No Drugs for Mild Hypertension? (Summary)

A Cochrane review of the evidence basis of drugs for mild (stage 1) hypertension (blood pressure (BP) 140-159/90-99 mm Hg) that I co-authored in 2012 concluded that drug treatment for mild hypertension is not evidence-based to benefit patients. Furthermore, drug related side effects severe enough to discontinue treatment occur each year in about 11% of patients treated.

Despite our findings published in a premier evidence-based medicine journal, the Eighth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-8) giving updated treatment recommendations in 2013 ignored our systematic review. JNC-8 panelists, funded by the National Institutes of Health, voted to continue recommending drugs for mild hypertension. My call for a retraction of the JNC-8 drugs for mild hypertension guidelines as a guest post in the KevinMD blog was also ignored by the JNC-8 Panel.

According to American Heart Association data, drug treatment of mild hypertension will cost about $41 billion in 2015, well over 1% of all health care costs. Due largely to the aging of baby-boomers, drugs and outpatient clinic visits for mild hypertension will cost more than $500 billion over the next 10 years (2015-2024). This projection assumes that only about half of approximately 50 million people with mild hypertension in the USA will receive drug treatment. To put this cost in perspective, the Congressional Budget Office projected that the net effect of the Affordable Care Act (Obamacare) over the next 10 years will be to increase the federal deficit by $109 billion. Therefore, saving $500 billion in health care spending while benefiting patients should be a big deal.

To date, no major newspaper has reported on the Cochrane review of drugs for mild hypertension. Relatively few thought leaders in medicine and hypertension policy have commented on the review. No evidence has emerged that many physicians have discussed the findings and implications of this review with their patients with mild hypertension.

Behind these mind-numbing numbers are real people—patients, doctors, and taxpayers. A friend of mine who had been taking lisinopril 20 mg/day for mild hypertension was found unresponsive at breakfast in a restaurant one morning. When paramedics arrived, they documented that his systolic blood pressure was 90 mm Hg. They brought him to a hospital where the doctors ran tests but failed to make a diagnosis for his black out. I suggested that his faint was due to the lisinopril. After some consideration, his Kaiser Permanente doctors agreed. However, instead of stopping the lisinopril, the primary care doctor reduced the dose from 20 mg/day to 10 mg/day. Even when several subsequent outpatient clinic visits showed blood pressure readings of around 122/70 mm Hg, my friend couldn’t talk the primary care physician out of ordering lisinopril. The doctor wouldn’t authorize a referral to a hypertension specialist. I worried about my friend’s risk of another episode of loss of consciousness.

The chief of the Kaiser Permanente hypertension service in my area happened to be a friend of mine. He was a medical student when I was a medical resident in training. We have stayed intermittently in touch for the subsequent 40 years. It turns out that he was also one of the 17 or so members of the JNC-8 panel. With my lisinopril-taking friend’s consent, I asked my hypertension specialist friend to consult on the advisability of drugs in this case. Fortunately, my doctor friend stopped the lisinopril. My friend’s blood pressure has averaged under 140/90 mm Hg for the subsequent 2 years.

A non-drug approach for management of mild hypertension and the associated cardiovascular disease risk involves therapeutic lifestyle changes. These include diet, exercise, relaxation therapies, smoking cessation, and alcohol moderation. The DASH diet (“Dietary Approaches to Stop Hypertension”) reduced mean systolic blood pressure by 11.5 mm Hg on average in participants with hypertension as compared to a control diet. In patients at high cardiovascular disease risk, the Mediterranean Diet has been shown to reduce total mortality by 56% and adverse cardiovascular events by 47%. The intensive lifestyle change program of Dr. Dean Ornish for cardiovascular disease patients reduced cardiovascular events in half in 5 years. With a fraction of the half trillion dollars over the next 10 years slated to go to drugs and clinic visits for drug treatment of mild hypertension, innovative lifestyle change interventions for patients with mild hypertension could potentially benefit many people and create many productive health enhancement jobs.

For over 30 years, JNC guidelines have endorsed drug treatment for mild hypertension without evidence that drugs benefit patients. Americans have wasted over $500 billion during that time on drugs for mild hypertension. Mild hypertension patients have suffered hundreds of millions of side effects and an unknown number of deaths from drug side effects. The National Heart, Lung, and Blood Institute as part of the National Institutes of Health, appointed all 8 JNC Panels and funded them.

I call on Frances Collins, MD, Director of the National Institutes of Health to direct NIH hypertension experts to respond to this challenge to the evidence-basis of JNC-8 drugs for mild hypertension guidelines.

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