Treating Mild Hypertension With Drugs May Be Misdirected

Veronica Hackethal, MD

Treating mild hypertension with drugs has unclear benefit and adds exorbitant sums to national healthcare expenditures, experts write in an article published online September 14 in BMJ.

Thresholds for management need to be reexamined, and priorities should shift to lifestyle change, according to Stephen A. Martin, MD, assistant professor of medicine at the University of Massachusetts Medical School in Boston, and colleagues.

The article’s publication coincided with the Preventing Overdiagnosis conference held in Oxford in the United Kingdom. Oxford’s Centre for Evidence-Based Medicine and the BMJ‘s Too Much Medicine campaign sponsored the conference, which focused on reducing unnecessary care and waste of healthcare resources.

“The practical point for clinicians is that before you subject someone to lifelong medical therapy and its potential side effects, be sure that other elements like lifestyle changes have really been given a fair shot. That means don’t pull the trigger too quickly,” senior author Vikas Saini, MD, president of the Lown Institute and lecturer at Harvard Medical School, Boston, Massachusetts, told Medscape Medical News.

Evidence of Benefit Unclear

Dr. Saini outlined 3 main reasons for this assertion. First, there is no clear evidence that treating mild hypertension with medication has the same effect it does on moderate to severe hypertension in terms of reducing risk for cardiovascular disease and related health problems.

Roughly 40% of adults in the world have hypertension, about half of which is thought to be mild (140 to 159/90 to 99 mm Hg). More than 50% of people with mild hypertension receive medication.

During the last few decades, thresholds for diagnosing and treating hypertension have been lowered. The assumption has been that treating mild hypertension, even in those without risk factors such as diabetes or kidney disease, can reduce the risk for cardiovascular disease and death. Studies, however, have not born this out.

In addition, overmedication contributes to ballooning healthcare costs, the authors argue. The United States spends about 1% of its annual healthcare expenses and more than 30% of its national public health expenses treating hypertension, amounting to more than $32 billion annually.

Overmedication with antihypertensives also carries risks for increased harms to the patients, such as falls, hip fractures, drug-related hospital admissions, and poor physical and mental health self image.

Second, Dr. Saini said, inaccurate blood pressure measurement contributes to overdiagnosis.

“You want to be sure the readings that you’re basing treatment on are reliable and accurate, and that often means getting home and multiple readings,” Dr. Saini explained. For example, so-called white coat hypertension recorded at office visits is notoriously inaccurate, and automated cuffs and home-based methods may prove better prognostically.

Last, focusing on medication diverts resources away from investment in public health, Dr. Saini pointed out. Increased emphasis on system-wide lifestyle changes is needed, such as weight loss, decreasing salt intake, smoking cessation, reduced alcohol consumption, and increasing exercise levels.

“I think clinicians are frustrated, rightly so, by the fact that you can’t change the patients’ lifestyle with a 5- or 10-minute conversation in the office,” Dr. Saini said. “To ask doctors or the medical community to shoulder that burden is really unfair.”

The solution, he writes, is to rethink the approach, with a shift in resources and emphasis on public health rather than medical treatment.

“Doctors, public health workers, and community leaders really need to form an alliance. The path of least resistance of prescribing a drug feels good, but we have no idea if this really makes a difference,” Dr. Saini emphasized. “Thirty billion dollars is a lot of expense for something that makes no difference. Thirty billion dollars would go a long way if it was organized in a collaborative effort across society to make lifestyle changes easier for all of us.”

Some Clinicians Remain Skeptical

It may still take some convincing, however, before practicing clinicians come on board with these recommendations.

“The main challenge to implementing these changes is the dynamic nature of blood pressure and the likely reluctance of patients and doctors to risk taking patients off medicines that are not causing perceptible side effects,” Neda Laiteerapong, MD, assistant professor of medicine at the University of Chicago, Illinois, told Medscape Medical News. “These medications likely provide some security for the patients and doctors that the blood pressure is well-controlled.”

Emphasizing lifestyle change is in line with providing cost-effective, patient-centered care, Dr. Laiteerapong agreed, and could work for “some people,” such as those in their 40s and 50s who are healthier and do not have other chronic illnesses that interfere with exercise or self-care.

“However, many patients with hypertension are over 65, and many have chronic diseases which impede their ability to successfully implement lifestyle change,” Dr. Laiteerapong added, “While the article mentions that lifestyle change works, it’s truly very difficult for many people to implement the level of change necessary to make significant changes in blood pressure.”

Gerry Gajadharsingh writes: 

Hypertension (high blood pressure) is something that many people worry about, sometimes with good cause. When I was a student the threshold for diagnosing hypertension was a diastolic of >100mmHg (the lower BP reading). Over the years the threshold has come down, for patients > 50, they are now considered hypertensive if the systolic (upper BP reading) is > 140mmHg and Diastolic > 90mg. This has pushed a lot more patients into the hypertensive category. The majority of those patients (>80%) are classified as having “essential” hypertension, a bizarre choice of word as we do not need to have high blood pressure and we certainly don’t want it! What it means is that there is often no “discernable cause”.

The authors above are rightly highlighting, backed by research, that perhaps we shouldn’t medicalise so many patients but first attempt to help patients understand how their lifestyle choices may well be causing their hypertension. As more than 50% of people with mild hypertension receive medication, that’s a lot of medication, potential side effects, potential drug interactions and a lot of money!!

It is possible to help patients manage their blood pressure with both life style modification and with targeted non-invasive intervention, such as changing their breathing pattern and mindfulness techniques. Vascular tone is influenced by the autonomic (subconscious) nervous system, helping peoples to change their breathing behaviour, increasing their Heart rate variability by decreasing sympathetic over activity, in conjunction with weight management dietary change or other lifestyle interventions can prove wonders. It is unrealistic to expect GP’s to burden this responsibility, even if they had the time and skills to do it. So the onus needs to be on patients and other clinicians, who have the time and necessary skills to parent GP’s in helping patients make these changes, assuming patients want to change in the first place!