Thursday, September 25, 2014

TREATING MILD HYPERTENSION IN PEOPLE AT LOW RISK

Mild Hypertension in people at low risk
                                                       BMJ 2014, Vol 349
Dr Stephen Martin ( Dept of Family Medicine and community health, University of Mass. Medical School ).

This is essentially a thought provoking editorial of the effectiveness of treating low risk mild hypertensives.
This paper is controversial. It is part of a series of papers on over-diagnosis and over-treatment                          

Introduction
                 Mild hypertension, as defined by BP of 140-159 / 90-99 mmHg ( JNC 7 and JNC 8 ) forms about 60% of the hypertensive population  presently. This is NOT a uniform class. We do have to separate them out into       1. White coat hypertension
                                           2. Primary Mild Hypertension without complications
                                           3. Primary mild hypertension with complications.
Conventional  View.
                             There is a large body of evidence that any rise in BP above 120/80 mmHg carries with it an increase cardiovascular risk of strokes, heart attacks and cardiovascular death ( example the Framingham studies and MR FIT ). There were some large scale studies which showed that treating hypertension, including mild hypertension, would reduced CVS mortality and morbidity. Most of these studies were done in the 90s and 2000. Since that time, two things have change. Medicine ( especially cardiology ) has found a new research tool. The office conducted “ trial by Meta-analysis “  and we have also realized that office BP may be erroneous and Home BP monitoring may be a better reflection of  genuine hypertension.
Till date all the hypertension clinical guidelines have been based on clinic BP monitoring and also clinical trials which included a whole bag of BP ranges. Some of those trials were based essentially on BP reduction and not on long term CVS morbidity and mortality reduction ( Just a numbers reduction ).

BMJ paper

                        What Dr Stephen and group is saying in the BMJ editorial is that we should re-think how we treat mild hypertensives discovered in the office clinics, especially the group without any co-morbidities ( the safe group, or low risk group ). Basing heavily on a meta-analysis carried out by the Cochrane Collaborators ( a group of experts who group together and analyze trials by meta-analysis ), published in 2012, together with analysis of some other studies.                         

They made a few points.
1.      1.  That the evidence for benefit in treating, safe, low risk mild hypertensives is small and may not out-weigh the risk of side effects.
2.       2. We need to encourage home BP monitoring and non-pharmacological means t lower BP
3.       3. That be treating almost 60% of hypertensives we increase healthcare cost , without any obvious benefits
4.       4. Treat the patient and NOT the number.
5.       5.  All the above does not apply to patients with mild hypertension with co-morbidities, like diabetes, or who have suffered previous CVS events like strokes, heart attacks, undergone by-pass surgery, renal impairment, etc etc.

My opinion
It is true, that we should treat the patient and not the number. We should empower the patient to
1.      1.  Do home BP monitoring.
2.      2.  Lifestyle modifications with diet, exercise, weight lost, stop smoking, prevent diabetes

My fear is that Patients may get the wrong message, that hypertension is not a serious disease. The danger from Stephen’s paper is that since it is low risk, mild hypertension is OK. That would be the wrong message for our population. There is a small risk with mild hypertension, and they need treatment but not necessarily with drugs.  They need to be monitored. In the event that they should develop co-morbidities like diabetes, then the mild HBP may require drug treatment.

And getting patients to do home BP monitoring is possible. More and more of my patients are doing it. I foresee that soon, smart phones will come with apps that can do that too.

Please know that this paper is controversial and thought provoking but is not yet the standard for medical practice.

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