Research shows that women suffer more from uncontrolled hypertension than men in every state, with the greatest prevalence of uncontrolled hypertension in the Southern United States. The study, Trends and cardiovascular mortality effects of state-level blood pressure and uncontrolled hypertension in the United States, is the first study to estimate mean systolic blood pressure (SBP) and uncontrolled hypertension prevalence at the state level by sex and age groups for two time periods. The work was carried out in collaboration with scientists at the Harvard School of Public Health.

Research findings

The researchers found that from 2001 to 2003, age-standardized uncontrolled hypertension prevalence was highest in Southern states (Mississippi, Louisiana, Alabama, Texas, Georgia, and South Carolina) and the District of Columbia, up to 18% to 21% for men and 24% to 26% for women. Prevalence was lowest in Vermont, Minnesota, Connecticut, New Hampshire, Iowa, and Colorado (15% to 16% for men and 21% for women). Women had a higher prevalence of uncontrolled hypertension than men in every state by 4% to 7%. In the 1990s, uncontrolled hypertension in women increased the most in Idaho and Oregon (by 6%) and the least in the District of Columbia and Mississippi (by 3%). For men, the worst-performing states were New Mexico and Louisiana (a decrease of 0.6% and 1.3% between the two time periods, respectively) and the best-performing states were Vermont and Indiana (a decrease of 4% and 3%, respectively).
Analyses also showed that SBP and uncontrolled hypertension increased with age, however, the age gradient was attenuated for those using medication. Age-standardized cardiovascular mortality attributable to higher-than-optimal SBP ranged from 200 to 370 per 100,000 for women and from 210 to 410 per 100,000 for men. Furthermore, there was little correlation between changes in SBP of men and women across states, indicating that state-level programs may not have systematically and uniformly benefited all demographic groups. 
These results illustrate important geographic patterns and trends in sex- and age-specific SBP and its cardiovascular mortality impacts at the state level.

Analytical approach

Researchers used data from the National Health and Nutrition Examination Survey and the Behavioral Risk Factor Surveillance System  to characterize the relationship between actual SBP/uncontrolled hypertension and self-reported hypertension, use of blood pressure medication, and a set of health system and sociodemographic variables among adults 30 years of age or older.  They used this relationship to estimate mean SBP and uncontrolled hypertension at the state level and by sex and age group for two time periods, 1988 to 1992 and 2001 to 2003. They then used comparative risk assessment methods to estimate cardiovascular mortality attributable to higher-than-optimal SBP at the state level. 

Research objective

Only self-reported hypertension status is measured at the state level in the United States. The aim of this study was to estimate levels and trends in state-level mean SBP, the prevalence of uncontrolled systolic hypertension, and cardiovascular mortality attributable to all levels of higher-than-optimal SBP.  This study is part of ongoing work by IHME to provide rigorous, comparable, and current scientific measurement of trends in diseases, analyzing data across countries and over time.

Recommendations for future work

Further research is needed to investigate lifestyle and pharmacological interventions in states with high levels of uncontrolled hypertension, with specific emphasis on methods of improving diagnosis and control among women. Future work should include cardiovascular risk factors other than SBP, such as body mass index, blood glucose, and cholesterol. Definitive conclusions about diagnosis coverage and subsequent management among those diagnosed with hypertension and how they may vary by sex requires further investigation. Regular reporting of risk factor levels and trends can help evaluate the performance of programs in individual states, and lessons can be learned from states with successful programs.


Ezzati M, Oza S, Danaei G, Murray CJL. Trends and cardiovascular mortality effects of state-level blood pressure and uncontrolled hypertension in the United States. Circulation. 2008 Feb 19; 117(7):905–914.