The People's Perspective on Medicine

Brits Contradict U.S. Experts About Blood Pressure Treatment

Half the American adult population has hypertension (HTN) according to guidelines. Why doesn't blood pressure treatment with meds for mild HTN save lives?

A key component of medical treatment is blood pressure management. Whenever you visit a doctor’s office, you will almost always have your blood pressure measured. Guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) require health professionals to seek a systolic blood pressure goal of 130 or below and a diastolic blood pressure goal of 80 or below. Doctors are supposed to initiate blood pressure treatment if patients cannot get it down with lifestyle interventions alone. How well do medications work to reduce heart attacks and prolong life? A new British study challenges American guidelines.

A Truck Driver Can’t Achieve the Goals:

Q. I’m 34 years old and drive a truck commercially for a living. The Department of Transportation requires us to have regular physicals. My blood pressure (145-155/80-85) has caused the doctors concern. They all urged me to lose weight, lower my salt intake and exercise regularly.

I lost 90 pounds and now eat 1700 mg or less of sodium a day. I ride a stationary bike for 30-60 minutes every day and have a resting pulse of about 55 bpm.

My blood pressure is 145/78 at this very moment, even after living this lifestyle for two years. This is just who I am. Obviously, I’m healthier, but my efforts did nothing for my “hypertension.”

A. Congratulations! Losing weight and exercising regularly are among the most important steps you can take for good health.

Guidelines for physicians encourage people with blood pressure higher than 130/80 to implement lifestyle measure like yours. If that doesn’t work to lower blood pressure, doctors are supposed to prescribe antihypertensive drugs.

Blood Pressure Treatment: Did It Make A Difference?

A new study, however, calls U.S. blood pressure guidelines into question (JAMA Internal Medicine, Oct. 29, 2018).  British researchers reviewed the records of over 38,000 people with untreated blood pressure between 140/90 and 159/99. Half of these individuals were prescribed medications while the other half were not.

At the end of six years of follow-up, there was no difference in the rates of heart attack, stroke or death.

Here is the conclusion of the British researchers:

“This prespecified analysis found no evidence to support guideline recommendations that encourage initiation of treatment in patients with low-risk mild hypertension. There was evidence of an increased risk of adverse events, which suggests that physicians should exercise caution when following guidelines that generalize findings from trials conducted in high-risk individuals to those at lower risk.”

High Risk vs. Low Risk Hypertension:

Everyone recognizes that people with serious hypertension must be treated if they cannot get their blood pressure under control with diet and exercise. Very high blood pressure increases the risk for heart attacks, strokes, kidney damage, visual problems and early death.

But where is the cutoff? There is no question in our mind that lower blood pressure is better than higher blood pressure. If you can get your blood pressure reasonably close to 130/80 by losing weight, meditating and exercising, that is great.

The British Cutoff is Very Different!

If you go back and look at the British study, you will discover that people with systolic blood pressure between 140 and 159 and diastolic blood pressure between 90 and 99 did not benefit from blood pressure treatment with medications.  That result contradicts American guidelines.

The leadership of the American cardiology community will no doubt challenge the British conclusions that blood pressure treatment with drugs for mild hypertension did not prevent cardiovascular disease or prolong life.

The British scientists added insult to injury by stating that:

“…treatment exposure may be associated with an increased risk of adverse events…in the context of little evidence of benefit, suggests that physicians should be cautious when initiating new treatment in this population, particularly because such an approach may affect millions of individuals.”

Surrogate Endpoints–A Misleading Goal:

Far too often health professionals have relied upon indirect measures of health: blood pressure, cholesterol, blood sugar. Although these numbers are important for assessing overall health, lowering them into a “normal range” with drugs does not mean you will automatically achieve a positive outcome.

What people really care about is not a lab value, but a meaningful outcome. Will they live longer, healthier lives? There are many examples of drugs that moved the needle on some metric like blood glucose or cholesterol, but did not improve outcomes like heart attacks, strokes or lifespans.

We have written about this in much greater detail in our book, Top Screwups. It provides insights into blood pressure treatment as well as cholesterol management. You will also learn about how to avoid diagnostic errors and hospital mistakes.

Share your thoughts about the pros and cons of blood pressure treatment below in the comment section. If you are on blood pressure treatment for mild hypertension, never stop your medication suddenly! That could lead to serious complications, including a heart attack. But you may wish to print a copy of the British research published in JAMA Internal Medicine (Oct. 29, 2018) and have a candid discussion with your physician about the results of this study.

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About the Author
Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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In your book “The New Peoples Pharmacy” you recommend the Omron plood pressure cuff. Can you update your recommendation for home testing of blood pressure, please?

When my doctor told me that the new goal was a blood pressure reading of 120, I told her it was a plot by the pharmaceutical industry to get everyone on blood pressure medication. She laughed and dropped the discussion for that visit

Let’s make sure BPs are correctly measured! Has anyone had the experience of being marched through a maze of hallways after sitting for an hour in the waiting room and then having an automatic cuff slapped on their arm as soon as you sit down? BP should be measured after a 5 minute rest, in a chair with supportive back, arm well supported and “manual” cuff used. See the AHA website for more about how to correctly measure a BP. I have nothing against auto cuffs for home use as long as they have been checked against a “real” BP and are being used absolutely per manufacturer’s recommendations. I always tell my patients that auto cuffs for home use are great for monitoring trends.

I agree, Kathleen! I had not been to a doctor in years, but finally booked a physical exam. After trotting back through the hallways with the nurse, jumping on a scale, walking between numerous nurses and techs as they peered at me, the nurse had me hop up on a table, legs dangling, back unsupported, all the while asking me sharp questions about symptoms and meds. Then she put a bp cuff on me and turned on that infernal whining machine. Then she took a meat thermometer and started to jab it at my face. I finally realized she wanted me to open my mouth and to get an under-the-tongue body temperature. Then she grabbed my hand and pinched my finger with a strong clip. I later learned this read my pulse. The whole experience felt like an assault. So guess what? My bp was running a little high…

Get a dog that suits your lifestyle and start walking. Great health benefits! And, the dog is good company for those of us without partners/husbands/wives. I absolutely have to get up, very few exceptions, and walk the dog. She’ll start to misbehave after 2 or 3 days of not walking. She’s a pet but also a ‘tool’ which forces me to rise even when I don’t want to. Over weight? Get a dog. Depressed? Get a dog. Lonely? Rescue and adopt a dog!

I’m a Brit and follow the more conservative British medical guidelines in general.
In the case of blood pressure, on top of all this, you have to consider the difficulty of getting good readings. Many physicians do not follow good practice when taking blood pressure. And there are many of us with known white coat syndrome to contend with.

I gave my doctor a copy of this essay: Hawthorn: For the Heart By Christopher Hobbs. She was reluctant to take me off the two prescriptions I was taking for HBP.

She let me do it and much to her surprise and delight when I saw her six weeks later my blood pressure was 139/75.

She was amazed. I use one dropperful of Hawthorn Tincture with breakfast. I doubt if she recommended the herbal remedy to other patients though.

I am not Hypertensive yet when I have a blood pressure reading of 120/ 82 my Dr. wants me to take Losartan in addition to the 25mg of Beta Blocker I take. When I do this, my legs feel like lead. I have a hard time mowing the lawn or walking. I stopped the Losartan and can get my BP to 120 over 80 or lower by just breathing deeply. He disagrees but I like to do things, not just sit on my butt.

25 years ago, when my blood pressure was 138, my primary care doctor prescribed a pill and I refused. I researched, found the foods that help lower blood pressure, practiced belly breathing and drank red hibiscus tea 3 or 4 times a week. My blood pressure is normally 120 over 74, rarely does it go over 125. I am 78 years old, and yet, twice, when I have been sick with viruses or gastric problems I have had doctors try, once again, to put me on a regimen of blood pressure medicine. Two different doctors yelled at me when I refused their advice during a recent hospital stay for a viral infection. When I told one of them to check with my primary care physician about my normal blood pressure, he said he didn’t care what it was normally! Are doctors making money for prescribing this stuff? It defies all reasonable explanations.

MDs need to pay more attention to how Vets practice. I won’t forget a vet at a pet emergency clinic doing a followup on my husky, who had a sudden bleeding problem another vet recognized and treated effectively. This vet diagnosed the problem by SMELLING the dog’s blood, verified it with some lab work. The F/U vet looked at his labs, still on the low side, looked at him all perked up, and decided not to order another unit of greyhound blood. “I prefer to look at the patient before changing the plan because of lab values.” Husky lived several more years of an active happy life.

A systolic reading pf 130 or below for everyone? IMPOSSIBLE! This makes just as much sense as saying EVERYONE needs to consume 1600 calories or less per day, or your heart rate should be 50 BPM, or we can’t exceed 12 respirations per minute. We are all different. There is no, and there can not be, a one-size-fits-all, cure-all in any shape or form. What are your daily caloric needs? How much time do you need to run a mile? We all have different needs, and we all need to be “treated” ONLY when we’re ill.

Seconding Dagonet’s advice. If it’s not broken, don’t try to “fix” it. Doctors’ heavy-handedness, no doubt aided by Big Pharma bonuses and crappy generic drugs, are the third cause of death in the US.

If you have arteriosclerosis low blood pressure will kill you faster than high blood pressure. In Britain the number 3 cause of death is vascular dementia which is caused by low blood pressure not to high.

Maybe it’s time to change doctors? Or ask different questions. This is an excellent book/guide to know what to ask your doctor. My opinion about doctors isn’t exactly stellar and this book has taught me how to to communicate with them in “their language”. Don’t be bullied.

Having a heart attack or stroke is not the only factor in lowering blood pressure. There is also the problem of cardiomyopathy. If the heart has to labor with high blood pressure, the heart becomes weaker and may enlarge.

If your heart does not produce cardio homeostasis it will not be able to deliver enough blood to the periphery and you will have induced the problem with medications.

Rising blood pressure is NOT necessarily a sign of illness.

Just do a search in the Cochrane Library, and you will find several studies on this.

My family doctor is a geriatric physician. I am about to turn 85, and average BP is 125-140 over 75-85.
He tells me not to worry about anything in the 140’s because it is NORMAL for seniors to have higher BP than younger people. I averaged 125/80 until my 70’s.

I have been a regular exerciser since 1974 and eat a good diet. I have no family history of heart disease.

I DO have problems with several of the BP meds previously prescribed for me. At night, I get an extreme dry mouth, and it causes sleeplessness and hacking coughs all night.

My instructions now are to take my BP every morning, and take a half of my amlodipine if I go over the 140’s into 150 or more. So far, I have had to do that only once in 3-4 months, and I was ill with flu at the time.

All prescription drugs have side effects and may do more harm than good. I am 75 and have never taken a prescription drug. BP averaged 121/70, with a resting heart rate of around 58. I eat very healthy, and don’t worry about BP, blood sugar, and all the rest other older people worry about. If you go by a big chain pharmacy, look where all the filled prescriptions are hanging. It looks like thousands of them. If one goes to a doctor, one is going away with a prescription for some type of drug. Doctors may do more harm than good, too . . . LOL.

As you point out in your book and as do Prasad and Cifu in Ending Medical Reversals – Improving Medical Outcomes, Saving Lives, so often we look at “surrogate” end points like BP and cholesterol and not actual disease. And that this study points out the harm that prescribing medicine can do. This is particularly important with the recent new BP guidelines by the American Heart Association and American College of Physicians recent guidelines set to massively increase the number of people medicated for mild hypertension.

Unfortunately, in medicine it appears that when one end point is reached, we tend to change the end point. Is this because we just want to have a goal that has not been reached, a challenge so to speak? Is it like chasing the 4 minute mile?

No, it is the MONEY!!

I am on this medicine. What is a good one, that will not kill you before you’re time? What is a good alternative med for anxiety? Sure glad I get your Emails. Thank you so much.

Magnesium is what you need for panic attacks and anxiety. Low levels of magnesium will cause anxiety. I have not had an attack since taking 150 mg of magnesium chloride. Also, if your blood pressure tends to run on the high side, red hibiscus tea is excellent for reducing it.

A regular meditation or mindfulness practice will really help with anxiety..so does the breathing in yoga..

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