How Should Mild Hypertension Be Treated?

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.

15 Comments

Aug 20, 2012 - 2:15pm
I don't have access to the full paper, but given the 95% probability intervals, I'm not sure this study had the statistical power to draw any real conclusions.

In the abstract, the nominal relative risk of a CV event is given as 0.97 with a 95% probability interval of 0.72 to 1.32. Thus the study fails to prove a benefit of treatment, but this is a far cry from proving no benefit.

I'd guess that the error bars around the NNT estimate are pretty broad as well. But assuming that the nominal value of 128 is correct, the cost of preventing one stroke with generic Norvasc comes to 128 x 5 x $60 = $38K (assuming the NNT is for 5 years treatment.) Not cheap, but I'd challenge the authors to get a patient through a coronary bypass and rehab (for the survivors) for an amount significantly less than that.

Aug 20, 2012 - 4:40pm
"However, some experts say the widespread use of anti-hypertensives to treat mild hypertension may do more to benefit industry than patients." Why look at the expert opinion cited and see what relationship with industry they have. A partial list of side effects from blood pressure medicines include hearing loss; vision loss and an occasional stroke. The fact is there is no evidence for half of the patients treated none. Medicine from...' first do no harm ' to shoot first and ask questions latter .
Aug 21, 2012 - 10:59am
Very annoying study. As with most Cochrane analyses, it appears deeply flawed. Let's hope this doesn't result in many unnecessary events and even deaths. Yes, we should be using lifestyle adjustments first. every doctor I've ever dealt with attempts this. But it hardly ever works because patients are people and hypertension has no symptoms. So then what? How do we define "mild" hypertension? If you are that 1 of 128 who avoided a CV event, it probably doesn't seem like a bad idea that your hypertension was treated. The antihypertensive medication market is heavily genericized, so blaming overtreatment of hypertension on drug companies is yesterday's news. What were the drug classes used in the studies Cochrane pulled? If they're all old (no ACEis or ARBs) as I suspect) then it's less surprising to see little benefit. A look at the literature shows that the classes of treatment are not equally protective. Finally, how long were the studies? Treating hypertension to prevent CV events and death is a long term strategy, especially in "mild" hypertension. Anything short of 10 years is irrelevant. Finally, if you use a newer class of antihypertensive at a low dose, the side effects are negligible (unless you get pregnant taking an ARB).
Aug 21, 2012 - 11:33am
Agree with ted. Another underfunded garbage in/garbage out study by the discredited Cochrane Collaboration. Hope this will be the last one Ed posts.

Here's the real science, ted, as you know. A four year study is worthless for long term followup. I'll do you 10 tines better-a 40 year followup by the Framingham Heart Study, which compared the prevalence of long term sustained hypertension and its treatment in 1950, 1960, and 1970 using the Mantel-Haenszel test. Cardiovascular disease (CVD) incidence and mortality were compared between patients with LTS hypertension with and without long-term treatment by use of the χ2 test. Cox proportional hazards regression analysis was used to estimate 10-year risk of death as a function of risk factor levels and treatment. While CVD incidence was similar (26% versus 25%), all-cause mortality was significantly lower among men with long-term treatment (31% versus 43%; P<.05), and CVD mortality was less than half (13% versus 28%; P<.01). Among treated women, all-cause mortality was 21% (versus 34%; P<.01), and CVD mortality was 9% (versus 19%; P<.01). Ten-year risk of CVD death for patients with LTS hypertension with long-term treatment compared with those without was 0.40 (95% CI, 0.27 to 0.60).

http://circ.ahajournals.org/content/93/4/697.full

the mantra: TREAT. HYPERTENSION. AGGRESSIVELY

Aug 21, 2012 - 5:03pm
Lets look at this red herring'

"1950, 1960, and 1970 among three cohorts of men and women in the Framingham Heart Study " since none of this relates to the data on treating 'mild hypertension' what actual scienec is presented on this topic here.

Aug 21, 2012 - 8:18pm
Vince, the data are this: there is a 90% risk probability that if you are at least 55 years of age you will develop some form of hypertension, mild or greater. If you don't want to get checked or treated that's your call, but when you stroke out remember to carry your drool cup in your good hand so that you don't soak you keyboard.

What's your street cred, Vinny? Can you tell the difference between a series of unrelated medium term placebo control trials and a solid long term longitudinal cohort control study? Maybe you should order an epidemiology book from Amazon before lecturing us on herrings red or otherwise.

Aug 21, 2012 - 8:30pm
BTW, read this and you'll see that up until recently the "purity" of the Cochrane reviews has been influenced by the fact that some reviewers have received commercial support. The CC godfathers have tried to put a halt to this but in this atmosphere of financial austerity I don't doubt that the holy water of the Cochrane Collaboration will have a few drops of commercial crude admixed in for a long time to come.

http://www.cochrane.org/about-us/commercial-sponsorship

Aug 22, 2012 - 11:37am
Mild hypertension management can't be done properly using the drugs developed for critical hypertension - that's the issue.
Hi Dzieczko,

Thanks for the thoughts. I have a quick question about your last comment - why wouldn't dosing solve that problem?

ed

Aug 22, 2012 - 9:35pm
Dosing would indeed solve that. In fact I have mild hypertension and a daily dose of 5 mg of Norvasc keeps it under control very nicely. That's we we do Phase II dose ranging studies in hypertensives along with nested subgroup analyses to determine which doses are effective for which BP strata.

However, in practice, because these drugs have side effects, the general practice is that when single agent control becomes difficult, rather than escalate the dose of one agent it is general practice to add a low dose of a second agent, so that the patient can be controlled at the lowest efective dose of each.

Whether you choose to initiate treatmnent with a diuretic, beta blocker, calcium channel blocker or ACE inhibitor they are all very effective at low doses in mild to moderate hypertension. If they were too strong for the patients with mild hypertension we would see patients dropping in their tracks from low BP, but we don't.

Aug 23, 2012 - 12:00pm
Agree that the lowest effective dose is how clinicians attempt to manage "mild hypertension", but, unfortunately, the optimum dose that everyone thinks they found is less stable - meaning that it quits working properly (as defined by side effects) much more frequently in the mild hypertensive patients.

So more dosing changes are needed, in general. It's almost a continuous and frustrating process with some people - and so they quit taking the meds. Then they go back for a check-up, after being self-unmedicated, so to speak, often for many months, and it's discovered that their steady state BP is no longer in the "mild hypertensive" range - it's in the "normal" range.

It's a completely different "dataset" that deserves study - in other words, there is no condition that is "mild hypertensive".

Aug 23, 2012 - 8:11pm
This is mostly red herring to me. I had an MI in 1998 largely due to stress.I had unstable angina and multiple blocks and was advised bypass surgery. I declined it. With a not too strict vegetarian food and other regimen and no medication except aspirin. I have recovered and last week climbed 500 steep steps to the top of a hill fort. All my indicators are optimal(BP 70/110) I am 72 My wife is 'mildly hypertensive' and is controlling her BP through a diet quite well. Why be in the thrall of the drug and insurance industry when there are means to reduce health expenses for the family and the country? Is this part of commitment to unbridled capitalism?
Aug 23, 2012 - 8:17pm
Hey pal, if you had put down that jar of herring in the first place you could have saved yourself some chest pain. Almost 1/2 gram of sodium/jar:

http://www.livestrong.com/thedailyplate/nutrition-calories/food/vita/herring-in-wine-sauce/

Sep 5, 2012 - 3:09pm
Original industry insider after considering what you wrote and taking several books out I must apologies and ask you one simply question here's your link http://circ.ahajournals.org/content/93/4/697.full from it "...Prevalence of hypertension in each cohort is presented in terms of point prevalence (hypertensive at baseline examination in 1950, 1960, or 1970) and period prevalence (hypertensive status during 1950 to 1960, 1960 to 1970, and 1970 to 1980). Hypertension is defined as SBP ≥160 mm Hg and/or DBP ≥95 mm Hg or the patient taking antihypertension medication.14 15 Hypertension is considered to be controlled if SBP is <160 mm Hg and DBP is <95 mm Hg while the patient is taking antihypertension medication and is uncontrolled if SBP is ≥160 mm Hg and/or DBP is ≥95 mm Hg regardless of treatment"

How in the world you with all your "street cred " can see as addressing ''mild hypertension" is simply beyond me

Sep 5, 2012 - 7:51pm
Point taken Vince. You do a great job of cutting and pasting but I fail to see your point. Or, as Warden Norton said to Andy Dufresne "am I being obtuse?"