2015 HYPERTENSION AND RESISTANT HYPERTENSION DISEASE DYNAMICS REPORT

2015 Analysis

OVERVIEW:
In this report, Dymedex provides a detailed landscape of diseases far beyond what is currently available in the public domain. While individual clinical papers provide specific snapshots of a disease or strive to understand its epidemiology or other dimensions, no single clinical paper attempts to aggregate the hundreds of pieces of information that exist about a given disease and synthesize them into an integrated perspective. This report details the progression of a patient from undiagnosed hypertension, through diagnosis and drug titration, to possible resistant disease. It quantifies and diagrams the overlap of multiple comorbidities within each of these patient segments, as well as the underlying incidence and prevalence of resistant hypertension, and describes the portion of hypertensive patients currently being diagnosed and optimally treated.

Contents include:
  • Synthesis of over 125 peer-reviewed studies into a single report
  • Detailed analysis of hypertension and resistant hypertension patient population
  • Prevalence, Incidence and Duration of hypertension and resistant hypertension in the United States, as well as important subsegments of these populations
  • Forecasts through 2024 based on dynamics of underlying hypertension patient population
The scope of this report includes a detailed description and quantification of the hypertension and resistant hypertension populations in the United States.  Patient dynamics discussed in detail include comorbidities, the aging population, the effect of improved diagnostic and titration capabilities, and the effects of various hypertension measurement techniques. 

TABLE OF CONTENTS:
1 Table of Contents
 
List of Figures and Tables 

2 Introduction
 
2.1 Dymedex Methods 

3 Summary of Key Insights

4 Executive Summary

5 Key Segments and Intersections of the Hypertension Landscape

5.1 The 30,000-foot view of Hypertension
5.2 Classification of Blood Pressure & Diagnosis of Hypertension 
	5.2.1 Blood Pressure Measurement in The Clinic 
	5.2.2 Ambulatory and Home Blood Pressure Measurement 
	5.2.3 Summary of Blood Pressure Measurement 
	5.2.4 Blood Pressure Classification 
	5.2.5 Normal Blood Pressure 
	5.2.6 Hypotension 
	5.2.7 Pre-hypertension 
	5.2.8 Current segmentation of the Hypertension Population 
5.3 Types of Hypertension 
	5.3.1 Primary Causes of Hypertension 
	5.3.2 Secondary Causes of Hypertension 
	5.3.3 How the 'White Coat' effect changes our impression of the Hypertension landscape 
	5.3.4 Why the resistant hypertension Landscape is complex and Heterogenous 
	5.3.5 Summary of Types of Hypertension
 
Key Insights into the hypertension landscape
 
6 Management of Hypertension Patients in the United States Today
 
6.1 Management of patients with hypertension 
6.2 Current treatments - how sub-optimal diagnostics affect a patient's treatment 
	6.2.1 The effect of lifestyle modifications on hypertensive patients 
	6.2.2 Antihypertensive Drug Treatment 
6.3 How emerging therapies will be adopted into the hypertension patient care continuum 
	6.3.1 Renal Denervation 
	6.3.2 BARORECEPTOR ACTIVATION THERAPY 
	6.3.3 Arteriovenous Fistula 
	6.3.4 Carotid Body Modulation 

Key Insights into the Management and Treatment of Hypertension 

7 Incidence, Prevalence, and Duration of Hypertension in the United States
 
7.1 Consensus view on hyertensive prevalence in the United States 
	7.1.1 Trends in Prevalence by Age, and how the baby boom will skew the hypertension demographic 
	7.1.2 How the hypertension rates by gender shift as we age 
	7.1.3 The surprising trends in hypertension rates by ethnicity 
7.2 Surprising changes in hypertension duration based on disease status 
7.3 An unexpectedly low annual incidence of hypertension in the United States 
	7.3.1 Trends in Hypertension Incidence by Gender and Ethnicity 
7.4 The heavy burden of comorbidities on individuals with hypertension 
7.5 How the future epidemiology of hypertension is more positive than expected 

Key Insights into Hypertension Epidemiology
 
8 A Comprehensive Breakdown of Controlled, Uncontrolled, and Untreated hypertension
 
8.1 Untreated hypertension patients are common, and some will never be treated 
8.2 How treatment dynamics affect control rate of hypertension patients 
8.3 The severity of uncontrolled hypertension 
8.4 The annuual Incidence and average Duration of Treated vs. Untreated Hypertension 
8.5 Controlled, Uncontrolled, and Untreated Hypertension in a single view 

Key Insights into controlled, uncontrolled, and untreated hypertension
 
9 Resistant Hypertension:  A Complex and Heterogeneous Clinical Classification
 
9.1 Diagnosing and Defining Resistant Hypertension 
	9.1.1 Diagnosed vs. Undiagnosed Apparent Resistant Hypertension 
	9.1.2 Understanding Controlled vs. Uncontrolled Resistant Hypertension 
	9.1.3 Key Subsegments of Apparent Resistant Hypertension 
	9.1.4 Segment Map of the Apparent Resistant Hypertension Landscape 
9.2 What proportion of the resistant hypertension population remains Undiagnosed? 
9.3 Prevalence of Resistant Hypertension 
	9.3.1 Prevalence of Undiagnosed and Diagnosed Apparent Resistant Hypertension 
	9.3.2 Prevalence of True Secondary Conditions 
	9.3.3 Prevalence of White-coat hypertension 
9.4 The Surprising Conclusion About Resistant Hypertension Treatment 
9.5 The Annual Incidence of Apparent REsistant Hypertension 
9.6 How Age and Ethnicity affect Resistant Hypertension 
9.7 The significant correlation between resistance and comorbidities 
9.8 Resistant hypertension significantly reduces life expectancy 
9.9 A complete view of resistant hypertension 

Key Insights into resistant hypertension
 
10 Unexpected ways in which hypertension will grow in the coming decade
 
Key questions
 
10.1 Aging Population 
10.2 Treatment Rate 
10.3 Increased Drug Titration and Patient Adjudication 

Key Insights into hypertension disease dynamics
 
11 Forecasts for Hypertension Segments Through 2024
 
Key questions
 
11.1 Hypertension incidence & prevalence Forecast 
11.2 Forecasting the Treated vs. Untreated population 
11.3 Forecasting Controlled vs. Uncontrolled Hypertension 
11.4 Forecasting the overlapping dynamics of Resistant Hypertension 

Key Insights from Hypertension forecasts
 
12 Key Insights for Hypertension Treatment & Management
 
12.1 Improved Hypertension Diagnosis and Screening 
12.2 Improved Condition Management, Drug Titration, and Diagnostic Resolution 
12.3 Improved Identification of Resistant Hypertension 
12.4 The Evolving Hypertension Landscape 
12.5 Resource Utilization 
12.6 Lifetime Costs of Patients 
12.7 Future Economic Impact 

13 Appendix A: Graphic Summary of Hypertension Segmentation
 
14 Appendix B:  Graphic Summary of Resistant Hypertension Segmentation
 
15 Appendix C: Bibliography
 
16 Appendix D: About Dymedex
 
17 Appendix E: Dymedex methodology
 
18 Appendix F: Updated Hypertension Guidelines JNC-8
 
19 Appendix G: Glossary
 
LIST OF FIGURES AND TABLES:

Figure 1: Executive Summary - Hypertension Landscape 
Figure 2: Hypertension Comorbidities Map 
Figure 3: Resistant Hypertension Comorbidities Map 
Figure 4: Physiologic Systems Involved in BP Regulation 
Figure 5: Summary of the Various Etiologies and Multifactorial Pathophysiology of Hypertension 
Figure 6: Organ-specific Complications Associated With Hypertension 
Figure 7: Classifications within the Current HTN Population 
Figure 8: Secondary Hypertension v. Exacerbating Conditions 
Figure 9: Overall Hypertension Classification Landscape 
Figure 10: Treatment Flow for Hypertension Population 
Figure 11: Illustration of Optimal Anti-Hypertension Medication Titration Model 
Figure 12: Illustration of how antihypertensive medication drug classes target organ sites of action 
Figure 13: Illustration of the Mechanisms of Action of the Five Main Antihypertensive Drug Classes 
Figure 14: Anti-Hypertension Drug Classes 
Figure 15: Hypertension Incidence, Prevalence and Duration Dynamics 
Figure 16: Incidence, Prevalence, and Duration of Hypertension among U.S. Adults, 2014 
Figure 17: Historical Prevalence of Hypertension in the United States, NHANES 1988-2008 
Figure 18: Prevalence Rate of Hypertension by Age Group, NHANES 1999-2008 
Figure 19: 2014 Hypertension Prevalence Segmented by 10-year Age Groups 
Figure 20: Prevalence Rate of Hypertension by Age Group and Gender, NHANES 1999-2004 
Figure 21: Distribution by Age of Hypertension Prevalence, Separated By Gender, 2014 
Figure 22: Distribution by Gender of Hypertension Prevalence, by 10 Year Age Group 
Figure 23: Hypertension Prevalence in Non-Hispanic Whites, Non-Hispanic Blacks, Non-Hispanic Asians, and Hispanics ≥18 years old 
Figure 24: Differences in Hypertension Prevalence Rates across Ethnicity and Age 
Figure 25: Incidence Rate of Hypertension by Age Group, 2014 
Figure 26: Size of the 2014 U.S. Hypertension Incidence Population Segmented by 10-Year Age Groups 
Figure 27: Distribution of Incident Hypertension Patients by Age and Gender (Daugherty, 2011) 
Figure 28: Comparison of Hypertension Incidence Rate by Age and Ethnicity, 2014 
Figure 29: Age Distribution of Hypertension Incidence vs. Prevalence, 2014 
Figure 30: Size of the Hypertension Prevalence vs. Incidence Populations by Age, 2014 
Figure 31: Rates of Individual Comorbidities among the Hypertension Population 
Figure 32: Overlap of Comorbidities in Hypertension 
Figure 33: Comorbidity Distribution of the Hypertension Population 
Figure 34: Summary of the Controlled, Uncontrolled, and Untreated Hypertension Prevalence and Incidence, 2014 
Figure 35: Distribution of the Total Hypertension Population by Treatment and Control Status, 2014 
Figure 36: Hypertension Treatment and Control Rates by Age Groups, NHANES 2005-2008 
Figure 37: Ethnic Differences in Control Rates among Treated Patients, NHANES 2005 - 2008 
Figure 38: Distribution of Stage 1 vs. Stage 2 Hypertension by Number of Prescribed Antihypertensive Medications 
Figure 39: Distribution of Stage 2 Hypertension by Number of Prescribed Antihypertensive Medications 
Figure 40: Distribution of Controlled vs. Uncontrolled vs. Untreated Hypertension in 2014 
Figure 41: Dymedex Titration Framework 
Figure 42: Undiagnosed Apparent Hypertension 
Figure 43: Degrees of Control within the Apparent Resistant Hypertension Population 
Figure 44: Pseudo-resistant Hypertension as Currently Defined in the Clinical Community 
Figure 45: White-coat and Resolvable Subsegments of Uncontrolled RHTN 
Figure 46: Key Subsegments of Apparent Resistant Hypertension 
Figure 47: Effects of Full Titration on the Currently Uncontrolled aRHTN Population 
Figure 48: Prevalence of Apparent Resistant Hypertension among Treated Hypertensive Adults, NHANES 1988-2008 
Figure 49: Distribution of Controlled vs. Uncontrolled Hypertension by Number of Prescribed Antihypertensive Medications 
Figure 50: Illustration of Drug Titration Model 
Figure 51: The Total Prevalence of Apparent Resistant Hypertension Stratified by Diagnostic State and Status of Blood Pressure Control 
Figure 52: Prevalence of Diagnosed and Undiagnosed Apparent Resistant Hypertension 
Figure 53: Prevalence of Resistant Hypertension Subsegments 
Figure 54: Apparent vs. True Resistant Hypertension 
Figure 55: The Complete Map of Resistant Hypertension Prevalence 
Figure 56: Mean Age of Diagnosed Resistant Hypertension vs. Treated Hypertension (Uncontrolled on < 3 drugs or Controlled < 4 drugs) 
Figure 57: Incidence and Duration of Hypertension and Resistant Hypertension 
Figure 58: Overview of the Incidence, Prevalence and Duration of Total and Resistant Hypertension, 2014 147
Figure 59: Mean Age of Resistant Hypertension vs. Uncontrolled, Controlled, and Untreated Hypertension, NHANES 2003-2008 
Figure 60: Distribution of Treated Hypertension Patients by Race, Control Status, and Number of Prescribed Antihypertensive Medications, NHANES 2005-2008 
Figure 61: Rates of Individual Comorbidities among the Resistant Hypertension Population Compared with Primary Hypertension 
Figure 62: Overlap of Major Comorbidities among the Resistant Hypertension Population 
Figure 63: Mean Age at Death for Hypertension Patients 
Figure 64: Prevalence, Incidence, Duration of Total Hypertension, Treated Hypertension, and Resistant Hypertension, 2014 
Figure 65: Projected Year-to-Year Growth of the Total Population (18+) vs. the Hypertension Population, 2014-2024 
Figure 66: Hypertension Prevalence Rates, NHANES 1988-2008, Dymedex Model 2012-2024 
Figure 67: Hypertension Treatment Rates, NHANES 1988-2008, Dymedex Model 2012-2024 
Figure 68: Treated and Uncontrolled Hypertension Rates, NHANES 1988-2008, Dymedex Model 2014-2024 
Figure 69: 10-Year Forecast of the Total Hypertension Prevalence, 2014-2024 
Figure 70: 10-Year Forecast of the Prevalence of Hypertension by Age Group, 2014-2024 
Figure 71: 10-Year Forecast of the Total Hypertension Incidence, 2014 -2024 
Figure 72: Comparison of the 10-Year Total Hypertension Prevalence Projections of the Dymedex Model vs. Current Standard of Care, 2014-2024 
Figure 73: 10-Year Forecast of the Treated and Untreated Hypertension Prevalence, 2014-2024 
Figure 74: 10-Year Forecast of the Treated and Untreated Hypertension Incidence, 2014-2024 
Figure 75: Distribution of Controlled and Uncontrolled Hypertension Prevalence, 2014-2024 
Figure 76: 10-Year Forecast of the Uncontrolled Hypertension Prevalence Segmented by Number of Prescribed Antihypertensive Medications, 2014-2024 
Figure 77: 10-Year Forecast of Controlled Hypertension Prevalence by Number of Prescribed Antihypertensive Medications, 2014-2024 
Figure 78: 10-Year Forecast for the Prevalence of Controlled and Uncontrolled Hypertension, 2014-2024 
Figure 79: 10-Year Forecast for the Prevalence of Controlled and Uncontrolled aRHTN, 2014-2024 
Figure 80: 10-Year Forecast for the Prevalence of Diagnosed and Undiagnosed aRHTN, 2014-2024 
Figure 81: 10-Year Forecast of Resistant Hypertension Sub-types 
Figure 82: Distribution of Diagnosed aRHTN Prevalence between Controlled, Uncontrolled, Resolvable Secondary Causes, and White-coat Resistance, 2014-2024 
Figure 83: 10-Year Forecast of the Incidence of Controlled and Uncontrolled Resistant Hypertension, Resistant Hypertension due to Resolvable Secondary Causes, 
and Resistant hypertension due to White-coat Hypersensivity, 2014-2024 
Figure 84: Distribution of Diagnosed aRHTN Incidence between Controlled, Uncontrolled, Resolvable Secondary Causes, and White-coat Resistance, 2014-2024 
Figure 85: 10-Year Projection for the Percentage of Undiagnosed Hypertension, 2014-2024 187
Figure 86: Projected % Year to Year Change of Uncontrolled Hypertension Prevalence, 2015-2050 
Figure 87: Comparison of the 10-Year Uncontrolled Hypertension Prevalence Projections of the Dymedex Model vs Current Standard of Care, 2014-2024 
Figure 88: Comparison of the 10-Year Controlled Hypertension Prevalence Projections of the Dymedex Model vs. Current Standard 
Figure 89: Undiagnosed Apparent Resistant Hypertension Forecast, 2014-2024 
Figure 90: 10-Year Projection for the Distribution of True Resistant Hypertension versus Resistant Hypertension due White-coat Hypersensitivity or Resolvable 
Secondary Causes, 2014-2024 
Figure 91: Evolution of the Diagnosed RHTN Population, 2014-2024 
Figure 92: Venn Diagram of the Evolving Overlap Between Diagnosed Resistant Hypertension Truly Resistant Population 
Figure 93: 10-Year Forecast of the Distribution across the Segments of the Treated Hypertension Landscape, 2014-2024 
Figure 94: 10-Year Forecast of the Distribution across the Segments of the Uncontrolled Hypertension Landscape, 2014-2024 
Figure 95: 10-Year Projection of the Economic Impact of the Direct Costs Associated with Treating the Controlled and Uncontrolled Hypertension Populations, 2014-2024 
Figure 96: 10-Year Projection of the Economic Impact of the Direct Costs Associated with Treating the Segments of the aRHTN Population, 2014-2024 

Table 1: Characteristics of Clinic, Home, and Ambulatory Blood Pressure Measurement Methods 
Table 2: American Heart Association Blood Pressure Classification 
Table 3: JNC-7 Hypertension Blood Pressure Classifications and Treatment Guidelines 
Table 4: Impact of Lifestyle Modifications on Systolic Blood Pressure 
Table 5: Prevalence of Normal Blood Pressure, Pre-Hypertension, and Hypertension among U.S. Adults, 2014 
Table 6: Mean Duration of Hypertension vs. Normal Blood Pressure, Dymedex Model 
Table 7: Summary of U.S. Hypertension Prevalence, Incidence, and Population at Risk with Distribution by Age Group, 2014 
Table 8: Summary of Prevalence, Incidence, and Duration of Hypertension in the United States, 2014 
Table 9: Summary of the Prevalence of Hypertension Patients with Comorbidities, 2014 
Table 10: Distribution of the Undiagnosed and Untreated Hypertension Prevalence, 2014 
Table 11: Incidence, Prevalence, and Duration of Treated vs. Untreated Hypertension in the United States, 2014 
Table 12: Summary of the Stage I vs. Stage II Distribution among the Uncontrolled Hypertension Population, 2014 
Table 13: Factors Associated with True Resistant Hypertension 
Table 14: Prevalence of Exacerbating Conditions and Secondary Causes among the Treated Hypertensive Population and Diagnosed Resistant Hypertension Population 
Table 15: Prevalence of Undiagnosed and Diagnosed Apparent Resistant Hypertension Patients in the United States 
Table 16: Incidence, Prevalence, and Duration of Resistant Hypertension, 2014 
Table 17: Summary of the Burden of Major Comorbidities across the U.S. Adult Resistant Hypertension Population, 2014 
Table 18: Distribution of the Prevalence and Incidence of Resistant Hypertension, 2014 
Table 19: Hypertension Classification Guidelines JNC-8 vs. JNC-7


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