|Family physicians Stephen Martin, MD, and Marcy Boucher, MD.|
Millions of people diagnosed with mild hypertension are overtreated with medications instead of being advised to make lifestyle changes that would improve their health without potential side effects, according to an analysis by UMass Medical School family physicians Stephen Martin, MD, and Marcy Boucher, MD.
“When you start looking at the guidelines and literature, the evidence for drug treatment of mild hypertension in otherwise well individuals is not clear,” said Dr. Boucher, assistant professor of family medicine & community health. “In fact, there is not much literature on pharmaceutical treatment at these blood pressure levels at all.”
Hypertension is the most common diagnosis at medical visits in the United States. As the thresholds for mild (140-159 mm Hg/90-99 mm Hg) versus moderate hypertension have dropped, prescriptions for blood pressure medications have skyrocketed, exposing many to potentially serious side effects when there is scant evidence that the medication will improve cardiovascular health, the doctors said.
“Studies suggest over half of people with mild hypertension are treated with drugs even though this approach has not been proven to decrease mortality or morbidity,” said Dr. Martin, assistant professor of family medicine & community health. “Overemphasis on drug treatment risks adverse effects, such as increased risk of falls, and misses opportunities to modify individual lifestyle choices and tackle lifestyle factors at a public health level.”
While it is well documented that increased blood pressure can decrease health, and that treating severe and moderate hypertension can improve health, the benefits of treating mild hypertension with drugs is less certain. The approach has largely been assumed from results achieved in more severe cases. Their concerns about the harms versus benefits of medicating many more patients than before led Martin, Boucher and co-authors James Wright, MD, PhD, professor of anesthesiology at the University of British Columbia, and Vikas Saini, MD, president of the Lown Institute, to conduct the extensive literature review which resulted in the analysis published Sept. 14 by The BMJ.
In “Too much medicine: Mild hypertension in people at low risk,” Boucher, Martin and co-authors note that the uncertainty that surrounds mild hypertension, which accounts for more than 60 percent of those diagnosed with above-normal blood pressure globally. Evidence suggests no net benefit from drug treatment of mild hypertension in people who do not have heightened risk for cardiovascular disease due to previous cardiovascular events, diabetes or chronic kidney disease.
Nevertheless, most people with mild hypertension are treated with drugs that can cause potentially serious, even dangerous, side effects. These include lightheadedness, falls, irregular heartbeat, weakness, fatigue, and diarrhea—and associated emergency department visits and hospitalizations.
The study further noted that improper measurement techniques are a major cause of inaccurate elevated blood pressure readings, resulting in unnecessary treatment for mild hypertension. To address this problem, the Barre Family Health Center where Martin and Boucher practice has initiated quality initiatives that include making sure the patient has been sitting for at least five minutes before measuring blood pressure and using automated cuffs which have been shown to be more accurate than manual readings.
“In addition, patients receive help with lifestyle changes including diet, exercise, and smoking cessation” said Martin. “We also consider the presence of white coat hypertension—blood pressure that rises only in the doctor’s office—and help our patients measure home blood pressures, a more important predictor of health.”
The authors call for more randomized trials comparing drug and lifestyle interventions for individuals with mild hypertension. “As with all evidence-based medicine approaches, we want to ensure interventions don’t just move a number, but actually improve health.” Martin concluded.