Sept. 24, 2014 -- Treating mild high blood pressure with drugs has unclear benefit and adds steep sums to national health care expenses, experts write in an article published online Sept. 14 in BMJ.
Doctors, in turn, shouldn't "pull the trigger too quickly" on prescribing medication, senior author Vikas Saini, MD, tells Medscape Medical News. Saini is a lecturer at Harvard Medical School.
Evidence of Benefit Unclear
Saini outlines three main reasons for this argument. First, there is no clear evidence that treating mild high BP with medication has the same effect it does on moderate to severe hypertension in terms of lowering risk for cardiovascular disease and related health problems.
Roughly 40% of adults in the world have high blood pressure, about half of which is thought to be mild (140 to 159/90 to 99). More than 50% of people with mild hypertension receive medication.
During the last few decades, the assumption has been that treating mild hypertension, even in those without risk factors such as diabetes or kidney disease, can lower the risk for cardiovascular disease and death. Studies, though, have not borne this out.
Also, over-medication contributes to ballooning health care costs, the authors argue. The United States spends about 1% of its annual health care expenses and more than 30% of its national public health expenses treating high BP, amounting to more than $32 billion annually.
Over-medication also carries risks for greater harms to the patients, such as falls, hip fractures, drug-related hospital admissions, and poor physical and mental health.
Second, Saini says, inaccurate blood pressure measurement contributes to too many diagnoses of high BP.
"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," Saini says. For example, high blood pressure recorded at office visits is notoriously inaccurate, and automated cuffs and home-based methods may prove better.
Lastly, focusing on medication diverts resources away from investment in public health, Saini says. Greater emphasis on system-wide lifestyle changes is needed.
Those changes include:
- Lose excess weight.
- Cut back on salt.
- Quit smoking.
- Drink less alcohol.
- Get more exercise.
"I think clinicians are frustrated, rightly so, by the fact that you can't change the patients' lifestyle with a 5- or 10-minute conversation in the office," Saini says. "To ask doctors or the medical community to shoulder that burden is really unfair."
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," Saini says. "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."
Some Doctors Remain Skeptical
It may still take some convincing, though, before doctors come on board with these recommendations.
"The main challenge to implementing these changes is the dynamic nature of blood pressure and the likely reluctance of patients and doctors to risk taking patients off medicines that are not causing perceptible side effects," Neda Laiteerapong, MD, tells Medscape Medical News. She's an assistant professor of medicine at the University of Chicago. "These medications likely provide some security for the patients and doctors that the blood pressure is well-controlled."
Emphasizing lifestyle change is in line with providing cost-effective, patient-centered care, Laiteerapong agrees, and could work for "some people," such as those in their 40s and 50s who are healthier and don't have other ongoing illnesses that interfere with exercise or self-care.
"However, many patients with hypertension are over 65, and many have chronic diseases which impede their ability to successfully implement lifestyle change," she says. "While the article mentions that lifestyle change works, it's truly very difficult for many people to implement the level of change necessary to make significant changes in blood pressure."
The authors and Dr. Laiteerapong have disclosed no relevant financial relationships.