Prevalence, Treatment, and Control of Combined Hypertension and

Hypercholesterolemia in the United States

Nathan D. Wong, PhDa,*, Victor Lopeza, Simon Tang, MPHb, and G. Rhys Williams, ScDb

Hypertension and hypercholesterolemia are important modifiable risk factors for cardio-
vascular disease (CVD). We examined the prevalence, treatment, and control of combined
hypertension and hypercholesterolemia in United States adults aged >20 years (n ⴝ 2,864,
projected to 118 million, 52% women) from the National Health and Nutrition Examina-
tion Survey 2001 to 2002 by gender, age group, ethnicity, and co-morbidities (metabolic
syndrome, diabetes mellitus [DM], and preexisting CVD). Hypertension was defined as
blood pressure of >140/90 mm Hg (>130/80 mm Hg if DM was present) or on treatment.
Hypercholesterolemia was defined as a low-density lipoprotein cholesterol level of >130
mg/dl (>100 mg/dl if DM or CVD was present) or on treatment. The overall prevalence of
hypertension, hypercholesterolemia, and hypertension and hypercholesterolemia combined
was 30%, 47%, and 18%, respectively. The incidence of the 2 combined was 20% in women
versus 16% in men (p <0.05), ranging from 1.9% in those aged 20 to 29 years to 56% in
those aged >80 years (p <0.001). Combined hypertension and hypercholesterolemia was
least prevalent in Hispanics (9.8% compared with 19% in whites and 22% in African-
Americans, p <0.01) and highest in those with CVD plus DM or metabolic syndrome
(69%), CVD only (44%), DM only (41%), and metabolic syndrome only (37%). Of those
with combined hypertension and hypercholesterolemia, 29% were being treated (8.3% in
those aged 20 to 29 years to 38% in those aged 70 to 79 years, p <0.01). Treatment was least
prevalent in Hispanics (12% vs 24% in African-Americans and 30.4% in whites, p <0.01).
Overall control of hypertension and hypercholesterolemia was only 9% and was low in all
disease groups (5.5% to 16%). In conclusion, treatment and control of combined hyper-
tension and hypercholesterolemia are suboptimal. Increased efforts to improve treatment of
these conditions are needed. © 2006 Elsevier Inc. All rights reserved. (Am J Cardiol 2006;
98:204 –208)

Hypertension and hypercholesterolemia represent highly
prevalent conditions in the United States, the control of
which can substantially reduce the future risk of cardiovas-
cular disease (CVD) events and mortality.1,2 According to
data from the Framingham Heart Study, 80% of patients
with hypertension have additional CVD risk factors.3 Fur-
thermore, the combination of hypertension and hypercho-
lesterolemia more than additively increases the risk of CVD
events compared with the occurrence of 1 of these risk
factors alone.4 Previous studies have indicated that hyper-
tension and hypercholesterolemia frequently co-exist, caus-
ing what is known as “dyslipidemic hypertension.” Previous
prevalence estimates for concomitant hypertension and hy-
percholesterolemia range from 15% to 31% in the United
States.5,6 The present investigation aimed to examine the prev-
alence, treatment, and control of combined hypertension and
a mmol/dl (126 mg/dl) according to the National Cholesterol
Heart Disease Prevention Program, Division of Cardiology, Depart-
ment of Medicine, University of California, Irvine, School of Medicine,
Irvine, California; and bPfizer Pharmaceuticals, New York, New York.
Manuscript received November 5, 2005; revised manuscript received and
accepted January 19, 2006.
This study was supported by a grant from Pfizer Pharmaceuticals, New
York, New York.
* Corresponding author: Tel: 949-824-5561; fax: 949-824-5567.
E-mail address: ndwong@uci.edu (N.D. Wong).
hypercholesterolemia in the adult population in the United
States from 2001 to 2002 and the variation by gender, age
group, ethnicity, and co-morbidities, including metabolic syn-
drome (MS), diabetes mellitus (DM), and CVD.
•••
In the National Health and Nutrition Examination (NHANES)
Survey 2001 to 2002, we identified adults aged ⱖ20 years
(n ⫽ 2,864 projected to 117.5 million, 52% women) with hy-
pertension and hypercholesterolemia who had complete data
on fasting lipids and blood pressure. MS was defined by the
presence of ⱖ3 of the following: waist circumference ⬎102
cm for men and ⬎88 cm for women; triglyceride level of
ⱖ1.69 mmol/L (150 mg/dl) if fasting; high-density lipoprotein
(HDL) cholesterol level of ⬍1.04 mmol/L (40 mg/dl) for men
or ⬍1.29 mmol/L (50 mg/dl) for women; blood pressure
ⱖ130/85 mm Hg or on antihypertensive medications; and/or
fasting glucose level ⱖ6.1 mmol/L (110 mg/dl) and ⬍6.99
Education Program criteria.2
DM was defined by a fasting glucose level of ⱖ6.99
mmol/L (126 mg/dl), or ⱖ11.1 mmol/L (200 mg/dl) if
nonfasting, on oral hypoglycemic medications or insulin, or
self-reported DM. CVD was defined as a self-report of
previous myocardial infarction, stroke, or heart failure. Hy-
pertension was defined as a blood pressure level of ⱖ140/90

0002-9149/06/$ – see front matter © 2006 Elsevier Inc. All rights reserved. www.AJConline.org
doi:10.1016/j.amjcard.2006.01.079
 Preventive Cardiology/Combined Hypertension and Hypercholesterolemia 205

Table 1 Table 2
Prevalence of combined hypertension and hypercholesterolemia in Percent treated for hypertension and hypercholesterolemia among United
United States adults (n ⫽ 2,864, projected to 117.5 million) States adults with combined hypertension and hypercholesterolemia
(n ⫽ 638 projected to 21.5 million)
Variable Overall Men Women
(n ⫽ 2,864) (n ⫽ 1,380) (n ⫽ 1,484) Variable Overall Men Women
(n ⫽ 638) (n ⫽ 298) (n ⫽ 340)
Overall (n ⫽ 2,864) 18.3% 16.4%* 20.2%
Age (yrs) Overall (n ⫽ 638) 28.5% 27.2% 29.5%
20–29 (n ⫽ 587) 1.9% 3.5%*† 0.2%† Age (yrs)
30–39 (n ⫽ 511) 8.0% 9.4% 6.6% 20–29 (n ⫽ 11) 8.3%* 8.9%† 0.0%*
40–49 (n ⫽ 533) 13.4% 12.2% 14.7% 30–39 (n ⫽ 41) 5.0% 8.0% 0.9%
50–59 (n ⫽ 383) 24.0% 21.4% 26.5% 40–49 (n ⫽ 76) 22.2% 19.4% 24.7%
60–69 (n ⫽ 370) 48.3% 43.1% 52.7% 50–59 (n ⫽ 95) 35.5% 32.3% 37.9%
70–79 (n ⫽ 276) 51.3% 42.5%* 58.7% 60–69 (n ⫽ 171) 30.6% 35.8% 27.0%
ⱖ80 (n ⫽ 204) 55.9% 49.7% 59.2% 70–79 (n ⫽ 138) 38.3% 38.5% 38.1%
Race ⱖ80 (n ⫽ 106) 28.7% 25.9% 29.4%
African-American 21.7%† 21.2%† 22.2%† Race
(n ⫽ 518) African-American (n ⫽ 139) 23.7%* 25.9%† 21.8%
Hispanic (n ⫽ 769) 9.8% 11.0% 8.6% Hispanic (n ⫽ 110) 12.4% 9.6% 15.9%
Non-Hispanic white 19.4% 17.0%* 21.7% Non-Hispanic white (n ⫽ 368) 30.4% 29.3% 31.1%
(n ⫽ 1,482) Co-morbidity
Co-morbidity None (n ⫽ 217) 16.7%* 14.4%* 18.8%*
None (n ⫽ 1,932) 8.9%† 8.8%† 9.0%† MS (n ⫽ 221) 28.1% 21.7% 31.2%
MS (n ⫽ 551) 36.7% 28.7%‡ 42.5% DM (n ⫽ 45) 18.4% 19.9% 15.8%
DM (n ⫽ 98) 40.7% 39.1% 43.8% CVD (n ⫽ 63) 42.7% 68.9%‡ 17.7%
CVD (n ⫽ 147) 44.4% 39.3% 50.5% CVD plus DM or MS 57.0% 48.0% 64.9%
CVD plus DM or 69.0% 65.3% 72.7% (n ⫽ 92)
MS (n ⫽ 136) Risk factors§
Risk factor§ 0–2 (n ⫽ 577) 28.2% 26.3% 29.5%
0–2 (n ⫽ 2,731) 17.5%† 15.1%‡ 19.7% ⱖ3 (n ⫽ 61) 31.9% 32.6% 30.1%
ⱖ3 (n ⫽ 133) 39.2% 35.6% 54.4%
* p ⬍0.01 and † p ⬍0.05 across age group, ethnicity, or disease group;
* p ⬍0.05 between genders; † p ⬍0.01 across age group, ethnicity, or ‡
p ⬍0.01 between genders.
disease group; ‡ p ⬍0.01 between genders. §
Age (men ⱖ45 years, women ⱖ55 years), HDL cholesterol ⬍40
§
Age (men ⱖ45 years, women ⱖ55 years), HDL cholesterol ⬍40 mg/dl, DM, and smoking.
mg/dl, DM and smoking.
and hypercholesterolemia were defined individually. The
mm Hg (ⱖ130/80 mm Hg in patients with DM) or self- treatment and control rates were defined for those with
reported use of medication for hypertension. Hypercholes- hypertension aged ⱖ20 (n ⫽ 3,049, projected to 125 mil-
terolemia was defined as a low-density lipoprotein (LDL) lion, 51% women) and for those with hypercholesterolemia
cholesterol level of ⱖ130 mg/dl (ⱖ100 mg/dl in patients aged ⱖ20 years (n ⫽ 2,982 projected to 122 million, 51%
with DM or CVD) or the self-reported use of medication to women). Analyses were also done by gender, age group
control cholesterol. LDL cholesterol was calculated using (⬍40, 40 to 49, 50 to 59, 60 to 69, and 70 to 79 years),
the Friedwald equation (LDL cholesterol ⫽ total ethnicity (African-American, Hispanic, and non-Hispanic
cholesterol ⫺ HDL cholesterol ⫺ [1/5] triglycerides), if tri- white), and disease group according to the presence of MS,
glycerides were ⬍400 mg/dl. Blood pressure was measured DM, CVD, or CVD plus either MS or DM and compared
using a mercury sphygmomanometer, and the average of 4 with those with none of these conditions. Cross-tabulation
readings was used. Treatment was defined by self-report. procedures with SUDAAN statistical software, version
Detailed specimen and data collection have been reported in 8.0.2 (Research Triangle Park, North Carolina) were used
the NHANES Laboratory/Medical Technologists Proce- for population-weighted percentages. Statistical Analysis
dures Manual.7 Systems statistical software, version 8.1 (SAS Institute,
When examining control within the hypertension and Cary, North Carolina) and SUDAAN software were used
hypercholesterolemia subgroup, we defined control as blood for analysis and computation of weighted estimates for
pressure of ⱕ140/90 mm Hg (ⱕ130/80 mm Hg in patients projection to the population of the United States.
with DM) and LDL cholesterol of ⱕ130 mg/dl (ⱕ100 mg/dl The overall prevalence of hypertension alone and hyper-
in patients with DM or CVD). Control was also defined cholesterolemia alone was 30% and 47%, respectively, with
using the National Cholesterol Education Program guide- hypercholesterolemia more common in men (52%) than in
lines,2 incorporating the Framingham global risk estimates women (42%, p ⬍0.01). Their prevalence increased dra-
when defining LDL cholesterol control as ⱕ130 mg/dl matically with increasing age. Overall, 64% of patients with
(ⱕ100 mg/dl in patients with DM or coronary heart disease hypertension were on treatment, but only 23% of patients
or a calculated Framingham 10-year risk of ⬎20%). with hypercholesterolemia were on treatment. Treatment for
The prevalence, treatment, and control of hypertension hypertension was lower in men (56%) than in women (71%,
206 The American Journal of Cardiology (www.AJConline.org)

Table 3
Percent controlled for combined hypertension and hypercholesterolemia among United States adults with combined hypertension and
hypercholesterolemia (n ⫽ 638, projected to 21.5 million)
Variable Overall Men Women Overall, GR Men, GR Women, GR
(n ⫽ 638) (n ⫽ 298) (n ⫽ 340) (n ⫽ 638) (n ⫽ 298) (n ⫽ 340)

Overall (n ⫽ 638) 9.0% 11.7% 6.9% 5.6% 7.8% 3.9%

Age (yrs)
20–29 (n ⫽ 11) 8.3% 8.9% 0.0% 13.1% 8.9% 77.0%
30–39 (n ⫽ 41) 3.4% 5.9% 0.0% 7.3% 9.6% 4.3%
40–49 (n ⫽ 76) 6.4% 8.1% 4.9% 3.9% 7.2% 0.9%
50–59 (n ⫽ 95) 9.6% 9.4% 9.7% 6.4% 4.0% 8.3%
60–69 (n ⫽ 171) 11.0% 15.8% 7.8% 4.6% 7.0% 2.9%
70–79 (n ⫽ 138) 13.0% 19.5% 9.1% 8.2% 15.0% 4.1%
ⱖ80 (n ⫽ 106) 5.3% 10.0% 3.1% 1.4% 4.3% 0.0%
Race
African-American (n ⫽ 139) 6.5%* 8.3%* 5.0%* 5.8% 6.0% 5.7%
Hispanic (n ⫽ 110) 0.0% 0.0% 0.0% 4.0% 3.5% 4.7%
Non-Hispanic white (n ⫽ 368) 10.8% 14.1%† 8.3% 4.9% 7.7%† 2.8%
Co-morbidity
None (n ⫽ 217) 5.5%‡ 3.0%* 7.9%‡ 1.6%* 1.7%* 1.6%‡
MS (n ⫽ 221) 9.4% 12.7% 7.8% 6.7% 12.2% 4.0%
DM (n ⫽ 45) 2.0% 3.2% 0.0% 9.6% 15.2% 0.0%
CVD (n ⫽ 63) 14.8% 30.4%§ 0.0% 0.0% 0.0% 0.0%
CVD plus DM or MS (n ⫽ 92) 16.3% 25.7% 8.2% 15.8% 17.5% 14.2%
Risk factors储
0–3 (n ⫽ 577) 8.5% 10.9% 6.9% 4.5%‡ 6.5% 3.1%
ⱖ3 (n ⫽ 61) 14.0% 16.8% 6.2% 18.5% 16.3% 24.6%

* p ⬍0.01 across age group, ethnicity, or disease group; † p ⬍0.05 between genders; ‡ p ⬍0.05 across age group, ethnicity, or disease group; § p ⬍0.01
between genders.
储
Age (men ⱖ45 years, women ⱖ55 years), HDL cholesterol ⬍40 mg/dl, DM, and smoking.
GR ⫽ Framingham global risk assessment (hypertension and hypercholesterolemia defined as previously mentioned but control definition included
Framingham GR assessment) in defining National Cholesterol Education Program goals for LDL cholesterol.

p ⬍0.01). Among those with hypertension and hypercho-
lesterolemia individually, treatment increased dramatically
by age group (p ⬍0.01). Overall, 41% of those with hyper-
tension were controlled, but only 11% of patients with
hypercholesterolemia were controlled, without any appre-
ciable differences by gender. The control rates for hyper-
tension and hypercholesterolemia individually were higher
in older age groups than in younger age groups.
The overall prevalence of combined hypertension and
hypercholesterolemia was 18% (Table 1). Women had a
slightly higher percentage of combined hypertension and
hypercholesterolemia than men (20% vs 16%, p ⬍0.05)
(Figure 1). A marked increase was seen in the prevalence of
combined hypertension and hypercholesterolemia with age,
from 1.9% in those aged 20 to 29 years to 56% in those aged
ⱖ80 years (Figure 2). Among the ethnic groups, the preva-
lence of combined hypertension and hypercholesterolemia was
19% in non-Hispanic whites, 9.8% in Hispanics, and 22% in
African-Americans (p ⬍0.01) (Figure 3). Of those without
MS, DM, or CVD, the prevalence of combined hypertension
and hypercholesterolemia was 8.9%, much lower than the
prevalence in those with MS (37%), DM (41%), or CVD
(44%), or CVD plus DM or MS (69%, p ⬍0.01 across
disease groups).
Overall, of those with combined hypertension and
hypercholesterolemia, 29% were receiving treatment
(Table 2). Women had a similar treatment rate as men
(30% and 27%, respectively). When examining across
age groups, a significantly higher percentage of treatment
was seen (8.3% in those aged 20 to 29 years vs 38% in
those aged 70 to 79 years, p ⬍0.01). Hispanics had the
lowest treatment rate at 12% compared with African-
Americans (24%) and non-Hispanic whites (30%, p
⬍0.01 across race) (Figure 3). By disease group, for
those without MS, DM, or CVD, 17% were on treatment
compared with those with MS (28%), DM (18%), or
CVD (43%), or CVD plus DM or MS (57%, p ⬍0.01).
The overall control rate of hypertension and hyper-
cholesterolemia among those with combined hyperten-
sion and hypercholesterolemia was 9.0% (Table 3). Men
tended to have higher control rates than women (12% vs
6.9%, p ⫽ NS) (Figure 1). The control rates appeared to
peak in those aged 60 to 69 years (11%) and were lowest
among those aged ⱖ80 years (5.3%) (Figure 2). Hispan-
ics had the lowest control rate (0.0%) compared with
African-Americans (6.5%) and non-Hispanic whites
(11%, p ⬍0.01) (Figure 3). Among disease groups, for
those without MS, DM, or CVD, only 5.5% had con-
trolled hypertension and hypercholesterolemia compared
with those with MS (9.4%), DM (2.0%), or CVD (15%),
or CVD plus DM or MS (16%). When examining control
of hypertension and hypercholesterolemia using the in-
corporation of the Framingham global risk assessment
 Preventive Cardiology/Combined Hypertension and Hypercholesterolemia
Figure 1. Combined hypertension and hypercholesterolemia: prevalence
(dotted bars), treatment (slashed bars), and control (black bars) by gender.
Prevalence indicates percentage with hypertension (blood pressure
ⱖ140/90 or 130/80 mm Hg if DM was present or on antihypertensive
medication) and with hypercholesterolemia (LDL cholesterol ⱖ130 or
ⱖ100 mg/dl if DM or coronary heart disease was present or on lipid-
lowering medications). Treatment indicates percentage on treatment among
those with combined hypertension and hypercholesterolemia. Control in-
dicates percentage controlled to below previously mentioned cutpoints of
those with combined hypertension and hypercholesterolemia. p ⬍0.05
comparing percentage controlled among men versus women.
Figure 2. Hypertension and hypercholesterolemia: prevalence (dotted
bars), treatment (slashed bars), and control (black bars) by age group.
Prevalence indicates percentage with hypertension (blood pressure
ⱖ140/90 or 130/80 mm Hg if DM was present or on antihypertensive
medication) and with hypercholesterolemia (LDL cholesterol ⱖ130 or
ⱖ100 mg/dl if DM or coronary heart disease was present or on lipid-
lowering medications). Treatment indicates percentage on treatment among
those with hypertension and hypercholesterolemia. Control indicates per-
centage controlled to below previously mentioned cutpoints of those with
hypertension and hypercholesterolemia. p ⬍0.01 across age groups for
prevalence and treatment only.
(Table 3), the control rates were much lower overall and
by the subgroups examined.
•••
The results of this study have shown that a high prevalence
of hypertension and hypercholesterolemia continues to exist
207
Figure 3. Hypertension and hypercholesterolemia: prevalence (dotted
bars), treatment (slashed bars), and control (black bars) by ethnicity.
Prevalence indicates percentage with hypertension (blood pressure
ⱖ140/90 or 130/80 mm Hg if DM was present or on antihypertensive
medication) and with hypercholesterolemia (LDL cholesterol ⱖ130 or
ⱖ100 mg/dl if DM or coronary heart disease was present or on lipid-
lowering medications). Treatment indicates percentage on treatment among
those with hypertension and hypercholesterolemia. Control indicates per-
centage controlled to below previously mentioned cutpoints of those with
hypertension and hypercholesterolemia. p ⬍0.01 for prevalence, treatment,
and control across ethnic groups.
in the United States adult population, with approximately
1/5 of all adults having combined hypertension and hyper-
cholesterolemia. Less than 1/3 of these were on treatment
for the 2 conditions, and the treatment rates were apprecia-
bly lower in African-Americans and Hispanics. Less than
1/10 of those with combined hypertension and hypercho-
lesterolemia had the 2 conditions under adequate control.
The major strength of our study was the ability to project
the prevalence of combined hypertension and hypercholes-
terolemia, as well as the treatment and control rates, to the
adult population of the United States, given the population-
representative National Health and Nutrition Examination
Survey data we used. One limitation of our study was the
reliance on measures of blood pressure and lipids taken at a
single visit, and thereby not accounting for the inherent
variability in these measures that may have affected the
prevalence. Moreover, the use of medications was based on
self-report of taking medications for hypertension or ele-
vated cholesterol to ensure comparability with previous
publications of national statistics on prevalence and treat-
ment.1,8,9 Our measure of hypercholesterolemia was based
only on having increased LDL cholesterol or being on
medication for lipids; a much greater number of patients
would have been identified had the criteria for hypercholes-
terolemia also included decreased HDL cholesterol or ele-
vated triglycerides. Likewise, a much lower proportion
would have been noted to be in control had the criteria for
control included cutpoints for HDL cholesterol and triglyc-
erides.
208 The American Journal of Cardiology (www.AJConline.org)
The results of our study have demonstrated that impor-
tant gaps remain in the treatment and control of hyperten-
sion and hypercholesterolemia, and in particular, when the 2
conditions are present together—the case for ⬎1/2 of older
adults in the United States. Greater efforts are needed to
identify and adequately treat each condition individually,
and especially if present together, for which the importance
of adequate control is even greater because of the higher
risk of future coronary heart disease.
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