A VIEW FROM THE OFFICE
MEDICINE'S DIRTY LITTLE SECRET
HYPERTENSION DOESN'T NEED TO BE TREATED (A LOT OF IT ANYWAY): In 1990 I reviewed all of the then available studies on the treatment of mild to moderate hypertension and was more than mildly surprised by the following observations:
- The trials showed a significant benefit in reducing both fatal and nonfatal stroke (40-44% reductions).
- The benefit for stroke reduction in middle-aged patients could be observed after only 4-6 weeks of treatment.
- No statistically significant benefit in the reduction of fatal or nonfatal MI was observed.
- There appeared to be no value in treating isolated mild to moderate hypertension in younger adults in the absence of risk factors.
- Treatment of mild to moderate hypertension was not cost-effective.
(I published the results of my review in J Am Board FP in 1993 May-Jun;6(3):243-54.) (1)
This led me to the conclusion that pharmacological management of mild-to-moderate hypertension should be directed only at those with elevated cardiac risk profiles. This, of course, meant that you would actually have to perform a cardiac risk assessment to determine global cardiac risk. Otherwise lifestyle measures are all that is needed for everyone else. My subsequent research into the effects of healthy lifestyles also supported this conclusion.(2)
I have been alone in this opinion for most of my career, but now at last the Cochrane Collaboration has published a definite confirmation of this approach.(3) Their conclusions are likely to surprise you. The authors reviewed 11 RCTs and based their conclusions on only 4 qualified studies. These studies included 8,912 subjects who were treated for 4 to 5 years with antihypertensive drugs as compared to placebo. Active treatment with medication did not reduce total mortality. In 7,080 participants treated with antihypertensive drugs as compared to placebo did not reduce coronary heart disease, stroke, or total cardiovascular events.
A follow-up editorial in JAMA explains how we came to be managing hypertension all wrong for over 20 years.(4) The author begins with a quotation from Julian Tudor Hart, the pioneer of screening for hypertension at the previous threshold of 160/100 mm Hg: "Why has it taken more than 30 years to reach this conclusion, when it was already evident from any careful and critical reading of the trials claimed originally to justify interventions in the diastolic range 90-100 mm Hg?"
The effect of changing the disease definition was to create 13 million new hypertensive patients in the US. In that same year, more than 800 physicians, pharmacists, and scientists from 42 countries signed an open letter to the Director-General of the WHO complaining that these new guidelines 'would result in increased use of antihypertensive drugs, at great expense and for little benefit.' The editorial goes on to observe:
"The following year, Getz and colleagues described the results of applying these European guidelines to the entire population of a county in Norway. The Nord-Trondelag Health Study provides BP and serum cholesterol level data for some 62,000 adults aged between 20 and 79 years in the period 1995 through 1997. When the European guidelines are applied, half the population are considered to be at risk by the early age of 24 years. By the age of 49 years, this proportion increases to 90%, and as much as 76% of the total adult population are found to be at 'increased risk.' Yet the current life expectancy at birth in Norway is 79 years for men and 83 years for women, making it one of the longest-living populations in history. In this context, the thresholds cannot be appropriate, and it is perhaps important to note that every one of the numerous authors of the European guidelines reported some degree of support from the pharmaceutical industry.
"In 204, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) sponsored by the US National Heart, Lung, and Blood Institute pushed the thresholds even lower, stating the prehypertensive individuals (systolic BP, 120-139 mm Hg, or diastolic BP, 80-89 mm Hg) require health-promoting lifestyle modifications to prevent the progressive rise in BP and cardiovascular disease. Nine of 10 members of the Executive Committee responsible for JNC7 record conflicts of interest relating to the receipt of payments from the pharmaceutical industry."
It was after the publication of JNC 7 that I first began to suspect that the drug companies were deliberately leading us astray. I wrote extensively on my disagreements with JNC 7 in The Action Advisor for Primary Care, "You Should Read the JNC 7 Guidelines on Hypertension and Then Freely Deviate from Them As You Feel Appropriate for Your Practices".(5)
The primary article above cites the guidance from the national Institute for Health and Care Excellence; according to this guideline drug treatment for hypertension should be offered to people aged younger than 80 years with stage 1 hypertension (BP < 160/100) only if they also have target organ damage, established cardiovascular disease, renal disease, diabetes, and/or a 10-year cardiovascular risk equivalent to 20% or greater. Dr. Heath concludes: "In view of the mounting evidence of both waste and harm, it is well time that we returned to the higher threshold of 160/100 mg Hg for the pharmaceutical treatment of hypertension in otherwise healthy people. The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure provides a timely opportunity for achieving this, but, with the probably degree of industry entanglement, it seems a remote possibility. However, sooner or later the pharmaceutical treatment of mild hypertension seems likely to be consigned to what the novelist Amitav Ghosh has described as 'medicine's vast graveyard of discredited speculations.'"
COMMENT: Isn't the practice of medicine rather a marvel!? Just don't say I didn't tell you so.