Shakia Hardy, PhD, MPH, is an associate professor in the department of epidemiology at the University of North Carolina at Chapel Hill.

Shakia Hardy, PhD, MPH

Shakia Hardy, PhD, MPH | Image Credit: UNC Gillings School of Global Public Health

 were not taking antihypertensive medication, despite having a systolic blood pressure (SBP) and diastolic blood pressure (DBP) within 10 mmHg of the 2025 American Heart Association/American College of Cardiology (AHA/ACC) goal, according to a recent study.

Investigators utilized data from the National Health and Nutrition Examination Survey (NHANES) 2021-2023 data. The team included patients aged ≥20 years with hypertension, defined as SBP ≥130 mmHg or DBP ≥80 mmHg, or self-reported use of antihypertensive medication. Uncontrolled blood pressure was defined as SBP ≥130 mmHg or DBP ≥80 mmHg.

A total of 3216 patients were included, of whom an estimated 79.1% (95% CI, 77.2-81.1%) had uncontrolled blood pressure. Of these, roughly 61.3% (95% CI, 58.8-63.9%) were not taking antihypertensive medication. Those not taking antihypertensive medication were younger (estimated mean age, 49.2 vs 62.4 years; 

 <.001) and were less likely to have health insurance (88.8% vs 95.1%; 

 <.001), a routine place for health care (83% vs 95.9%; 

Additionally, patients with uncontrolled blood pressure who were taking antihypertensive medication were substantially more likely to have SBP or DBP above goal by ≥10 mmHg (52.6% vs 34.6%; 

For further insight into these data, we spoke with Shakia T. Hardy, PhD, MPH, associate professor in the department of epidemiology at the University of North Carolina at Chapel Hill, in the following Q&A:

 Could you provide a brief overview of your study and its findings?

: We conducted a study that was somewhat motivated by the new 2025 AHA and ACC blood pressure guidelines, and we really wanted to see where the US population was in relation to the new thresholds. So, our study was partially motivated by that, but also by our desire to understand how close people were to that threshold. We often describe blood pressure control in terms of a proportion, but we don't really characterize how far away from that goal people are. So we found that 8 in 10 US adults who had hypertension had uncontrolled blood pressure, and the vast majority of those were not taking antihypertensive medication, and those that were not taking medication were closer to goal. So, we felt like they could easily achieve the treatment goal with the initiation of antihypertensive medication or lifestyle modifications. What I think was most unique about what we found that we didn't necessarily expect was that 80% of those who had blood pressure above goal that were uncontrolled had access to health care. They had health insurance, and they had a regular place to go for care, yet they weren't treated with antihypertensive medications.

 Do you view these findings as a failure of detection, treatment, initiation, intensification, or health system follow-through? Or is it really all of the above?

: I think it's really all of the above. We didn't look at awareness in this study, but oftentimes, once we do, we see that most people are aware. I don't know that it's necessarily a lack of awareness or access to care. I think it is more about the way people are managed within care systems. I think there should be a larger focus, from the clinician standpoint, on initiating medication earlier and titrating medication when people are not reaching blood pressure goals.

 Based on these data, younger adults with uncontrolled blood pressure were much less likely to be treated. How should clinicians rethink hypertension risk communication for patients in their 40s and 50s?

 I think we as a society have come to think of hypertension as a disease of older age, and more recent evidence suggests that hypertension is beginning as early as adolescence for a lot of people, and by middle age, when people are above the threshold. I think the common way of handling that has been to wait and see if blood pressure rises more, as opposed to managing it when it's around the threshold for treatment. From my perspective, I would hope that people were treated earlier, once their blood pressure is consistently above the threshold used for defining hypertension and qualifying people for anti-hypertensive medication.

: Among those already on therapy, a large portion were still ≥10 or ≥20 mmHg above goal. What does this tell us about the need for combination therapy and rapid titration?

 Recent evidence has suggested that a lot of people are still being initiated on monotherapy, even though there's strong evidence that suggests combination therapy is necessary for most people to achieve control. I would hope that titration, whether it's increasing dosage on the medication that people were initiated on or trying combination therapy, would happen earlier in the treatment process than it is currently happening.

 How much of this problem do you believe reflects clinical inertia versus patient-level barriers, such as cost concerns, side effects, or risk perception?

 I don't think it's a cost barrier; anti-protection medications are not that expensive. I do think it might be some patient hesitancy. I've talked to several clinicians who say that their patients are really familiar with the 140/90 threshold for blood pressure, and they're hesitant to bring their blood pressure lower than that. I think part of it might be patient awareness, education, and the desire for their blood pressure to be lower, but I also think part of it is clinical inertia.

 The study highlighted dementia risk as well as cardiovascular risk. Do you believe that framing blood pressure control as “brain protection” might change patient engagement?

 I would hope so. Dementia is a very popular topic right now that people are aware of, and I think it is an outcome that a lot of us fear. I think the risk of dementia being increased with uncontrolled blood pressure might make people rethink whether they want their blood pressure to be lowered. People might be hesitant to take more medications to lower their blood pressure. I think if we emphasize the risk of dementia more, it might convince people that blood pressure lowering is a good thing.

 Which patient populations do you think are the most vulnerable to being left behind by guideline-based hypertension care, and how can future research address that?

 I think it's young adults. There's a lack of evidence for hypertension treatment among the young adult population. And I think because of that, clinicians are hesitant to start young adults on antihypertensives when we don't have the clinical trial data to support it. But then, to look at the long-term implications of that, I am most concerned about the young adult population. In our study, you can see that those who are not on medication were more likely to be younger. I'm most concerned about them being left behind in the long term, and what that means for their cardiovascular disease and dementia risk.

Editor’s Note: Hardy reports no relevant disclosures.

Hardy ST, Jaeger BC, Emanuel E, Muntner P. Blood pressure above goal among US adults with hypertension. JAMA. Published online February 2, 2026. 

Writing Committee Members*, Jones DW, Ferdinand KC, et al. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2025;152(11):e114-e218. 

Articles

NHANES 2021–2023 data indicate that hypertension control remains poor relative to 2025 AHA/ACC targets: ~79% of US adults with hypertension had SBP/DBP ≥130/80. Among those uncontrolled, ~61% were untreated and tended to be younger, less insured, and less connected to routine care, yet most still had healthcare access. Untreated individuals were often within 10 mmHg of goal, suggesting high leverage for early initiation and lifestyle intervention. Treated patients more frequently remained ≥10–30 mmHg above goal, implicating undertitration and insufficient combination therapy.

Hardy discussed the disparity between treatment access and usage, highlighting the fact that most patients are within 10 mmHg of guideline recommendations.