To what extent should mild hypertension be treated aggressively? A new review published in the Cochrane Library suggests that widespread use of anti-hypertensives for this purpose may not be so beneficial, even though an estimated $20 billion is spent each year in the US, when including a variety of medicines, such as diuretics, as well as trips to the doctor, according to Cochane Library researchers who cite data from the Heart Disease and Stroke Statistics 2012. The Cochrane review analyzed almost 9,000 patients from four placebo-controlled, randomized trials and found many patients with mild hypertension are actually being overtreated (here is the abstract). And about half of the costs are spent on patients with mild hypertension, but none of them had a previous diagnosis of cardiovascular. The suggestion is that some patients may not receive any benefit from the medications, but could be exposed unnecessarily to possible side effects.
Specifically, the analysis found the meds do not reduce mortality or morbidity in adults with mild high blood pressure and no previous diagnosis of cardiovascular disease. Even though the researchers determined that the four trials had a moderate to high risk of bias favoring drug treatment, they found almost identical rates of adverse cardiovascular events in patients who were treated with drugs and those treated with a placebo. They estimated that 400 people would have to be treated with first-line drug for five years to prevent one death, and the number needed to treat to prevent one cardiovascular event during that time would be 128.
One Cochrane researcher believes doctors should think twice before prescribing blood pressure meds to patients with mild hypertension. “In the USA alone, as much as $20 billion per year may be saved and millions of side effects avoided by switching patients with mild hypertension from drug treatment to lifestyle modification measures—DASH diet, aerobic exercise, stress management, etc.,” David Cundiff, a former internal medicine physician at the LA County/ USC Medical Center, writes us.
One possible explanation for the widespread use of the drugs is simply to prevent high blood pressure from developing. Many physicians follow guidelines published by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, which were published by the National Heart, Lung and Blood Institute, and state that life style modification is first-line treatment, along with a thiazide diuretic (read here).
However, these were published in 2003 and an update is in the works. Meanwhile, the Cochrane review is unlikely to change practices, if only because physicians - and insurers - are likely to prefer to wait for still more evidence of this sort to become apparent. However, some experts say the widespread use of anti-hypertensives to treat mild hypertension may do more to benefit industry than patients.
“Drug treatment of mild hypertension, like intensive treatment of severe hypertension, may be of great value to drug makers,” Jerome Hoffman, a former professor of clinical medicine at the University of California at Los Angeles, told Slate, “but it was almost predictable that it would provide little or no benefit for patients... We shouldn’t subject patients to possible harm unless and until we have reasonably good evidence that it’s worth doing."
But not everyone agrees. "The results are not surprising to the people who've been in the blood pressure field for a while," American Heart Association spokesperson Roger Blumenthal, who is a director of the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins University, tells MedPage Today. The review, he adds, highlights a lack of a large number of trials supporting the use of antihypertensives in patients with mild hypertension, and that overall evidence suggests the detrimental effects of mild hypertension in the long terms suppose the use of medication.