Treating Mild Hypertension With Drugs May Be Misdirected
Written by Editor   
Wednesday, September 24, 2014 04:01 PM

Treating mild hypertension with drugs has unclear benefit and adds exorbitant sums to national healthcare expenditures, experts write in an article published online September 14 in BMJ.  Thresholds for management need to be reexamined, and priorities should shift to lifestyle change.

"The practical point for clinicians is that before you subject someone to lifelong medical therapy and its potential side effects, be sure that other elements like lifestyle changes have really been given a fair shot. That means don't pull the trigger too quickly," senior author Vikas Saini, MD, president of the Lown Institute and lecturer at Harvard Medical School, Boston, Massachusetts, said.

Dr. Saini outlined 3 main reasons for this assertion:

First, there is no clear evidence that treating mild hypertension with medication has the same effect it does on moderate to severe hypertension in terms of reducing risk for cardiovascular disease and related health problems.  Roughly 40% of adults in the world have hypertension, about half of which is thought to be mild (140 to 159/90 to 99 mm Hg). More than 50% of people with mild hypertension receive medication.  During the last few decades, thresholds for diagnosing and treating hypertension have been lowered. The assumption has been that treating mild hypertension, even in those without risk factors such as diabetes or kidney disease, can reduce the risk for cardiovascular disease and death. Studies, however, have not born this out.  In addition, overmedication contributes to ballooning healthcare costs, the authors argue. The United States spends about 1% of its annual healthcare expenses and more than 30% of its national public health expenses treating hypertension, amounting to more than $32 billion annually.

Second, Dr. Saini said, inaccurate blood pressure measurement contributes to over diagnosis.  "You want to be sure the readings that you're basing treatment on are reliable and accurate, and that often means getting home and multiple readings," Dr. Saini explained. For example, so-called white coat hypertension recorded at office visits is notoriously inaccurate, and automated cuffs and home-based methods may prove better prognostically.

Last, focusing on medication diverts resources away from investment in public health, Dr. Saini pointed out. Increased emphasis on system-wide lifestyle changes is needed, such as weight loss, decreasing salt intake, smoking cessation, reduced alcohol consumption, and increasing exercise levels.

The solution, he writes, is to rethink the approach, with a shift in resources and emphasis on public health rather than medical treatment.  "Doctors, public health workers, and community leaders really need to form an alliance. The path of least resistance of prescribing a drug feels good, but we have no idea if this really makes a difference," Dr. Saini emphasized. "Thirty billion dollars is a lot of expense for something that makes no difference. Thirty billion dollars would go a long way if it was organized in a collaborative effort across society to make lifestyle changes easier for all of us."