BP ≥140/90 mm Hg), and hypertension control (BP <130/80 mm Hg among hypertensives) by urbanization, classified by levels of metropolitan statistical areas as large MSAs (population ≥1,000,000), medium to small MSAs (population 50,000-999,999), and non-MSAs (population <50,000). RESULTS: All prevalence ratios (PRs) were compared with large MSAs and adjusted for demographics and risk factors. The PRs of hypertension were 1.07 (95% confidence interval (CI) = 0.99-1.14) for adults residing in medium to small MSAs and 1.06 (95% CI = 0.99-1.13) for adults residing in non-MSAs. For stage II hypertension, the PRs were higher for adults residing in medium to small MSAs 1.21 (95% CI = 1.06-1.36) but not for adults residing in non-MSAs 1.06 (95% CI = 0.88-1.29). For hypertension control, the PRs were 0.96 (95% CI = 0.91-1.01) for adults residing in medium to small MSAs and 1.00 (95% CI = 0.93-1.06) for adults residing in non-MSAs. CONCLUSIONS: Among US adults, urbanization was associated with stage II hypertension.

Comparing Blood Pressure Values Obtained by Two Different Protocols: National Health and Nutrition Examination Survey, 2017-2018.

Objectives Blood pressure (BP) is traditionally measured using a mercury sphygmomanometer. Given environmental concerns about mercury, clinical and survey settingsare moving to automated devices with an oscillometric protocol to obtain BP. This report compares BP measurement using the mercury and oscillometric protocols.

Comparison of 3 Devices for 24-Hour Ambulatory Blood Pressure Monitoring in a Nonclinical Environment Through a Randomized Trial.

BACKGROUND: The U.S. Preventive Services Task Force recommends the use of 24-hour ambulatory blood pressure monitoring (ABPM) as part of screening and diagnosis of hypertension. The optimal ABPM device for population-based surveys is unknown. METHODS: We compared the proportion of valid blood pressure (BP) readings, mean awake and asleep BP readings, differences between awake ABPM readings and initial standardized BP readings, and sleep experience among three ABPM devices. We randomized a convenience sample of 365 adults to 1 of 3 ABPM devices: Welch Allyn Mobil-O-Graph (WA), Sun Tech Classic Oscar2 (STO) and Spacelabs 90227 (SL). Participants completed sleep quality questionnaires on the nights before and during ABPM testing. RESULTS: The proportions of valid BP readings were not different among the 3 devices (P > 0.45). Mean awake and asleep systolic BP were significantly higher for STO device (WA vs. STO vs. SL: 126.65, 138.09, 127.44 mm Hg; 114.34, 120.34, 113.13 mm Hg; P < 0.0001 for both). The difference between the initial average standardized mercury systolic BP readings and the ABPM mean awake systolic BP was larger for STO device (WA vs. STO. vs. SL: -5.26, -16.24, -5.36 mm Hg; P < 0.0001); diastolic BP mean differences were ~ -6 mm Hg for all 3 devices (P = 0.6). Approximately 55% of participants reported that the devices interfered with sleep; however, there were no sleep differences across the devices (P > 0.4 for all). CONCLUSION: Most of the participants met the threshold of 70% valid readings over 24 hours. Sleep disturbance was common but did not interfere with completion of measurement in most of the participants.

Hypertension Prevalence Among Adults Aged 18 and Over: United States, 2017-2018.

Hypertension is a major risk factor for cardiovascular disease. Lowering blood pressure has been shown to decrease the incidences of stroke, heart attack, and heart failure (1,2). This report provides 2017-2018 U.S. hypertension prevalence estimates using the 2017 American College of Cardiology and American Heart Association definition of hypertension (3) and new guidelines, which redefine hypertension by lowering the previous threshold levels of 140/90 mmHg to 130/80 mmHg (4). This change categorizes a greater percentage of people as having hypertension.

Mean mid-arm circumference and blood pressure cuff sizes for US children, adolescents and adults: National Health and Nutrition Examination Survey, 2011-2016.

BACKGROUND: Measuring blood pressure (BP) requires an appropriate BP cuff size given measured mid-arm circumference (mid-AC). OBJECTIVE: To provide mid-AC means and percentiles for US population aged more than 3 years and examine the frequency distribution of mid-AC cuffed by Baum and Welch Allyn cuff systems. PATIENTS AND METHODS: The 2011-2016 National Health and Nutrition Examination Survey, a cross-sectional survey, was used to estimate mean mid-AC (n=24 723). RESULTS: Mean mid-AC did not differ from 2011 to 2016 (31.0 vs. 31.3 cm, P>0.05). During 2011-2016, mean mid-AC was greater for males than females (32.0 vs. 30.4 cm, P<0.001) and was largest among adults 40-49 years (34.0 cm). Non-Hispanic Black persons had the largest mean mid-AC (32.0 cm) and non-Hispanic Asian persons the smallest (28.4 cm). Increased BMI was associated with increased mean mid-AC for those 3-19 years (normal, 22.0 cm and obese, 31.5 cm, P<0.001) and more than 20 years (normal, 28.2 cm and obese, 37.8 cm, P<0.001). Among those aged 8-17 years, high BP status was associated with a larger mean mid-AC (normotensive 26.1 cm vs. high BP 28.2 cm, P=0.001). Among adults aged 18 years and older, hypertension status was associated with a larger mean mid-AC (normotensive 32.4 cm vs. hypertensive 34.2 cm, P<0.001). Among those aged 12-19 years, 13.0% required a Baum large cuff (35-46.9 cm mid-AC) and 21.7% required a Welch Allyn large cuff (32-39.9 cm mid-AC). Among those aged more than 20 years, 33.2% required a Baum large cuff, 48.2% required a Welch Allyn large cuff, 1.3% required a Baum extra-large cuff (44-66 cm mid-AC), and 9.5% required a Welch Allyn extra-large cuff (40-55 cm mid-AC). CONCLUSION: Currently, BP is obtained in clinic, pharmacy, home, and ambulatory setting using single or multiple cuffs. National Health and Nutrition Examination Survey mid-AC data should be considered for accurate cuffing avoiding cuff hypertension or hypotension.

Factors Associated With Hypertension Control in US Adults Using 2017 ACC/AHA Guidelines: National Health and Nutrition Examination Survey 1999-2016.

BACKGROUND: Factors and trends associated with hypertension control (BP < 130/80 mm Hg) and mean blood pressure (BP) among hypertensive adults (BP ≥1 30/80 mm Hg or medicated for hypertension). METHOD: Data on 22,911 hypertensive US adults from the 1999-2016 National Health and Nutrition Examination Survey. RESULTS: For men, hypertension control prevalence increased from 8.6% in 1999-2000 to 16.2% in 2003-2004 (P < 0.001), and continued the increasing trend afterwards to 23.2% in 2011-2012 (P < 0.001) and then plateaued. For women, hypertension control prevalence increased from 1999-2000 to 2009-2010 (10.8-26.3%, P < 0.001) and then plateaued. For men with hypertension, systolic BP decreased from 1999-2000 to 2011-2012 (135.7-132.8 mm Hg, P < 0.001) and then increased to 135.3 mm Hg in 2015-2016 (P < 0.001). For women with hypertension, systolic BP decreased from 1999-2000 to 2009-2010 (139.7-131.9 mm Hg; P < 0.001) and then increased to 134.4 mm Hg in 2015-2016 (P = 0.003). Diastolic BP decreased from 1999-2000 to 2015-2016 (men: 79.1-75.5 mm Hg and women: 76.4-73.7 mm Hg, P < 0.001 for both). In 2011-2016, hypertension control was 22.0% for men and 25.2% for women. The adjusted prevalence ratio (PR) of hypertension control were lower for non-Hispanic black men and women (PR = 0.72, 95% confidence interval (CI) = 0.61-0.86; PR = 0.83, 95% CI = 0.70-0.99, respectively; non-Hispanic white (NHW) as reference), Hispanic and non-Hispanic Asian men (PR = 0.70, 95% CI = 0.54-0.92; PR = 0.59, 95% CI = 0.39-0.86; respectively; NHW as reference). CONCLUSION: Hypertension control significantly increased from 1999-2000 to 2011-2012 (men) and 2009-2010 (women) and then plateaued. About a quarter of US adults with hypertension were controlled in 2011-2016.

Factors Associated With Home Blood Pressure Monitoring Among US Adults: National Health and Nutrition Examination Survey, 2011-2014.

BACKGROUND: Home blood pressure monitoring (HBPM) has a substantial role in hypertension management and control. METHODS: Cross-sectional data for noninstitutionalized US adults 18 years and older (10,958) from the National Health and Nutrition Examination Survey (NHANES), years 2011-2014, were used to examine factors related to HBPM. RESULTS: In 2011-2014, estimated 9.5% of US adults engaged in weekly HBPM, 7.2% engaged in monthly HBPM, 8.0% engaged in HBPM less than once a month, and 75.3% didn't engage any HBPM. The frequency of HBPM increased with age, body mass index, and the number of health care visits (all, P < 0.05). Also, race/ethnicity (Non-Hispanic Blacks and non-Hispanic Asians), health insurance, diagnosed with diabetes, told by a health care provider to engage in HBPM, and diagnosed as hypertensive, were all associated with more frequent HBPM (P < 0.05). Adjusting for covariates, hypertensives who were aware of, treated for, and controlled engaged in more frequent HBPM compared to their respective references: unaware (odds ratio [OR] = 2.00, 95% confidence interval [CI] = 1.53-2.63), untreated (OR = 1.99, 95% CI = 1.52-2.60), and uncontrolled (OR = 1.42, 95% CI = 1.13-1.82). Hypertensive adults (aware/unaware, treated/untreated, or controlled/uncontrolled), who received providers' recommendations to perform HBPM, were more likely to do so compared to those who did not receive recommendations (OR = 8.04, 95% CI = 6.56-9.86; OR = 7.98, 95% CI = 6.54-9.72; OR = 8.75, 95% CI = 7.18-10.67, respectively). CONCLUSIONS: Seventeen percent of US adults engaged in monthly or more frequent HBPM and health care providers' recommendations to engage in HBPM have a significant impact on the frequency of HBPM.

Comparison of blood pressure measurements obtained in the home setting: analysis of the Health Measures at Home Study.

BACKGROUND: Automated blood pressure (BP) devices have been used in the home for self-management purposes and are increasingly being used in population-based research. Although these devices are convenient and affordable and may be used by inexperienced lay personnel, the potential impact of an examiner's skill level on the results needs to be evaluated quantitatively. The aim of this study was to compare BP measurements obtained in a home setting by personnel with healthcare experience with those obtained by personnel without healthcare experience. In addition, the percent agreement in high blood pressure (HBP) classification between the home BP measurement by the field interviewer (FI) and measurements obtained in a standardized environment was examined. METHODS: The Health Measures at Home Study was a pilot study carried out among 128 adult participants recruited from the National Health and Nutrition Examination Survey. The Health Measures at Home Study provided the opportunity to compare the BP values obtained with an automated device in a home setting by both experienced health technicians (HTs) with those obtained by FIs who had no healthcare experience. Differences between measurements obtained by the HT and measurements obtained by the FI were assessed using paired t-tests, Pearson's correlations, and Bland-Altman plots. Percent agreement and κ-statistics were used to assess agreement in HBP classification between examiners in the home. Measurements obtained by the FI were also compared with those obtained in the National Health and Nutrition Examination Survey mobile exam center (MEC) by a physician using percent agreement and κ-statistics. RESULTS: There was a high correlation in both systolic blood pressure (SBP; r=0.903) and diastolic blood pressure (DBP; r=0.894) between measurements obtained by HTs and those obtained by FIs. The mean SBP and DBP obtained by the FIs (SBP, 119.0±14.4 mmHg; DBP, 71.9±9.8 mmHg) were significantly higher than the HT measurements (SBP, 117.0±12.7 mmHg; DBP, 69.9.9±9.2 mmHg). In the home, the FI classified 11.7% as having HBP, whereas the HT classified 7.0%. The percent of individuals classified as having HBP by the physician in the MEC was 10.2% of the participants. CONCLUSION: Operationally, FIs could take BP measurements in the home; however, there were some differences between measurements obtained by the FI and HT. The absolute difference between measurements obtained by the FI and those obtained by the HT in the home showed that measurements obtained by the FI tended to be higher than the HT, but the magnitude of these differences was less than 5 mmHg. The HT classified 7.0% of HBP whereas the FI classified 11.7% of HBP. Similarly, the FI and the MEC physician classified a different percent of individuals with HBP. Further investigation is warranted to determine the cause of these small but significant absolute differences between measurements obtained by the FI and HT.

Blood pressure cuff comparability study.

BACKGROUND: Manufacturer-supplied blood pressure (BP) cuffs are part of the automatic oscillometric BP devices algorithm. MATERIALS AND METHODS: This study assessed the differences in BP values using the Omron HEM 907-XL (Omron) device with two types of cuffs: the Baum cuff (BC) and the supplied Omron cuff (OC). A sample of 102 adults participated in the study, 34 per cuff size (adult, large, and extra-large). After a 5-min resting period, three pairs of BP determinations (systolic and diastolic) were taken simultaneously on both arms. One arm was cuffed with a BC and the other arm was cuffed with an OC. The cuffs were switched to opposite arms after 5 min of rest. The order was decided randomly as to which cuff was applied to which arm first. RESULTS: The BP readings were highly correlated between the cuffs (systolic BP, r=0.98; diastolic BP, r=0.98). The overall mean differences (BC-OC) were 2.66 mmHg (SD=3.9 mmHg) for systolic BP (P<0.05) and 0.33 mmHg (SD=2.03 mmHg) for diastolic BP (P>0.05). Increased cuff size corresponded to increased differences in systolic BP values (adult: 1.51 mmHg; large: 2.56 mmHg; and extra-large: 3.9 mmHg; P<0.05). For diastolic BP values, a statistically significant difference was observed only for adult cuff size (difference=1.31 mmHg, SD=1.34 mmHg, P<0.05). CONCLUSION: Using a BC with the Omron could result in higher systolic BP readings and higher diastolic BP readings with the adult cuff size.

Collection and laboratory methods for dried blood spots for hemoglobin A1c and total and high-density lipoprotein cholesterol in population-based surveys.

BACKGROUND: The Health Measures at Home Study was a study designed to evaluate the feasibility of incorporating dried blood spots (DBS) collection into the National Health Interview Survey and to compare the proficiencies between field interviewers and health technicians in obtaining DBS. METHODS: DBS collection and venipuncture were attempted on 125 participants. The DBS were collected in the participant's home and venous blood was collected in the National Health and Nutrition Examination Survey (NHANES) mobile examination center. The DBS results were compared to venous results in the NHANES for the measurements of hemoglobin A1c (HbA1c) and total and high-density lipoprotein (HDL) cholesterol. RESULTS: Field interviewers and health technicians were able to collect the DBS for greater than 95% of participants. For DBS, health technicians and field interviewers were highly correlated for HbA1c (r=0.92) and total cholesterol (r=0.89), but not for HDL cholesterol (r=0.72). The DBS results of interviewers and health technicians compared to the venous method for HbA1c (r=0.90), but did not compare well for HDL cholesterol (r=0.64-0.66) and total cholesterol (r=0.65-0.67). CONCLUSION: DBS was comparable to venous HbA1c, but not for total and HDL cholesterol. Health technicians and field interviewers had similar performance for DBS methods, except HDL cholesterol.

Validating prediction equations for mid-arm circumference measurements in adults: National Health and Nutrition Examination Survey, 2001-2012.

BACKGROUND: Accurate measurement of blood pressure (BP) requires choosing an appropriate BP cuff size. OBJECTIVES: The objective of this study was to examine the validity of regression equations to predict mid-arm circumference (mid-AC) using 2001-2012 National Health and Nutrition Examination Survey height and weight data. METHODS: National Health and Nutrition Examination Survey uses a complex multistage probability sample design to represent the civilian, noninstitutionalized US resident population. The sample consisted of 29 745 participants aged 20 years and older. RESULTS: For both men and women, the correlations between the predicted and measured mid-AC values were as follows: r=0.91 and 0.92, P<0.001, respectively. For both sexes, the difference between the predicted and measured mid-AC mean values was less than 1.5 cm. The overall percent agreement for selecting the appropriate BP cuff, using the American Heart Association cuff size criteria and comparing the predicted mid-AC values with measured values, was 83.0% for men and 80.0% for women. The percent agreement for small adult cuff was 10.0% for men and 54.0% for women; for adult cuff it was 87.0% for men and 88.0% for women; for large adult cuff it was 82.0% for men and 80.0% for women; and for thigh cuff it was 84.0% for men and 74.0% for women. All agreement statistics were above chance (for men, γ=0.96, and Kendall's Tau-b=0.73; for women, γ=0.97, and Kendall's Tau-b=0.76). CONCLUSION: When possible, mid-AC should be directly measured for appropriate BP cuffing; however, the results of this validation study suggest that the prediction equations for mid-AC estimations were highly correlated and had an overall 80.0% agreement with measured mid-AC.

Trends in blood pressure among adults with hypertension: United States, 2003 to 2012.

The aim of this study is to describe trends in the awareness, treatment, and control of hypertension; mean blood pressure; and the classification of blood pressure among US adults 2003 to 2012. Using data from the National Health and Nutrition Examination Survey 2003 to 2012, a total of 9255 adult participants aged ≥18 years were identified as having hypertension, defined as measured blood pressure ≥140/90 mm Hg or taking prescription medication for hypertension. Awareness and treatment among hypertensive adults were ascertained via an interviewer administered questionnaire. Controlled hypertension among hypertensive adults was defined as systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg. Blood pressure was categorized as optimal blood pressure, prehypertension, and stage I and stage II hypertension. Between 2003 and 2012, the percentage of adults with controlled hypertension increased (P-trend <0.01). Hypertensive adults with optimal blood pressure and with prehypertension increased from 13% to 19% and 27% to 33%, respectively (P-trend <0.01 for both groups). Among hypertensive adults who were taking antihypertensive medication, uncontrolled hypertension decreased from 38% to 30% (P-trend <0.01). Similarly, a decrease in mean systolic blood pressure was observed (P-trend <0.01); however, mean diastolic blood pressure remained unchanged. The trend in the control of blood pressure has improved among hypertensive adults resulting in a higher percentage with blood pressure at the optimal or prehypertension level and a lower percentage in stage I and stage II hypertension. Overall, mean systolic blood pressure decreased as did the prevalence of uncontrolled hypertension among the treated hypertensive population.

Comparison of in-home collection of physical measurements and biospecimens with collection in a standardized setting: the health measures at home study.

OBJECTIVES: Collection of physical measurements and biospecimens in the home may be an efficient way to obtain objective health measurements. This study assesses differences between collection in the home and a standardized setting. METHODS: Participants had physical measurements and biospecimens taken in the National Health and Nutrition Examination Survey mobile examination center (MEC). Then, they had height and weight measured in the MEC using portable equipment. In the home, participants had height, weight, and blood pressure measured and dried blood spots collected using portable equipment. Two complete examinations were done in the home: one by a health technician and one by a field interviewer. RESULTS: Home environments were less standardized and presented more challenges to examiners. Correlations between all four height measurements and all four weight measurements were higher than 99%. Mean differences in height (0.3 cm) and weight (0.4 kg) were small but statistically significant. The home measurements perfectly or near-perfectly classified participants as obese relative to the standardized MEC examination. CONCLUSIONS: The selected physical measurements can be collected in the home by field interviewers using portable equipment. Before adding home collection of physical measurements to household interview surveys, further research should be done to examine the impact of these changes on interviewer training, participant recruitment, and participant response rates.

Mid-arm circumference and recommended blood pressure cuffs for children and adolescents aged between 3 and 19 years: data from the National Health and Nutrition Examination Survey, 1999-2010.

BACKGROUND: Accurately measuring blood pressure (BP) requires choosing an appropriate BP cuff size. OBJECTIVES: This study examined trends in mid-arm circumference (mid-AC) and in the distribution of appropriate BP cuffs using 1999-2010 National Health and Nutrition Examination Survey (NHANES) data. METHODS: NHANES uses a complex multistage probability sample design to select participants who are representative of the entire civilian, noninstitutionalized US population. The analytic sample consisted of 21 350 participants aged between 3 and 19 years at the time of examination. The mean mid-AC and the percentage of children requiring recommended BP cuff sizes were analyzed across survey years and by sex, age, race/ethnicity, and age-specific and sex-specific BMI categories. RESULTS: During NHANES 1999-2010, the overall trend in mean mid-AC in cm for boys and girls was not significant. During NHANES 2007-2010, 24% of boys aged between 9 and 11 years, 53% of boys aged between 12 and 15 years, and 89% of boys aged between 16 and 19 years required a standard adult cuff or larger to be cuffed correctly. Corresponding estimates for girls were 22, 48, and 57%, respectively. During NHANES 2007-2010, 30.4% of obese boys and 24.3% of obese girls required a large adult cuff and 2.1% of obese boys and 0.9% of obese girls required a thigh cuff for appropriate cuffing. CONCLUSION: During NHANES 2007-2010, 20% of boys and girls as young as 9-11 years required a standard adult cuff to be cuffed appropriately. In addition, approximately one-third of obese participants required adult large BP cuffs to be cuffed appropriately.

Hypertension among adults in the United States: National Health and Nutrition Examination Survey, 2011-2012.

The overall prevalence of hypertension has not changed appreciably since 2009-2010. The age-adjusted prevalence of hypertension among U.S. adults was 29.1% in 2011-2012. Among adults with hypertension in 2011-2012, 82.8% were aware of their hypertension, 75.7% were currently taking medication to lower their blood pressure, and 51.9% had their blood pressure controlled to less than 140/90 mm Hg. Men and women had similar prevalence and awareness of hypertension, but more women than men were treating their hypertension and had it under control. Young adults aged 18-39 continued to have lower awareness, treatment, and control of their hypertension compared with older adults. Hypertension prevalence was still highest among non-Hispanic black adults. However, awareness, treatment, and control of hypertension were similar among non-Hispanic black, non-Hispanic white, and Hispanic adults. Non-Hispanic Asian adults had a lower prevalence of awareness than the other race and Hispanic origin groups, and lower treatment than non-Hispanic white and non-Hispanic black adults. However, hypertension control was similar among non-Hispanic Asian adults and the other race and Hispanic origin groups. Hypertension is a common and manageable chronic condition. Based on recent national data from 2011-2012, treatment of hypertension exceeded the Healthy People 2020 target goal of 69.5%. However, the control of hypertension has neither met the goal of the Healthy People 2020 (61.2% by 2020) nor the Million Hearts Initiative (65% by 2017). These results provide evidence for continued efforts to improve the management of hypertension in order to attain these goals.

Mean mid-arm circumference and blood pressure cuff sizes for U.S. adults: National Health and Nutrition Examination Survey, 1999-2010.

BACKGROUND: Accurately measuring blood pressure (BP) requires choosing an appropriate BP cuff size. OBJECTIVES: This study examined trends in mid-arm circumference (mid-AC) and distribution of BP cuff sizes using 1999-2002, 2003-2006, and 2007-2010 National Health and Nutrition Examination Survey (NHANES) data. METHODS: NHANES uses a complex multistage probability sample design to select participants who are representative of the entire civilian, noninstitutionalized US population. The analytic sample consisted of 28 233 participants aged 20 years or older. Mid-AC and BP cuff sizes were analyzed across survey years by sex, age, race/ethnicity, hypertension, and diabetic status. RESULTS: Data from NHANES 2007-2010 show that the mean mid-AC for men was 34.2 cm and for women was 31.9 cm. Men showed a significant trend in mid-AC (from 33.9 cm in 1999-2002 to 34.2 cm in 2007-2010; P<0.05 for trend). In addition, 42.9% of men and 25.3% of women needed a large adult BP cuff and 1.9% of men and 2.8% of women needed thigh cuffs to be appropriately cuffed. Moreover, 52% of hypertensive men, 38% of hypertensive women, 59.1% of diabetic men, and 53.6% of diabetic women required the use of BP cuffs with sizes different from those of standard adult-sized BP cuffs for accurate BP measurement. CONCLUSION: There was an overall significant trend in the mean mid-AC in cm for men but not for women. On the basis of NHANES 2007-2010 data, ∼45% of adult men and ∼28% of adult women required the use of BP cuffs with sizes different from those of standard adult-sized BP cuffs for accurate BP measurement.

Blood pressure randomized methodology study comparing automatic oscillometric and mercury sphygmomanometer devices: National Health and Nutrition Examination Survey, 2009-2010.

OBJECTIVES: The mercury sphygmomanometer has been the gold standard used for obtaining blood pressure (BP) for the National Health and Nutrition Examination Survey (NHANES) from 1960 to the present. However, due to environmental concerns and an increased use of automated oscillometric BP devices, NHANES has been exploring an alternative to using the standard mercury sphygmomanometer (mercury) to measure BP. METHODS: The accuracy of Omron HEM-907XL BP readings was compared with that of mercury BP device readings for gender, age group, race and ethnicity, and body mass index categories and cuff-size subgroups. Each person had three BP measurements per device recorded sequentially. The order of the devices and readers were randomly assigned. A total of 6,460 participants had three valid systolic readings, and 6,338 had three valid diastolic readings. RESULTS: Omron and mercury measurements were correlated (r = 0.92, systolic BP; r = 0.79, diastolic BP). Overall, the mean between-device differences (Omron and mercury) were -1.6 mm Hg for systolic and -0.6 mm Hg for diastolic (p < 0.05 for both). The mean between-device differences were less than or about 2 mm Hg for each subgroup: gender, age group, race and ethnicity, and body mass index categories, and cuff-size subgroups. The exceptions were mean systolic between-device differences for those using the extra-large BP cuff (-3.1 mm Hg) and obese individuals (-2.6 mm Hg), and the mean diastolic between-device differences for the underweight group (-3.5 mm Hg). Assuming mercury to be the gold standard, between-device agreements for the frequency of high BP (140/90 mm Hg or more) and stage II high BP (160/100 mm Hg or more) were above chance (kappa = 0.72 for both). Omron underestimated the high BP frequency by 2.28% and stage II high BP frequency by 0.77%. CONCLUSIONS: Lower estimates of high BP by the Omron device may require adjusting future national prevalence estimates accordingly to account for between-device differences.

Resting pulse rate reference data for children, adolescents, and adults: United States, 1999-2008.

OBJECTIVE: This report presents national reference data on resting pulse rate (RPR), for all ages of the U.S. population, from 1999-2008. METHODS: During 1999-2008, 49,114 persons were examined. From this, a normative sample comprising 35,302 persons was identified as those who did not have a current medical condition or use a medication that would affect the RPR. RPR was obtained after the participant had been seated and had rested quietly for approximately 4 minutes. RESULTS: RPR is inversely associated with age. There is a mean RPR of 129 beats per minute (standard error, or SE, 0.9) at less than age 1 year, which decreases to a mean RPR of 96 beats/min (SE 0.5) by age 5, and further decreases to 78 beats/min (SE 0.3) in early adolescence. The mean RPR in adulthood plateaus at 72 beats/min (SE 0.2) (p < 0.05 for trend). In addition, there is a significant gender difference, with the male pulse rate plateauing in early adulthood, while the female resting pulse plateaus later when middle-aged. There are two exceptions, that is, infants under age 1 year and adults aged 80 and over, when the mean RPR is statistically and significantly higher in females than in males (females under age 20 have an RPR of 90 beats/min, SE 0.3, and males under age 20 have an RPR of 86 beats/min, SE 0.3, p <0.05; females aged 20 and over have an RPR of 74 beats/min, SE 0.2, and males aged 20 and over have an RPR of 71 beats/min, SE 0.3, p <0.05). After controlling for age effects, non-Hispanic black males have a significantly (p <0.001) lower mean RPR (74 beats/min) than non-Hispanic white males (77 beats/min) and Mexican-American males (76 beats/min). Among females, non-Hispanic black females (79 beats/min) and Mexican-American females (79 beats/min) had statistically and significantly (p < 0.01) lower mean RPRs compared with non-Hispanic white females (80 beats/min). Among males, the prevalence of clinically defined tachycardia (abnormally fast heart rate, RPR 100 beats/min) is 1.3% (95% CI = 1.1-1.7), and the prevalence of clinically defined bradycardia (abnormally slow heart rate, RPR < 60 beats/min) is 15.2% (95% CI = 14.1-16.4). For adult females, these prevalences are 1.9% (95% CI = 1.6-2.3) for clinical tachycardia and 6.9% (95% CI = 6.2-7.8) for clinical bradycardia. Controlling for age, males have higher odds (2.43, 95% CI = 2.09-2.83) of having bradycardia, and notably lower odds (0.71, 95% CI = 0.52-0.97) of having tachycardia than women. CONCLUSIONS: The data provides current, updated population-based percentiles of RPR, which is one of the key vital signs routinely measured in clinical practice.

Mean systolic and diastolic blood pressure in adults aged 18 and over in the United States, 2001-2008.

OBJECTIVE: This report presents estimates for the period 2001-2008 of means and selected percentiles of systolic and diastolic blood pressure by sex, race or ethnicity, age, and hypertension status in adults aged 18 and over. METHODS: Demographic characteristics were collected during a personal interview, and blood pressures were measured during a physician examination. All estimates were calculated using the mean of up to three measurements. The final analytic sample consisted of 19,921 adults aged 18 and over with complete data. Examined sample weights and sample design variables were used to calculate nationally representative estimates and standard error estimates that account for the complex design, using SAS and SUDAAN statistical software. RESULTS: Mean systolic blood pressure was 122 mm Hg for all adults aged 18 and over; it was 116 mm Hg for normotensive adults, 130 mm Hg for treated hypertensive adults, and 146 mm Hg for untreated hypertensive adults. Mean diastolic blood pressure was 71 mm Hg for all adults 18 and over; it was 69 mm Hg for normotensive adults, 75 mm Hg for treated hypertensive adults, and 85 mm Hg for untreated hypertensive adults. There was a trend of increasing systolic blood pressure with increasing age. A more curvilinear trend was seen in diastolic blood pressure, with increasing then decreasing means with age in both men and women. Men had higher mean systolic and diastolic pressures than women. There were some differences in mean blood pressure by race or ethnicity, with non-Hispanic black adults having higher mean systolic and diastolic blood pressures than non-Hispanic white and Mexican-American adults, but these differences were not consistent after stratification by hypertension status and sex. CONCLUSIONS: These estimates of the distribution of blood pressure may be useful for policy makers who are considering ways to achieve a downward shift in the population distribution of blood pressure with the goal of reducing morbidity and mortality related to hypertension.