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.