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The overtreatment of ‘mild’ hypertension is causing more harm than good, say experts

REUTERS/Lucy Nicholson
High blood pressure is defined as a systolic pressure of 160 or higher and a diastolic pressure of 100 or higher.

Millions of people around the world are being treated unnecessarily with drugs for “mild” hypertension (high blood pressure), exposing them to more potential harm than good and wasting health care resources, according to a recent commentary in the journal BMJ.

The commentary, whose authors include Dr. Stephen Martin of the University of Massachusetts Medical School and Dr. James Wright of the University of British Columbia, who is also a coordinating editor of the Cochrane Hypertension Review Group, was published last week in conjunction with BMJ’s ongoing “Too Much Medicine” campaign.

As Martin and Wright point out, the concept of “mild” hypertension has only been around for about a decade, and the idea that otherwise low-risk patients should be treated with blood-pressure-lowering drugs is controversial.

“Evidence suggests no net benefit from drug treatment of mild hypertension in people without the higher risks of diabetes or chronic kidney disease,” they write. “Nevertheless, most people with mild hypertension are treated with drugs.”

A lack of good evidence

Mild (or stage 1) hypertension is defined as a systolic pressure of 140 to 159 and a diastolic pressure of 90 to 99. High blood pressure is defined as a systolic pressure of 160 or higher and a diastolic pressure of 100 or higher. A person is considered at “low risk” if he or she does not have existing heart disease, diabetes or kidney disease.

As Martin and Wright note in their commentary, hypertension is being diagnosed — and treated — at progressively lower blood pressures. Today, up to 40 percent of adults worldwide are said to have hypertension, although more than 60 percent of those cases fall into the mild category.

And more than half of the people with mild hypertension are treated with blood-pressure-lowering drugs. Yet, “analyses of absolute cardiovascular risk show that drug treatment based on blood pressure alone is likely to have little individual effect in low risk patients with mild hypertension,” write Martin and Wright.

A 2012 Cochrane review (co-authored by Wright) found, for example, that treating mild hypertension with an antihypertensive drug had no beneficial effect on patient outcomes, including the rates at which patients developed heart disease or had a stroke.

Yet each year, billions of dollars are spent on treating mild hypertension. Here in the U.S., the annual cost is $32 billion — more than 1 percent of the country’s annual healthcare costs and more than one-third of its total national expenditures on public health, Martin and Wright point out.

Not without risk

Antihypertensive drugs are not risk-free. They can cause fatigue and muscle weakness, and are associated with an increased risk of serious, injury-causing falls, particularly among older people. People being treated with antihypertensive drugs are also more likely to be admitted to a hospital for medical issues related to the medications, and they tend to rate themselves as being in poorer physical and mental health than people with similar blood pressure measurements who are not taking the medications.

In addition, say Martin and Wright, taking antihypertensive drugs increases the risk that people will not be advised to make heart-healthy lifestyle changes, such as losing weight, increasing physical activity, quitting smoking and reducing alcohol consumption.

Write the two doctors (with British spellings):

For patients with mild hypertension, the focus on drug treatment reduces emphasis on lifestyle changes. Unlike drug treatment, lifestyle changes are free of side effects and provide benefits beyond reduced blood pressure. The health benefits of lifestyle interventions have been known for decades, yet the medical system does not adequately support these approaches.

Comments are often made about lack of adherence to advice about behaviour change, but 50-80% of patients are non-adherent with antihypertensive drugs.

Misdiagnoses — and missed opportunities

The commentary also talks about the need to measure blood pressure more accurately to avoid “white coat” hypertension — the phenomenon in which blood pressure spikes to abnormally high (and thus unrepresentative) levels while the patient is in the doctor’s office. Studies suggest that as many as 20 percent of people diagnosed with high blood pressure may actually have white coat hypertension.

“Blood pressure must be measured more accurately to ensure patients are correctly identified,” urge Martin and Wright. “Consideration should be strongly given to home measurement as the default.”

And for patient with mild hypertension, “doctors should be open about the lack of known benefits for drug treatment and the benefits of lifestyle improvements,” they add.

You’ll find an abstract of the commentary on the BMJ website, but, unfortunately, the full commentary is behind a paywall.

Comments (5)

  1. Submitted by E Gamauf on 09/24/2014 - 07:19 am.

    Question about “White Coat” hypertension

    This is an interesting article.

    Is White Coat Hypertension real,
    or is this just a lot of corn syrup?

    Merely the white coat of a doctor,
    or does this mean that a person reacting to doctor’s office stress is also likely to have BP spikes under other stressor circumstances?

    In a society in which ‘cooking’ has come to mean opening a box containing pre-fab contents & then read the microwave directions, what constitutes a “lifestyle improvement?”

    • Submitted by William Gleason on 09/24/2014 - 09:47 am.

      Yes white coat syndrome is real …

      Although the term may be misleading to those of a literal mind. (Merely the white coat of a doctor…) Doctors don’t always wear white coats nowadays.

      Visits to the doctor can be, of and in themselves, very stressful and raise normal blood pressure for a variety of reasons. The person may have serious health problems and be worried about them. Or the drive over to the doctor’s office may have been stressful. Or patients and staff may suffer with insurance issues before meeting with a doctor. The list goes on.

      A good and attentive doctor will often re-measure the initial blood pressure to see if it has decreased from the initial value after having gone through the issues relevant to the visit. This gives the patient an opportunity to settle down.

      Very good article on an important topic which is actually quite complicated.

      • Submitted by Chris Loters on 12/17/2014 - 12:59 pm.

        Re: White Coate Syndrome

        Indeed it is either the person is just tense about the reason why they visit the doctor that their blood pressure reading went up. I would think that white coat hypertension wont require any medication as long as it is not a sustained hypertension.

        Does the blood thinning effect of aspirin and Fish oil helps lower down high blood pressure? My wife has these supplements . I was wondering if I can also take these fish oil for hypertension instead of resorting to prescription meds. I’m at border line High on Lipid and High Blood pressure.

  2. Submitted by E Gamauf on 09/24/2014 - 06:29 pm.

    I think you missed the irony…

    …Or there’s a missing post.

    Perhaps the other post which said fructose is being implicated in some of the medical events, has gone missing.

  3. Submitted by sally morris on 06/07/2015 - 11:44 pm.

    medication been taking for a few weeks now side effects horrible

    please get back to me as soon as possible. I have had an extremely stressful situation with my husband who refuses to get meds and therapy and has been home since an injury since march 10 I went to my dr and he increased my synthroid, gave me a strong water pill and remparil blood presure medicationl Well I have bought every dry mouth product on the market feel tired cannot sleep for more then a few hrs. He then gave me a sleeping pill which I do not want to take I stopped the wter pill last week and stopped the high blood presure meds 2 days ago I think this was all too much for me in addition to the stress I have on a personal level Now he is going to give me annother bl pressure pill generic for advisil but after readin tonite I see it also has the same side effects. I might ad I always exercised and ate healthy but too tired to exercise even Any advice as what to do Really would appreciate it Thank You so much

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