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Hypertension Treatment—A Success Study

2006; Wiley; Volume: 8; Issue: 5 Linguagem: Inglês

10.1111/j.1524-6175.2005.05153.x

1751-7176

Marvin Moser,

Blood Pressure and Hypertension Studies

Physicians involved in the management of hypertension are prone to analyze and reanalyze data, discuss and rediscuss issues, and minimize advances that have been made in the treatment of this disease—perhaps more so than physicians in other disciplines. Emphasis has too often been placed on the “less-than-perfect” results of treatment in an attempt to advocate new approaches or new therapies. While it is important to question and critique as a prelude to making progress, perhaps criticisms of hypertension management have been too strident and may have become counterproductive. In the early 1930s and 1940s, experts questioned whether or not elevated blood pressure (BP) was truly a risk and whether increased pressures were actually necessary to get blood to the brain, kidneys, etc. The Framingham data and other epidemiologic studies put these questions to rest, indicating that elevated BP was a major cardiovascular risk factor and that patients with severe or malignant hypertension had a prognosis that was often worse than many people with a malignancy. In the 1940s, there were a few physicians who decided that, while the risk was great in using therapy such as antimalarial agents, typhoid fever injections, and later, mutilative sympathectomy and adrenalectomy to lower BP, the benefit outweighed the risk. In some patients with malignant hypertension, many of the findings were reversed—symptoms of heart failure were improved, renal function deterioration slowed down, and funduscopic changes improved. But skeptics in the 1950s persisted in questioning the benefits of treatment despite findings that even with less-than-ideal therapy, with ganglion- or peripheral-blocking agents or large doses of reserpine, whose use frequently resulted in annoying or severe side effects, BP was lowered and prognosis improved. Debates continued regarding the benefits of therapy in the 1960s and 1970s even after the findings of the first Veterans Administration Study in severe hypertensives and the Treatment of Mild Hypertension Study (TOMHS) were published. Numerous clinical trials followed, demonstrating a reduction in cardiovascular events in patients with diastolic Bps as low as 90 mm Hg, and some of the naysayers were finally silenced, at least regarding the benefits of treatment. When many of us were house staff officers in the 1940s and 1950s, every third or fourth bed in the hospital was occupied by a middle-aged patient (40–60 years of age) with hypertension—malignant or accelerated hypertension, CHF as a result of hypertension, stroke as a result of hypertension, or rapidly failing kidneys as a result of hypertension. These were all extremely sick patients. Today, the picture is different. It is difficult to find a seriously ill patient with elevated BP. The pattern has changed. Patients are being treated earlier, and complications are being prevented. There are still cases of congestive heart failure and end-stage renal disease that are related to elevated BP, but these are in older individuals who often have several comorbid conditions in addition to a history of long-standing and often poorly treated hypertension. Based on data from the clinical trials in the 1960s–1990s, physicians responded—perhaps not to the desired extent—but it is clear that there are now fewer cases of hypertension-related strokes and heart and kidney failure than even 15–20 years ago; progression from less severe to more severe hypertension is being prevented. Epidemiologic data report that the occurrence of strokes has decreased dramatically (by more than 60%) since the 1970s, when a national effort to control hypertension was launched; this, despite the fact that the percentage of hypertensive patients achieving goal BP is not as high as it possibly should be, even in well controlled office or clinic-based practices. In many clinical trials where physicians and nurse clinicians are encouraged to increase or change medications and to actively pursue lifestyle interventions, diastolic Bps are reduced to goal levels in about 80% of patients, but systolic BP goals are achieved in only about 60% of subjects. Morbidity/mortality has, however, been reduced significantly even with less-than-ideal decreases in BP. How can we do better? Criticisms are useful, but when they interfere with management approaches that have been shown to be effective and useful, they may be counterproductive. At present, there are numerous physicians and organizations that continue to minimize the benefits of hypertension treatment in the United States, treatment that has proved more effective in controlling a higher percentage of people than anywhere else in the world. They argue that despite the billions of dollars spent on the development of new antihypertensive drugs, on the elaboration of systems and controls, and programs to improve outcome, fewer than 50% of patients are controlled according to national guidelines. They believe that major changes in diagnostic approaches and health care delivery must be made to improve results. We must again address the question, “Are we running in place or making progress in the management of hypertension?” (see J Clin Hypertens [Greenwich]. 2002;4:256–258). The answer is that we are clearly making progress, but there is room for improvement. If we would focus more on the main issue of achieving goal Bps in more patients instead of spending millions of dollars and hundreds of precious education hours on the “my drug is better than your drug” issue, we might progress even further. Importantly, we do not have to make our approach to management more complex or expensive. It is reasonable to question why results have not been better. For many years, lack of patient adherence to therapy, side effects, cost of care, and the system of medical care delivery have been blamed for the less-than excellent results. In recent years, however, the focus has been on physician adherence. Physician inertia may be a major reason for the low percentage of patients at goal BP levels. Many physicians are still overly concerned about side effects of therapy. Many are failing to use appropriate doses or combination of medications and are not titrating therapy to goal BP levels. Some have been convinced by promotional literature that the use of certain effective agents such as thiazide diuretics might actually be harmful. There is little doubt that the literature has confused many practicing physicians and may have negatively influenced the appropriate use of medications. We must continue to critically examine the results of the clinical trials that demonstrate benefit or lack thereof, and to examine methods of delivery and cost of care. At the same time we should continue to emphasize that benefit far outweighs risk in the management of hypertensive patients and recognize how much disability and death have been prevented by lowering BP even to less-than-desirable levels. What we must be vigilant against, however, are the overinterpretations of comparative medication data and the use of statistical methods of questionable significance to convince us that we have been doing a poor job of managing hypertension. Most investigators will agree that the degree of BP lowering and not specific therapy accounts for most of the achieved benefit. We have excellent, effective, and relatively safe antihypertensive medications available. BP can be reduced in a large majority of patients with the use of one or, in many cases, several of these agents. We must not get hung up on the my drug is better than your drug debate or jump on the bandwagon every time the results of a new trial are published before we put the results in perspective. We have all seen the headlines proclaiming that “reserpine causes breast cancer,”“diuretics increase heart attack risk and end-stage renal disease,”“calcium channel blockers cause cancer and do not reduce coronary heart disease events” and, most recently, that “β blockers should be abandoned as useful agents in management.” These are examples of counterproductive claims that are not based on solid clinical evidence and confuse rather than help to improve outcome. Reduction of cardiovascular events has been achieved by lowering BP. Everyone will benefit if more people are put on appropriate therapy and titrated to goal. Further success will be achieved if this is remembered. While none of us should be satisfied with the present status of hypertension control at goal levels of <140/90 mm Hg set by national committees, we should recognize that hypertension management represents a major preventive medicine success story. It is easier to become a critic than to look constructively for methods to improve on this already significant achievement.