Treating hypertension with guidelines in general practice
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7465.523 (Published 02 September 2004) Cite this as: BMJ 2004;329:523
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Professor Haranath's comments concerning Hypertension are valid in
principle.
The recently revised margins for what constitutes normal fly in the
face of common sense.
It is also true that the risks of hypertension treatment far outweigh the
benefits.
Professor Haranth's mention of the following however, is not
supported by facts, inspite of the fact that the bogeyman is alive and
well.
Quote:
"Hypercholesterolemia is the major risk factor for coronary thrombosis and
hypertension for strokes...."
The cholesterol hypothesis is a truly dead horse and it has started
to smell badly enough for the common people to notice.
As to hypertension, a sensible guideline would be a return to the
past:
100 plus your age.
Works for me.
Competing interests:
None declared
Competing interests: No competing interests
Sir,
It is for patients to decide and not targets.1 With distressing side
effects, no guarantee of extended life or cause of death, patients and
practitioners shy away from drug treatment for hypertension and expect
satisfactory answers. Is hypertension reversible when the stress is
removed? With normal BP after long treatment can drugs be reduced or
paused? Aggressive drug treatment for life blunts BP regulation with no
end point or specificity, as in immunization.
Hypertension is elevation of arterial blood pressure (BP) above an
arbitrarily defined normal
value.2 BP record is subjective, not precise and variable. Statistics
with this variable numeral are error prone.3 Patients’ records are from
a vulnerable segment of population not normal. An epidemic of
hypertension is forecast with narrowed definitions. Normal values need to
be determined afresh in healthy persons including elders. Most medical
staff will be ‘prehypertensives’! The diagnosis ‘Prehypertension’
itself raises BP.
Those with hypertension alone without risk factors should be studied
if it is result or cause of vascular sclerosis / endothelial changes.
‘Risk of developing hypertension’ is equated to ‘risk of CVD’. All-
cause mortality, coronary heart disease and stroke mortality were similar
in hypertensive and normotensive men during the first decade, but
increased thereafter despite continuous good blood pressure control.
Hypercholesterolemia is the major risk factor for coronary thrombosis and
hypertension for strokes.4 In 1 million participants with 12%
mortality, stroke deaths (1.2%) are 1/3 of deaths due to ischemic heart
disease (3.4%).5
Systolic BP rises always more than diastolic and not readily
controlled by drugs. Not all agree with cut-off value 140 mm for
hypertension for all adults.
Dr. P.S.R.K. Haranath, MD, DSc
Retired: Professor of Pharmacology, Member British Pharmacological
Society, Director of Medical Education (AP), India
jagannath@vsnl.com
References:
1. Campbell NC, Murchie P. Treating hypertension with guidelines in
general practice. Patients decide how low they go, not targets. BMJ
2004;329:523-524
2. Brody TM Antihypertensive drugs In Wingard LB, Brody TM, Larner J,
Schwartz A. ed. Human Pharmacology – Molecular to clinical. Wolfe Mosby,
London 1991, p167
3. Green BB, Kaplan RC, Psaty BM. How do minor changes in the definition
of blood pressure control affect the reported success of hypertension
treatment? Am J Manage Care. 2003; 9: 219-24
4. Andersson OK, Almgren T, Persson B, Samuelsson O, Hedner T, Wilhelmsen
L. Survival in treated hypertension: follow up study after two decades BMJ
1998;317:167-171
5. Lewington S, Clarke R, Quizilbash N, Peto R, Collins R. Age-specific
relevance of usual blood pressure to vascular mortality: a meta-analysis
of individual data for one million: in 61 prospective studies. Lancet.
2002; 360(9340): 1903-13
Competing interests:
None declared
Competing interests: No competing interests
You may not be cynical enough. Management of hypertension will be
influenced by targets, but the measurement and recording of measurement
could be distorted by targets. Or certainly will be?
Competing interests:
None declared
Competing interests: No competing interests
I think many GPs across the country will find resonance with Campbell
and Murchie's views. Our otherwise well patients come to see us, have
their blood pressure measured and many start on a medical treadmill of
investigations, "treatments" and side effects.
These otherwise well people become ill - "I suffer with high blood
pressure, Doctor".
They develop swollen ankles, lethargy, impotence, headaches, hot
flushes, gout, electrolyte imbalances etc. They have blood tests and ECGs.
For all of the iatrogenic suffering, most people will not benefit
from lowering of their blood pressure, or cholesterol for that matter.
The only people who are benefitting from this are the 1 in however
many who are needed to treat, the researchers making a name and a career
for themselves and of course the big drug companies.
But, I have to go now and meet my Quality Framework targets!
Competing interests:
None declared
Competing interests: No competing interests
Sir,
It is fascinating to observe how the hypertension debate always resolves
into the same two camps. In one you have the academics, whose Holy Grail
is more protocols and guidelines, and in the other the GP's, who
stubbornly maintain that perfect control is impossible. As one of the
latter, I welcome this well balanced editorial.
Two things stand out. General practice is a broad and disputatious church,
yet there is remarkable unanimity on the difficulties of treating
hypertension. Surely this fact is significant? Perhaps it indicates that
there is an unknown factor, not necessarily a scientific one, which
prevents the mastery of this disease. It would certainly indicate why
guidelines and protocols never seem to get to the heart of the matter, and
why this feeling is shared amongst doctors of all specialities.
Secondly, it is nice to see the object of the exercise, the patient,
getting a mention at last. Half the problem with treating hypertension
is tailoring the medication to the individual siiting on front of you.
The other problem is trying to explain to the patient what is going on.
How many hypertensive patients get a genuine risk/benefit analysis of
their disease? And could any of us actually do it? Perhaps what we need is
a treatment/no treatment/percentage benefit of treatment chart which we
could discuss with the patient. You never know, it might do wonders for
the drugs bill.
Chris Nancollas
Competing interests:
None declared
Competing interests: No competing interests
This article needs to be read in conjunction with the letters on
hypertension in the same issue. On the one hand the BHS quotes the
'evidence' from usually sponsored trials. On the other GP.s are
increasingly anxious about the pressure to make whole subsets of the
population multiple pill takers. If one goes back to the MRC hypertension
trials clear NNT were published. Now we tend to see figures of marginal
risk reduction rather than absolute therbye increasing the percieved
benefit. It was therefore enlightening to read that the first drug provides
most benefit. After a patient is on three anti-hypertensive agents it
would be very interesting to know the NNT for a benefit in adding a
fourth. This month also carries an update in cardiovascular medicine in
the British journal of General Practice highlighting the fact that the
risk factors on terms of cholesterol over estimate the risk for most of
the UK population. These tables though contribute to the fact that statins
are now our practices highest prescribing cost. Finally is the British
Hypertension society sponsored or independent of the pharmaceutical
industry?
Competing interests:
None declared
Competing interests: No competing interests
Many thanks to Drs Campbell and Murchie for an excellent editorial
which recognises that GPs deal principally with individuals not
populations and certainly not the selected and disciplined populations of
clinical trials.
I agree that present blood pressure target levels, as with so many
others, are unachievable for most patients, not least because if we
believe in the idea of well informed patients being properly involved in
decisions about their care this has to include their right to say no.
Unfortunately the pressure to chase targets is relentless and comes
from many sources, ranging from the well meaning, like researchers,
epidemiologists and our specialist colleagues, to the more dubiously
motivated such as policy makers whose survival depends on simplifying
complex arguments into vote grabbing Grand Ideas.
More worrying is the financial incentive to chase targets which has
been introduced through the new GP contract. I cannot think of many more
chilling questions to be asked by a patient than 'Are you doing this for
the money, doctor?'.
If as a profession we have any ambitions left to preserve the level
of trust we've enjoyed from patients for so many years then people need to
know that we are still capable of recognising what makes them unique.
Sometimes this might mean ignoring a target.
It certainly means ignoring the money.
Competing interests:
None declared
Competing interests: No competing interests
I enjoyed reading Campbell and Murchie's article on treating
hypertension with guidelines and felt that their points about involving
the patient are crucuial. However I feel that they have sadly missed out
one of the key drivers for GPs in England and Wales to be aggressivley
treating Hypertension to targets which is the Quality and Outcome
framework of the new GMS contract (GMS2).
There are 20 points on offer for recording a blood pressure result in
our hypertensives, but a massive 56 for 70% of the hypertensives having a
blood pressure of 150/90 or less. Combining this with another 53 points
for blood pressure recording and targets in patients with coronary heart
disease, strokes and diabetes mellitus (with a lower treatment target),
this is a massive financial drive for GPs to treat their hypertensives. As
"points mean pounds" it will be interesting to review the impact of the
GMS2 on the level of blood pressure management in General Practice.
I may be cynical but I feel it may have more impact that the
Guidelines. However surely that is the intention of the Quality and
Outcomes Framework anyway.
Competing interests:
None declared
Competing interests: No competing interests
New targets for blood pressure as for cholesterol, very difficult to
achieve but 'desirable'.
Dialogue with the patient to ensure a better outcome.
All this means to me that brainwashing of the patient about the absolute
necessity for intervention is encouraged and will, so one assumes, bring
about better 'compliance'.
Before I take 4 or 5 pills to lower my blood pressure to some arbitrary
goal I will remind myself of the old gold standard that was in place
during my father's generation.
100 plus your age for systolic. For a politically correct diastolic
reading I would slightly alter my lifestyle, and, while doing that, stop
worrying.
Plenty of evidence is alleged to exist that the lowering of blood
pressure by medication is beneficial.
I wish someone would send me this evidence.
Competing interests:
None declared
Competing interests: No competing interests
Re: Re: Clarifications required on Guidelines for Treatment of Hypertension
I am glad to note the response of Dr. Herbert H. Nehrlich.
I am merely quoting the conclusion of Andersson OK, Almgren T,
Persson B, Samuelsson O, Hedner T, Wilhelmsen L. Survival in treated
hypertension: follow up study after two decades BMJ 1998;317:167-171,
regarding hypercholesterolemia and ischaemic heart disease
I wish that study of Hypertension without other risk factors deserves
a detailed study in all aspects both to determine the normal BP levels in
elders and to glean the relationship - result or Cause - between
Hypertension and vascular sclerosis and endothelial changes. With
antitobacco measures gaining ground, persons with hypertension alone seek
/need special attention.
Competing interests:
None declared
Competing interests: No competing interests