In the 21st century doctors pride themselves on practicing evidence-based medicine. Recent studies of treatment for hypertension suggest, though, that practice is sometimes influenced by belief and habit as much as by evidence.

Prescribing drugs for patients whose blood pressure is 160/100 or higher is well supported by research that shows such treatment saves lives. What is less clear, however, is whether patients with milder hypertension actually benefit from drug treatment.

A systematic review of high-quality clinical trials by the independent Cochrane Collaboration revealed that antihypertensive drugs have not been shown to benefit patients with mild hypertension and no pre-existing cardiovascular disease (Cochrane Database of Systematic Reviews, Aug. 15, 2012).

Mild hypertension was defined with the upper number (systolic blood pressure) running between 140 and 159 and the lower number (diastolic blood pressure) between 90 and 99. Most physicians in the U.S. have been trained to treat patients with blood pressure in this range using medications.

British doctors, on the other hand, tend to be more conservative. A recent commentary by a London physician, “Waste and Harm in the Treatment of Mild Hypertension,” pointed out that treating such patients does not offer them any benefit but does pose risks (JAMA Internal Medicine, online, May 13, 2013).

The author underscores the influence of the pharmaceutical industry on existing treatment guidelines. Lowering the threshold for blood pressure treatment has been called “disease creep.” It created 13 million new “hypertensive” patients in the U.S. overnight.

The physician who pioneered hypertension screening, Dr. Julian Tudor Hart, responded to the Cochrane analysis, “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 intervention in the diastolic range 90-100 mm Hg?”

People’s Pharmacy readers know that our first recommendations for lowering mildly elevated blood pressure are usually the non-drug approaches doctors refer to as therapeutic lifestyle changes (TLC). These include diet, exercise, relaxation therapies, smoking cessation, alcohol moderation, or certain mineral supplements.

Following through on such lifestyle interventions is challenging, but it can lower blood pressure nearly as well as medication. TLC do not trigger side effects and often have additional health benefits. Both the Mediterranean diet and the DASH diet (Dietary Approaches to Stop Hypertension) have strong evidence to support their positive influence on cardiovascular outcomes.

People often complain about dizziness or sexual side effects with blood pressure medicine. ACE inhibitors like lisinopril or ramipril can lead to persistent coughing that can be incredibly disruptive. One reader reported: “My doctor told me that the cough that developed a month after taking lisinopril could not be due to the medicine. He said it would have happened anyway. I was given an inhaler for asthma. After using it to no avail, I insisted that we change the BP medicine and the cough disappeared.”

To practice evidence-based medicine, doctors need to keep up with the research and follow their oath to “First, do no harm.”

 

In the 21st century doctors pride themselves on practicing evidence-based medicine. Recent studies of treatment for hypertension suggest, though, that practice is sometimes influenced by belief and habit as much as by evidence.

Prescribing drugs for patients whose blood pressure is 160/100 or higher is well supported by research that shows such treatment saves lives. What is less clear, however, is whether patients with milder hypertension actually benefit from drug treatment.

A systematic review of high-quality clinical trials by the independent Cochrane Collaboration revealed that antihypertensive drugs have not been shown to benefit patients with mild hypertension and no pre-existing cardiovascular disease (Cochrane Database of Systematic Reviews, Aug. 15, 2012).

Mild hypertension was defined with the upper number (systolic blood pressure) running between 140 and 159 and the lower number (diastolic blood pressure) between 90 and 99. Most physicians in the U.S. have been trained to treat patients with blood pressure in this range using medications.

British doctors, on the other hand, tend to be more conservative. A recent commentary by a London physician, “Waste and Harm in the Treatment of Mild Hypertension,” pointed out that treating such patients does not offer them any benefit but does pose risks (JAMA Internal Medicine, online, May 13, 2013).

The author underscores the influence of the pharmaceutical industry on existing treatment guidelines. Lowering the threshold for blood pressure treatment has been called “disease creep.” It created 13 million new “hypertensive” patients in the U.S. overnight.

The physician who pioneered hypertension screening, Dr. Julian Tudor Hart, responded to the Cochrane analysis, “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 intervention in the diastolic range 90-100 mm Hg?”

People’s Pharmacy readers know that our first recommendations for lowering mildly elevated blood pressure are usually the non-drug approaches doctors refer to as therapeutic lifestyle changes (TLC). These include diet, exercise, relaxation therapies, smoking cessation, alcohol moderation, or certain mineral supplements.

Following through on such lifestyle interventions is challenging, but it can lower blood pressure nearly as well as medication. TLC do not trigger side effects and often have additional health benefits. Both the Mediterranean diet and the DASH diet (Dietary Approaches to Stop Hypertension) have strong evidence to support their positive influence on cardiovascular outcomes. (You  can learn more about them in our book, The Peoples Pharmacy Quick and Handy Home Remedies.) People often complain about dizziness or sexual side effects with blood pressure medicine. ACE inhibitors like lisinopril or ramipril can lead to persistent coughing that can be incredibly disruptive. One reader reported: “My doctor told me that the cough that developed a month after taking lisinopril could not be due to the medicine. He said it would have happened anyway. I was given an inhaler for asthma. After using it to no avail, I insisted that we change the BP medicine and the cough disappeared.”

To practice evidence-based medicine, doctors need to keep up with the research and follow their oath to “First, do no harm.”

 

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  1. Don S.
    Reply

    Hi folks, I just received this comment in my email in box. I thought it might be nice to catch you all up on my current BP status.
    About a year ago, a friend mentioned she had good results from a simple diuretic, Chlorthalidone. I had such bad effects from a previous diuretic (hydrochlorothiazide, I was reluctant, but I tried it and it was dramatic. I found a doctor who would prescribe it, and I’ve been taking 25 mg once a day and my BP has generally been 120-130 over 80, often as low as 115/70.
    My doctor has trusted me to adjust it myself, so he has given me permission to cut it in half as I see fit. I’ve been taking a half dose – 12.5 mg for about 2 months and the BP has stayed down. I plan in a few weeks to start skipping a dose altogether a few times a week and see if the BP still stays down.
    Previously I had recommended in this space diet, exercise and 2:1 breathing as the best tx I have found.
    I’d like to add one more. I lost 25 pounds in 3 months in 2004 and kept it off (mostly) since, but I’ve felt that if I could lose 10 more pounds it would make it easier to keep the BP down. On a whim, I tried out Mark Hyman’s 10 day detox (you can get it online; it should be easy to find). I lost 10 pounds in 10 days and it’s been effortless to keep it off for the past 2 months, keeping to a diet very similar to what he recommends.
    I would say that that diet has been the single most dramatic thing I’ve done in the 10 years I’ve been working on lowering the BP. I’ve tried doing half dose before, but it’s never been so consistently low as since I did the 10 day detox. I can’t say for sure whether it’s the diet or the extra 10 pounds I lost, but it’s incredibly filling, enjoyable, very very easy and quick to prepare and actually much cheaper than the old way of eating (we’ve cut almost $300 a month off our food bills eating this way).
    I can’t recommend it strongly enough. It may seem like paleo, by the way, but Dr. Hyman doesn’t have anything against grains and legumes. You could even follow Joel Furhman’s vegan diet and do the 10 day detox, though it would be somewhat more challenging. It follows all the most widely accepted guidelines for eating, it just makes it much much simpler to follow (and he has a FANTASTIC breakfast shake that keeps you filled up, is incredibly healthy and takes about 5 minutes to make. I sometimes make a dinner version adding more veggies).
    So, hope that’s helpful.

  2. mat
    Reply

    I was diagnosed with hypertension about 15 years ago, at age 37. My doctor then put me on metoprolol 25mg. I don’t remember what my BP was at the time, but I had an episode of near syncope, became dizzy and fell in floor. BP was high on arrival to ER. Spent 3 days in hospital with serial EKGs, stress test, anti-anxiety meds. Was working in a very stressful environment, RN in understaffed ICU. About a month after being on the Metoprolol, I was getting ready to go to sleep, and felt heart palpitations. Checked my pulse, and it was 30. Called my doctor and he immediately stopped the Toprol and put me on Norvasc. BP stayed fine for a couple of years.
    About 12 years ago, my bp went back up, again related to stress. I was put on Diovan. I was also taking Minocin for adult acne. One day my joints started swelling. ALL my joints! My fingers and toes looked like sausages, my knees were huge, my elbows, ankles, all swollen. Went to ER, all tests negative, including RA. Was given anti inflammatories, steroids, and told to follow up with my own MD. He said was likely a drug reaction, but not sure which drug. Stopped Diovan, as well as Minocin. Said the Diovan was new, and the Minocin had been know to cause a “Lupus-like” reaction. Swelling went away, acne and BP problems returned. We started back on the Diovan. After 2 days, joints began to swell and hurt. Went off it. Waited a few days, started back on the Minocin, joints began to swell and hurt. Doctor took me off Minocin and gave me Erythromycin. Doctor put me on antidepressant and gave me antianxiety med for use as needed. During this time, I developed an asthmatic reaction to QUAT cleaners used in hospital. Quit smoking, but became sick after each 12 hour shift that I had to use the cleaners. BP okay for a while, and my doctor retired his practice. On going to new doctor, BP slightly high again after a few years. She put me on Losartan, even though I had reacted to Diovan. Had no problems with joint swelling, and at the time did not realize the drugs were related. I began to have joint pain, and by now am in my mid forties, post hysterectomy, menopausal, and depressed, still working as a nurse in different high stress job. She changed me to Cymbalta. When joint pain remained, she increased my Cymbalta. Joint pain remained, took NSAIDS until stomach would no longer tolerate them.
    Changed doctors. New doctor said I have arthritis, recommended exercise and Tylenol since pain not severe. On doing research into meds, discovered relationship between Losartan and Diovan. Asked doctor to change BP med, joint pain improved immediately. Was put on Lisinopril, developed a cough within 3 months, was taken off Lisinopril and put on a different “sartan”, but don’t remember name. Joint pain returned, doctor left his practice. Told new doctor of problem with joint pain, he put me on carvedilol, an now have a cough again, I have audible rales and wheezing that inhalers don’t help. Went off the Carvedilol, and cough is better. Am scheduled to see doctor in a week, BP is again high. Working in a lower stress job because of reactions to cleaners, but now diabetic, have osteoporosis with mild and moderate spinal stenosis with back pain and sciatica. Joint pain remains only in right shoulder and hip, and that is improved since going off carvedilol. I feel I am having systemic inflammatory reactions to these drugs, but am afraid of what my doctor is going to say. since these reactions are not listed in the known reactions. I know that these reactions are unusual, but I know they are real. I have a family history of unusual drug reactions. My father once had a reaction to erythromycin that consisted of a fever. Over the course of treatment, his fever went up after each IV dose of the drug, until it was 107 with chills so severe his bed could be heard shaking down the hall. He refused to take any more, and his fever went down immediately.

  3. Don Salmon
    Reply

    Ada, if you can afford it – if your doctor doesn’t listen to you, find another doctor. There’s simply no excuse for not taking a patient’s complaints seriously, and most important, it’s dangerous when the doctor doesn’t listen.

  4. Ada L.
    Reply

    Wow – thanks so much for posting this information. I was also diagnosed recently with borderline high BP and put on Lisinopril. AT first, I was taking only 1/2 of the tiny tablet…and I felt great. Most noticeably, my persistent ankle swelling almost immediately improved noticeably. When I told my doctor, she told me to go up to the full pill. About a week later, I started having continual lightheadedness and nausea every day. Even though I am not diabetic, I bought a glucose meter to check my blood sugar. All was fine with it. Then I decided to drop back to half a tablet of the Lisinopril, and the constant lightheadedness and nausea has gone away. I am still a little lightheaded when I awake in the morning, but it seems to go away within an hour. This article has motivated me to talk to my doctor about the medication. Thanks very much!

  5. Pat H
    Reply

    My story is very similar to yours. In 2003, I was told that I had hypertension and that I was going to die. This was said by a doctor that I did not know, in a very loud and rude tone. He set the stage for these last ten years of torment. At that time my readings were somewhere around 140/80. My primary physician at that time place me on lisinopril and then quit her practice. The next physician placed my on several other meds ranging from Toprol XL to Atacand, which almost killed me.
    At that time I had a very stress job that was driving me insane. I retired from it, learned joga, joined a gym, and learned swing dancing! My numbers were good then. I decided to return to work, and that was the wrong move. So now, I’m retired again. I have been through 4 different doctors and number 5 is being fired today. Doctor 5 is Dr Jekyl and Mr. Hyde. Two personalities. Rude. I have decided that I will not be treated like an idiot.
    When my pressure was elevated at her office this week, she assumed that I was not taking the meds. I explained that I was taking them, tried to show her my pressure log which indicated that my systolic was averaging 140-150 ish, but my diastolic averages 72-77. In her office everything was elevated because I am now terrified of doctors, pressure readings, etc. Since, I now have heart damage, according to the EKG that was performed in her office last month, I tried to ask her just how severe this damage is. She ignored my question, told me I could find a specialist if I did not follow her directions. She then proceeded to tell me that I will now be taking 40 mg. prinivil (which no longer works), 10mg amlodipine (I said that my feet will look like sausages), 6.25mg Coreg (What?), and lasix.
    Lasix was prescribed when I said that I have a strange reaction to drugs that contain sulfa, hence, I did not want to take HCTZ. And I’m supposed to return in three days or find myself a new doctor. I just don’t know what to do anymore. Thanks for letting me vent!

  6. Janet T.
    Reply

    2009 Primary care doctor said blood pressure 140/80 too high put me on Lisino pill. June/09, July/09, Aug/09, throat closed, gagging, coughing, nose dripping, vision problems like peering through puddles of water, reading paper, words/numbers disappeared replaced by green criss cross marks, called doctor she said go to hospital, call 911, yes they were all strokes, doctor said continue taking pill, so I took the last 10 pills and put them in the garbage disposal. I got back to normal. But heart did not.
    My aortic valve has to be replaced and until it is I have atrial fibulation and swollen legs. August 2013 cardiologist puts me in on diuretic/blood pressure pill since my blood pressure is too high at 143/80. Pill is 12.5grams of hydrochlorothelazide and guess what, the same symptoms showed up, throat closing, gagging, nose dripping, dry cough, weird vision, after 3 weeks I decided not another stroke and quit the pill cold turkey.
    I had one bad headache and what I call prism views, corner of the eye seeing images that eventually go away. Big change too, I went from my house with good diet to assisted care center with cheap starchy, fatty, sugary diet which I know is slowly killing all the residents here at my assisted care facility in Tigard, Oregon, including me.

  7. gail
    Reply

    I have been having a problem with “in the office blood pressure” readings. Most of my problem comes from the fact that I have VERY large arms and, even though a large cuff is used, when the cuff is being inflated in am in a great deal of pain (no, I DO NOT have a low pain threshold), and, inevitably, my pressure is 145/80 or 85.
    I refuse to take BP medications because I am of the opinion that pharmaceutical companies have convinced doctors that a 120/65 or 70 is the ideal BP. Go back 25 years ago and a 140/80 was fine. Doctors do not listen except on rare occasions. I always say, think for yourself, and question everything.

  8. Bdm
    Reply

    Aortic valve insuffiency. Have you been checked for a bicuspid valve with regurge?

  9. Joan
    Reply

    curious on follow up.

  10. HJL
    Reply

    Re: white coat syndrome. My Cleveland Clinic doc has his assistant take my pressure. He then sees me. After he sees me, the assistant comes back in and hooks me up to a machine and leaves. The machine takes 5 readings of BP over 5
    minutes.
    The doc then returns, looks at the results and gives his final talk.
    The average of the 5 readings is always significantly below the first reading.
    erhaps all docs should follow this procedure to get a more accurate BP picture and maybe stop the inexorable march of over medicating people.

  11. SalW
    Reply

    Again, thank you so much for getting to the real story behind the over prescribing of blood pressure medications. We would never heard it anywhere else but here! I just can’t believe that my geriatrist, 33 years in practice, has not gotten the message that the original trials to justify hypertension intervention were to treat in the diastolic range of 90-100 mm Hg.
    The very wealthy pharmaceutical industry has way too much influence on doctors, and, as a consequence, we patients then suffer from the “disease creep” that ultimately is created, especially in the area of hypertension treatment. Too much time is spent on treating symptoms, which is easier to just lower those numbers, instead of looking at alternatives/causes. I’ll never forget the recent comment of my husband’s cardiologist who said that most of their patients were diabetic. And what caused it? Another medication?
    At my recent physical, my blood pressure registered 144/77 (with a machine and how accurate?); I had not eaten in 13 hours (was hungry) and last Losartan/HCT 100-25 was taken 28 hours previously (I am 74 and female). He should at least have taken it again before I left (white coat hypertension?) and before he then increased my prescription to Valsart/HCT 320-12. I have no pre-existing cardiovascular disease. Pure “disease creep!” My average home readings the last 22 days have been 139/70.
    In light of the new bombshell of ARB’s possibly causing lung cancer (my father died of lung cancer), and I have been on ARB’s for a long time, I now will tell my doctor that I want to turn to more natural forms of blood pressure control like meditation (perhaps RESPeRATE), increase exercise, etc., and I know what foods to eat. I owe it to myself for the remaining days I have left to get it right!

  12. Don Salmon
    Reply

    This is for CF and Lester RB. Terry and Joe, I hope it’s ok to post again on the same topic.
    I’m a clinical psychologist, not a medical doctor. But I’ve seen 9 medical doctors since 2004 and read over 8 books on hypertension. I’ve also talked with many people who have had similar difficulties dealing with physicians regarding BP meds. But again – I”m not an expert, so this is just from my experience.
    My answer regarding every question (what causes high systolic, what are the side effects of a particular medication) is the same. This is what I’ve heard from every doctor. I’ll tell you in a moment, but it took me years to come to terms with their uniform answer.
    We don’t know.
    Or to put it more bluntly, “we have no idea.”
    I would collect data, twice a day over a month. There were, to me (and I’ve conducted quantitative research) clear trends, identifiable causes, associated with various foods, herbs, forms of exercise, or in several cases – with particularly dramatic results – breathing exercises.
    They would always shake their heads. The majority simply showed no interest whatsoever. The more humble ones would rather embarassedly admit something like, “Well, you would think we knew more about it, but as far as I know, nobody really knows.”
    Again, particularly with side effects, in my experience and in that of a half dozen people I’ve spoken with, doctors will either ignore you, trying to change the subject as fast as possible, or in the case of my first doctor, she actually said, “Oh, my patients don’t have side effects on these drugs.” My wife was there and heard her say that, and when I brought it up, she denied ever having said it. She also had one of those young blond drug reps in her office every time I went there.
    IN conclusion, if you really want to get better, I recommend being very mindful of what you do, what you eat, how you exercise and how you feel. Ultimately, you are the expert on getting better.
    One last thing I want to mention which was implicit in the editorial but wasn’t quite brought out. As far as i understand the research, the editorial is correct – BP meds haven’t been found to be helpful in actually lowering the incidence of heart disease for people with mild hypertension. But that DOESN’T mean you shouldn’t be concerned if you have mild hypertension (Apologies Terry and Joe – I know this is implicit but I was concerned it wasn’t as clear as it could be). It may seem hard but it will improve your whole life. There’s definitely tons of research showing that if you have mild hypertension, you ARE more likely to get heart disease and a host of other ailments. It’s just that treating it with pills doesn’t help; but treating it with lifestyle changes does.
    Here’s the 3 I’ve found most helpful:
    1. DASH II diet or something like it (the Mediterranean is mentioned above).
    2. Exercise: in almost all alternative publications I see food, herbs and supplements emphasized in much more detail. If I had seen detailed instructions about the benefits of aerobic exercise 8 years ago with the same frequency, I might have gotten off pills at least 5 or more years ago. Start walking 5 minutes a day if you think you dont’ have time. You’ll feel so much better you’ll make time to increase it. Intervals of fast and moderate walking are what lowered my blood pressure – I’ve seen more studies recently, now that I’m paying attention to it, showing the interval exercise, because it improves blood flow and makes the whole cardiovascular system more efficient, is especially good for lowering blood pressure.
    3. 2:1 breathing. Every article on alternatives to meds for lowering BP should include this. you can start now, as you’re reading, it costs nothing, and there’s a plethora of studies showing it works. Sit for 15 minutes, 4 times a week (if that seems to much, start with much less, but the research shows that works). Its incredibly simple – breathe out for twice as long as you breathe in. you want to work towards 4 or 5 breath cycles a minute (that’s around 4 seconds in and 8 seconds out).
    Good luck!
    People’s Pharmacy response: Don, we could not have said it better ourselves. Thank you for making all these points, especially the one about breathing. The FDA has approved a fancy device called RespErate that helps people learn to breathe more slowly. If you concentrate, however, you may be able to learn without the fancy device. It will lower your blood pressure.

  13. Don S.
    Reply

    by the way, in regard to my last comment, I definitely am not recommending anybody else do what I did – stop all BP meds suddenly.

  14. Don S.
    Reply

    Ahh, will this ever be taken seriously by doctors?
    Where to start. I found out I had 160/100 Bp in 2004. Do you know – at least at the time – if it wasn’t higher than 160/100, the American Heart Association still recommended 6 months of life style changes before trying meds. When I first went to the doctor, I had already dropped my average salt intake from about 4000 mg to 1000 mg, lost 25 pounds (have kept it off in the last 9 years) and started a regular exercise routine.
    Nevertheless, the doctor insisted on meds. Well, I thought, doctors know what they’re taking about. To put it briefly – the BP stayed 160/100 for the next three years. I always felt exhausted, and at least once a month for several days felt fluish. By the end of the 3 years, I felt fluish for 2 months straight. One day in June, 2007, I just stopped all the meds cold, figuring whatever rebound effect there was it couldn’t be worse than feeling like you have the flu all the time.
    The BP dropped to about 138/85 within 5 days and averaged about 142/86 for one year. Then, still believing medical propaganda, I thought, “well, I better take some pills to get it down further. 3 months later, I was in the ER with 190/120, a direct reaction to the pills (Clonidine, whereas I had had a succession of ARBs combined with hydrochlorothiazide before). Some months later I was back in the ER with 230/130.
    Finally, I tried Procardia, which got it down to 125/75 but I started having nausea for several days a month.
    To jump to the end, I’m on chlordalidone, 25 mg, a diuretic (and no side effects!) my BP averages about 120/75, my doctor said I can cut the pill in half in a few months, and he expects me to be off all meds by the end of the year.
    I’ve tried everything in the last 9 years – acupuncture, DASH II diet (with special emphasis on foods high in potassium, magnesium, and calcium), Ayurveda, 2:1 breathing (see Respirate), every conceivable herbal and other kind of supplement, yoga, Qigong, etc.
    You know has been the single most effective thing? Nothing that any of the 9 MDs I’ve seen (or even the alternative specialists) thought of.
    Upping my aerobic routine from an average of 20-30 to an average of 30-40 minutes. The single biggest drop in BP as well as the most effective stabilizer.
    It may be different for you, but I want to leave you with one thought – if you have high BP, whatever you do, don’t believe your doctor that you have to take pills or if you take pills, you have to be on them the rest of your life.

  15. Lester R B
    Reply

    I take losartin and my bp is usually in the range of 135/66. Does this medication have any of the side effects that you mention above.
    Please let me know.

  16. C. F.
    Reply

    I have a high systolic, from around 150 to 190, but my diastolic usually stays in the 60s, sometimes getting into the 70s. I am on a calcium channel blocker and HCTZ, which keeps my systolic in the 130 range. No side effects. What causes a high systolic and low diastolic?

  17. roseglass
    Reply

    This is very true, my husband and myself have been undergoing a lot of side effects due to our hypertension medications and our doctor just look at us, as if we are just making up everything that we have explained.
    I believe that this doctors need to keep up with what is right for their patients and even though there are some patient’s that just like to complaint(retired nurse) about almost everything, there is some of us that do not. for when we complaint we complaint because there IS something wrong.

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