Hypertension Heresy: Are We Overtreating High Blood Pressure?

Until August 15, 2012, if you asked almost any American physician whether someone with a blood pressure reading of 145/95 should be treated with medication, the answer would have been a resounding yes! Medical students and residents are taught that hypertension increases the risk of heart attacks, strokes and early death. Physicians have come to believe that aggressive treatment of patients with high blood pressure will lead to better outcomes.

Everything changed on August 15, 2012, when the Cochrane Collaboration published its analysis: “Benefits of antihypertensive drugs for mild hypertension are unclear.” The Cochrane Collaboration represents the highest level of scientific scrutiny of available studies. The experts who analyze the data are independent and objective and have come to be regarded as the ultimate authority on the medical interventions they evaluate. As far as we can tell, there is no better organization for assessing the pros and cons of pharmaceutical and alternative therapies than Cochrane.

There is no doubt that this review will create extraordinary controversy and push-back from the medical community. A bedrock belief is being challenged. That’s because these experts are suggesting that most of the nearly 70 million Americans diagnosed with high blood pressure are probably being treated unnecessarily. The researchers reviewed data from nearly 9,000 patients enrolled in four randomized controlled trials. These were people who had been diagnosed with what is called stage 1 hypertension. That means their systolic blood pressure was between 140-159 and their diastolic blood pressure was between 90 and 99.

Here is what the Cochrane Collaboration found:

“Individuals with mildly elevated blood pressures, but no previous cardiovascular events, make up the majority of those considered for and receiving antihypertensive therapy. The decision to treat this population has important consequences for both the patients (e.g. adverse drug effects, lifetime of drug therapy, cost of treatment, etc.) and any third party payer (e.g. high cost of drugs, physician services, laboratory tests, etc.). In this review, existing evidence comparing the health outcomes between treated and untreated individuals are summarized. Available data from the limited number of available trials and participants showed no difference between treated and untreated individuals in heart attack, stroke, and death.”

The abstract concluded:

“Antihypertensive drugs used in the treatment of adults (primary prevention) with mild hypertension (systolic BP 140-159 mmHg and/or diastolic BP 90-99 mmHg) have not been shown to reduce mortality or morbidity in RCTs [randomized controlled trials]. Treatment caused 9% of patients to discontinue treatment due to adverse effects. More RCTs are needed in this prevalent population to know whether the benefits of treatment exceed the harms.”
Over the last few decades something called “disease creep” has penetrated American medicine. That implies that the definition of illness has broadened dramatically. The label “hypertensive” used to be reserved for people with systolic blood pressure (the upper number) over 150 and diastolic blood pressure (the lower number) above 99. Nowadays, anyone with blood pressure readings greater than 120/80 may be labeled hypertensive.

There are data to suggest that once someone is labeled hypertensive it affects mental attitude. And most physicians feel it is their duty to treat high blood pressure aggressively to get the numbers as close to 120/80 as possible. That almost inevitably means medication; sometimes three or four different drugs are needed to achieve that number. Not uncommonly, these medications cause a range of side effects. ACE inhibitors can cause an unpleasant (and sometimes disastrous) cough. To read more about complications of this cough visit these links:

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Other antihypertensive medications can cause fatigue or dizziness and affect sexual function. It is important to know when to treat with drugs and when to encourage lifestyle changes (weight loss for example and relaxation techniques) to control mild hypertension.

To read more about the new Cochrane Collaboration conclusions we encourage you to read the reports by Jeanne Lenzer in the BMJ and Slate. She has done an excellent job reviewing the findings and making them understandable.

If you would like to learn more about ways to control high blood pressure with nondrug approaches we suggest you check out our Guide to Blood Pressure Treatment as well as the in-depth chapter in our book, Best Choices From The People’s Pharmacy.

No one should EVER stop taking a medication without consulting his physician. Those with definite hypertension, (like the fellow in the picture with a blood pressure reading of 189/101) must be treated aggressively with medication. Hypertension does cause heart attacks, strokes and kidney damage and leads to premature death.

We do encourage those with mild hypertension to make sure their physicians read the review in the BMJ and then take time to review the Cochrane Collaboration report. Shouldn’t physicians practice what they preach, ie “evidence based medicine?” The Cochrane Collaboration has reviewed the evidence and has challenged the status quo with hypertension heresy.

We hope the medical community will be open to considering the new data analysis. And we hope there will be more serious consideration of nondrug approaches such as losing weight, deep breathing, exercising and learning how to relax and shed some of the stress that can contribute to higher blood pressure readings. Health coaches can assist in this process. So can family and friends. Perhaps it is time to look beyond medications for mild hypertension.