Is it any wonder Americans are totally confused about treating high blood pressure? A few weeks ago the highly regarded Cochrane Collaboration issued an objective analysis of clinical trials for treating mild hypertension. The researchers were interested in whether controlling mild high blood pressure with medication prevented heart attacks, strokes and deaths from cardiovascular disease. The answer was no, at least not for otherwise healthy people with no pre-existing heart problems.
“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].”
Now, the CDC (Centers for Disease Control and Prevention) has issued a strong warning that 1 in 3 American adults have high blood pressure. According to the CDC, at least half of the 67 million people with hypertension are not controlling it appropriately.
The CDC defines hypertension as systolic blood pressure over 140 and diastolic blood pressure over 90. Using such cutoffs, it is hardly any wonder that they came up with such huge numbers of people with uncontrolled hypertension.
Everyone agrees that it is essential to treat really high blood pressure (systolic of 160 or above and diastolic of 99 or higher). Getting serious hypertension under control prevents strokes and saves lives. The controversy lies in the gray zone defined as mild hypertension. Physicians have been urged to treat all blood pressure above 140/90, and many even prescribe blood pressure pills for patients with systolic pressures between 130 and 140. Striving to get blood pressure down to “normal” levels of 120/80 subjects many people to potential drug side effects, not to mention the expense of medication.
Dizziness is a common complaint among people taking blood pressure pills. It is sometimes dismissed as a minor side effect, but if it leads to a fall that results in a hip fracture, that is catastrophic. Such fractures frequently lead to death in older people. Other complications of aggressive drug treatment can include sexual side effects, uncontrollable cough, hair loss, lack of energy and life-threatening allergic reactions (angioedema).
One physician reports a personal experience and comments on the problem of “disease creep” (lowering the arbitrary cutoff for treatment so that many healthy people end up on drugs).
“As a physician/psychiatrist I have been quite concerned about “illness creep” for a long time. At first I thought it was mostly a mental health phenomenon, but over the last 10-15 years it is clear that the entire medical field is at risk. Last week I had my first annual physical in 40 years, and fell right into this “mild hypertension” quagmire. It was my first visit with this doctor, and being a physician myself, he released me on my own “recognizance” to monitor at home. I can’t imagine how vulnerable one must feel going to a doctor’s office these days without having gone first to medical school. It is imperative to become as informed as possible about any medical concern.” –L.G.
Doctors and public health organizations (like the CDC) revere the idea of “evidence-based medicine.” But when the evidence fails to support their beliefs, it is often rejected as incomplete or inadequate. That seems to be the case when it comes to drug treatment for mild hypertension. The Cochrane Collaboration report is likely to disappear from medical consciousness because the message from the CDC will drown it out.
What should we conclude from these contradictions? People with moderate to severe hypertension absolutely benefit from medication to bring their blood pressure down. So do people with heart disease. This is cost-effective treatment. But the millions of otherwise healthy people with mild elevations in blood pressure might want to show their doctors the Cochrane Collaboration report and BMJ analysis and discuss the pros and cons of drug treatment and the possibility of lowering blood pressure with weight loss, diet and exercise. To facilitate that conversation we suggest our Guide to Blood Pressure Treatment and the in-depth chapter on hypertension in our book, Best Choices From The People’s Pharmacy.
