High Blood Pressure (Mild) And Medications

Mild Hypertension?  Don't Jump To Medications Too Fast

By Marc Braman, MD, MPH
 
blood pressure monitor 

Take Home:

Doctors may be getting pushed by checklists, grading systems, and skewed national recommendations to put tens of millions of Americans on medications for mild hypertension, but the evidence of benefit is grossly lacking unless you have other significant medical problems.  Know your facts before jumping on the medication bandwagon.
 

CDC Press Release

The morning "Breaking News" headline from one of the main medical news channels was "Uncontrolled BP Major Problem In U.S., CDC Says."  Unfortunately, their very name gives away the skewed approach they take to this problem.  The actual name of the organization is the "Centers for Disease Control and Prevention", but, they are very weak on the "Prevention" side of things.  How often have you heard them called the "CDCP"?  So goes their press release -- big on "disease control" and light on "prevention".  I'm bothered because: 1) they are looking and talking from a 30,000 feet in the sky view and have lost sight of the patient, and 2) I'm board certified in Preventive Medicine/Public Health and think they haven't done a good job managing all the important information for the public's health on this one.  Are they smart people who say and do many good things (they are Public Health specialist colleagues to me)?  Sure.  But they can do better on this topic.
 
When you go to their press release, you find lot's of good statistics.  Sixty-seven million Americans, about 1 in 3 adults, have high blood pressure.  Yes, this is a staggering number.  More than half of those with hypertension do not have it under control.  About 14 million don't know they have it.  About 6 million are aware they have it but are not being treated (medications).  About 16 million are being treated with medication but not enough to control their hypertension.  Eighty-nine percent of those with hypertension have a usual source of health care and 85% have health insurance.  The direct health care cost is $131 billion (yes, that is with a "b"!) every year. (MMWR, Vital Signs: Awareness and Treatment of Uncontorlled Hypertension Among Adults -- United States, 2003-2010)

The Important Facts

Studies show that your associated risk of heart disease and stroke are lowest at a blood pressure of 115/70 and below.  As your blood pressure gets above these numbers there is an increasing associated risk of heart problems and stroke, and especially stroke.  But, the question is: "At what point of increasing blood pressure does the risk become greater than the risk associated with prescription medication use?"  Our health care system has used a somewhat arbitrary number of 140/90 for a long time as a basic "line in the sand" for calling blood pressure "high".  But there is really nothing particularly magical about that number.  Actually, one's risk of stroke or heart attack rises fairly slowly with increasing blood pressure until you are getting in the 160/100 ball park.  After this it starts to climb fairly steeply.  It is one of those "exponential" sorts of curves - rising slowly for quite a ways and then swooping up and reaching for the sky.
 
So, if we want to address any increased risk, we should start treating people when their blood pressure gets above 115.  If we want to be sure that there is enough risk to warrant the cost, hassle, and side effects of prescription medications (and most people need more than one medication to get their numbers down), we would be using numbers above 160 to justify medication use.  So, it is a matter of where to draw that risk-to-benefit ratio line. 

Context: Hypertension Doesn't Happen In A Vacuum

I still remember being amazed to learn that people in many third world countries don't get hypertension -- not even in their 70s, 80s, and 90s.  I was taking a class "Epidemiology of Cardiovascular Disease" as part of my Masters in Public Health program.  I had already done medical school and had learned that hypertension was "just part of getting older"(which there is some truth to) -- it was "normal".  The facts are that hypertension is not "normal" to human experience -- it is an aberration.  We have created this disease with our "modern" society and its "modern" living.  Civilization isn't always a good thing.
 
The other stunner on hypertension for me was when I took some of my precious vacation time during my internship year to go to an NIH consensus development conference in Washington, DC.  All the top "brains" in the country on hypertension and physical activity were meeting to collectively decide what the latest and greatest science was revealing on the relationship between the two.  One researcher presented data from a study that wasn't yet published.  They took people with mild hypertension (BP 140-160) and randomly assigned them to two different groups.  One group got put on blood pressure lowering medications and the other group got put on a regular exercise program.  Who do you think lowered their blood pressure numbers more?  Nope -- you're wrong.  The people on the medications lowered their numbers more.  BUT -- who had fewer heart attacks and strokes?  Yep -- the exercisers.  This was an eye opener.  The numbers weren't the real issue.  The real issue was what was really going on that the numbers were just a product of.  Would you rather avoid blood pressure readings above 140 or would you rather avoid a stroke or heart attack?  Yeah, not too hard to decide.

Real World Side Effects

The fly in the ointment that the CDC isn't really dealing with, nor most of the standard-setting bodies for this topic, is medication side effects -- to say nothing of cost, hassle, etc.  I think of one patient who started seeing me after being put on the most common medication for hypertension and nearly killing herself (and maybe someone else) in a car wreck because she nearly lost consciousness from her electrolytes getting all out of whack.  Or I'm thinking of another patient who has to take a lot of prescription potassium to counteract a medication side effect, or her heart and other systems would experience life-threatening problems.  Or the man with severe fatigue and swelling and weight gain that is probably from the medication his cardiologist won't let him stop because a large study showed that on average people taking this medication had slightly fewer subsequent heart attacks.  Medications for hypertension have plenty of known side effects, which I think are terribly under-reported and unrecognized -- for a variety of reasons.  Depression may come on slowly from some medications, and the medications not be recognized as the cause.  Some die in a car wreck and we just think they weren't paying attention or something.  I don't want to make it seem like everyone gets side effects and that they are always extreme -- because that is not the case.  But neither are they rare or always mild.  Most affect quality of life.  The less common side effects can be downright deadly.

The Other Side Of The Science

A friend recently sent me some links to articles on studies questioning the use of medications for mild hypertension (BP 140-160).  One, not from a source I usually get medical news from, Slate.com, was actually very well done.  It is entitled, "Most People Who Take Blood Pressure Medication Possibly Shouldn’t".  As you read this article it is helpful to know that the Cochrane Collaboration is probably the most objective and professional scientifically based medical organization in the world.  They looked at all the data from all the studies they could find using medication to treat mild hypertension.  And -- guess what -- they found no benefit.  Yes, that's right -- no benefit!  I'll let you read some of the "why" from the article.  There are a couple of really important concepts brought out in it that you won't hear elsewhere (see if you can find them).  The closing few sentences are great, so I'll include them here:
 
  "Given the possibility that future trials will identify at best a small, currently nonapparent benefit, it seems clear that the best thing for doctors to do would be simply to tell patients the truth—that while the best current evidence doesn’t support routine treatment of mild hypertension, we really don’t know for sure. But we do know this: Emphasizing far more effective—and evidence-based—approaches, such as exercising, quitting smoking, and following a Mediterranean diet, seems to be a very good idea. And besides, they work."
 
It makes me wonder where the CDC is coming from with their recommendations...
 
The second news summary is from a medical source, medpagetoday.com.  Again, it was discussing the Cochrane review of many studies' data.  Excerpts follow:
 
"Using antihypertensive medications to treat adults with mild hypertension and no previous cardiovascular events does not appear to reduce mortality or subsequent events, at least through about 5 years, a meta-analysis showed."
 
"That lack of benefit was accompanied by a significant increase in withdrawals due to adverse effects...."
 
""The results are not surprising to the people who've been in the blood pressure field for a while," said Roger Blumenthal, MD, an American Heart Association (AHA) spokesperson and director of the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins University in Baltimore.
Blumenthal told MedPage Today that the review highlights the lack of a large number of trials supporting the use of antihypertensives in patients with mild hypertension."
 
"In the pooled analysis, antihypertensive treatment was not associated with significant reductions in any of the outcomes of interest versus placebo."
 
"They estimated that 400 people would have to be treated with first-line drug treatments for 5 years to prevent one death. And the number needed to treat to prevent one cardiovascular (like a nonfatal heart attack) event over that same time-frame would be 128."
 
Did you catch that?  IF it does work, you would have to provide 2,000 (400 X 5 years) years of treatment to prevent one death.  Consider that about 9% dropped out due to medication side effects, likely within the first year.  And this is to say nothing of all those who didn't recognize the side effects that made life harder or recognized them and chose to "just live with it".  I think the following statement by the lead author is very telling.  The huge "if" that almost never happens is "patients given this information".
 
""It is likely that many such patients given this information would choose nondrug treatments for hypertension (e.g., diet, exercise, stress management, etc.) rather than drug therapy," Diao (lead researcher) and colleagues wrote. "They would be even less likely to choose drug treatment when they were told that these estimated benefits are a best-case scenario and uncertain based on the best available evidence at this time from this review."" 

Other Conditions Change The Equation

It is important to realize that these studies are primarily in reference to mild hypertension in people without other significant medical diagnoses.  If a person has had a heart attack, has kidney disease, has diabetes, etc., that changes the equation.  The weight of evidence is that when other serious conditions are present that involve the cardiovascular system, it is more important to get the blood pressure down -- that benefits will outweigh risks at lower BP numbers than when one has mild hypertension alone.

Application

I am loathe to say this, but...I don't think you can trust the CDC on this one.  They've definitely dropped the "P" from prominence in my opinion.  High blood pressure definitely should get your attention and you should engage and do something about it.  It is a sign that something isn't right (and no, it's not a sign of a medication deficiency).  Just don't go with the standard, uninformed medication option as a knee jerk response.  Keep in mind that each person's circumstances are different.  Some have a lot of problems with prescription medications while others do just fine.  Some have strong reservations about prescription medications and only choose to use them as a "last resort".  You want benefits to be greater than the problems for you.  Be informed, use common sense and good judgment, and get on with enjoying life -- possibly without as much medication.
 

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Written 9/4/12.