Hypertension, health inequities, and implications for COVID-19

The COVID-19 pandemic has led many people to forego follow-up and treatment of chronic health conditions such as hypertension (high blood pressure). It is now quite evident that people with hypertension are also more likely to develop severe complications from the coronavirus. In the US, African Americans and other racial and ethnic minorities, including Hispanics and Native Americans, are more likely to have hypertension, and consequently have been disproportionately affected by the COVID-19 pandemic.

What is the link between high blood pressure and heart disease?

Hypertension is the most common modifiable risk factor for major cardiovascular events including death, heart attack, and stroke, and it plays a major role in the development of heart failure, kidney disease, and dementia. Over the past few decades, major efforts have been launched to increase awareness and treatment of hypertension.

Hypertension increases stress on the heart and arteries as well as on other organs including the brain and kidneys. Over time, this stress results in changes that negatively impact the body’s ability to function. To reduce these negative effects on the heart, medications are typically prescribed when blood pressure goes above 140/90 for those without significant cardiovascular risk, or above 130/80 in people with known coronary artery disease or other coexisting diseases like diabetes.

Certain groups are disproportionately affected by hypertension and severe COVID-19

According to a recent study published in JAMA, the proportion of study participants with controlled blood pressure (defined as < 140/90 mm Hg) initially increased and then held steady at 54% from 1999 to 2014. However, the proportion of patients with controlled blood pressures subsequently declined significantly, to 44% by 2018. Further, certain subgroups appeared to have a disproportionately higher rate of uncontrolled hypertension: African Americans, uninsured patients, and patients with Medicaid, as well as younger patients (ages 18 to 44) and older patients (ages 75 and older). An accompanying editorial noted that the prevalence of uncontrolled blood pressure was disproportionately higher in non-Hispanic Black adults from 1999 to 2018.

With a higher prevalence of hypertension, African American, Native American, and Hispanic communities have had higher rates of hospitalization and death during the pandemic, according to the CDC. While vulnerability to severe complications of COVID is highest among older patients regardless of race or ethnicity and socioeconomic circumstance, according to the National Bureau of Economic Research, “vulnerability based on pre-existing conditions collides with long-standing disparities in health and mortality by race-ethnicity and socioeconomic status.”

How does hypertension result in severe COVID-19 complications?

The link between hypertension and severe coronavirus disease remains complex. Some experts believe that uncontrolled blood pressure results in chronic inflammation throughout the body, which damages blood vessels and results in dysregulation of the immune system. This results in difficulty fighting the virus, or a dangerous overreaction of the immune system to COVID-19. Certain classes of blood pressure medicines (ACE inhibitors and angiotensin receptor blockers, or ARBs) were initially thought to worsen infection, but this has since been disproven. Several research groups have shown that with close monitoring, these medications are safe to use during COVID infection.

What do people with hypertension need to know about reducing their risk?

Proper blood pressure control has long-term health benefits and may help prevent severe COVID-19 symptoms. Therefore, we strongly encourage taking your medications as directed and following healthy lifestyle practices like regular exercise, achieving and maintaining a healthy weight, following a low-sodium, heart-healthy diet such as the Mediterranean diet, and reducing stress and practicing mindfulness.

In addition, following up with your doctor to keep blood pressure under control is more important now than ever. While the idea of heading into the hospital or a doctor’s office in the middle of a pandemic may put people on edge, many hospitals and clinics are quite safe due to appropriate safety measures like universal mask wearing and social distancing. Many have also expanded telemedicine or virtual visits for patients.

What can we do to tackle inequities in healthcare delivery?

COVID-19 has forced us to confront inequities in health care delivery that contribute to worse clinical outcomes in vulnerable patient groups.

With rising numbers of people with uncontrolled blood pressure, and the pandemic disrupting management of chronic health conditions, this may serve as a prime opportunity for us to purposefully change the current trends in hypertension and narrow the gap in health inequity. Potential areas of focus include:

• promoting research on how the COVID-19 pandemic has affected management of chronic diseases like high blood pressure
• identifying barriers to care, particularly in vulnerable subgroups
• increasing awareness of the importance of chronic disease management, particularly in communities where health care inequities exist
• innovating to make virtual health technology more broadly accessible
• delivering additional resources for chronic disease management to vulnerable subgroups
• implementing long-term policy solutions to address health inequities.

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