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October 1, 2000

Less is Less: the Undertreatment of High Blood Pressure

If your doctor says your blood pressure is "a little high," you should betreated with anti-hypertensive drugs.
All of us have had our blood pressure taken during a checkup or exam. Many of us have been told by a doctor that our blood pressure is too high and that we should "watch" it. Few of us, however, leave the doctor's office understanding how serious a health problem high blood pressure is or that it can lead to heart disease, stroke and kidney failure.

It is not that high blood pressure is especially difficult to control. Today's doctors can prescribe a wide range of good, affordable drugs that will lower your blood pressure and help you live a longer, healthier life. The problem is many of them simply don't.

Hypertension and History
High blood pressure, or hypertension, has been recognized for as long as blood pressure itself has been measured and understood, that is for more than a hundred years. But it's only in the last few decades that medical experts have understood just how serious a health problem hypertension really is.

Unfortunately, the vast majority of Americans with the condition continue to go untreated. Possibly because many doctors do not take hypertension seriously as a health threat, this is true even for those who are diagnosed.

As recently as the end of World War II, there was wide disagreement about whether it was a good idea to attempt to lower a person's blood pressure. Some experts argued that raising blood pressure was the body's way of handling various circulatory problems. They thought that treatment might even be dangerous.

Medical thinking began to change when one scientific study after another established a clear association among heart disease, stroke, kidney disease and hypertension. The question that remained was whether hypertension was a cause, an effect or merely a condition associated with these health problems. In the 1960s, several large studies settled the question -- hypertension by itself shortens life.

Today we can diagnose and treat hypertension fairly easily. Unfortunately, the vast majority of Americans with the condition continue to go untreated. Possibly because many doctors do not take hypertension seriously as a health threat, this is true even for those who are diagnosed.

Hypertension Kills
If you look at it in dollars and cents, the fight against hypertension seems impressive. In Y2000, Americans will spend more than $30 billion on drugs to lower blood pressure. Despite this expense, however, most Americans who are hypertensive either go untreated or do not get the most effective treatment available.

How Big Is the Problem?
Blood pressure is measured by two numbers, which are written on top of each other. The top number is called the "systolic" and measures the force of the blood as it is pumped from the heart, while the bottom number, the "diastolic," measures the pressure remaining in the system. Both numbers are measured by how high ( in "mm" or millilmeters) the force can push up a column of mercury (chemical abbreviation "Hg"). Hypertension is usually defined as either a systolic blood pressure of 140 mm Hg or more or a diastolic blood pressure of 90 mm Hg or more.

Under this definition, more than 50 million people in the U.S., or nearly one in four adults, are afflicted with hypertension. And as the large Baby Boom generation ages, these numbers will only get worse. That is because, as we get older, we become more and more susceptible to high blood pressure. 44% of Americans, aged 50 to 59, and 67% of those older than 70 years are hypertensive.

What Does This Mean in Terms of Our Health?
Of the estimated one million deaths annually in the U.S. that are attributed to cardiovascular disease (50% coronary heart disease, 16% stroke, 4% heart failure), according to one scientist, "high blood pressure alone is responsible for 40,000 of these deaths." Furthermore, there is a direct correlation between how high your blood pressure is and your risk of stroke. While experts debate whether hypertension can cause kidney failure, there is no doubt that it can accelerate the damage done to the kidney by diabetes and other diseases.

Drug Treatments: A Problem of Application
There are many different antihypertensive drugs available to today's physicians, but something, however, seems to be going wrong with our ability to deliver these drugs to those who need them. Studies have shown that only about 27% of hypertensive Americans between the ages of 18 and 74 are treated successfully. Success is defined as seeing a reduction in blood pressure to below the 140/90 mm Hg benchmark. Believe it or not, in other Western nations, the numbers are even worse -- 6% in the United Kingdom and 15% to 24% in other countries (Figure 1).

These studies have consistently shown that blood pressure can be reduced in large groups of people and that when this is done, for example, the chance of getting a heart attack or dying from one fall dramatically.

Part of the problem is skepticism about the seriousness of hypertension. This attitude is understandable because not everything about the relationship between health and high blood pressure is understood. Skeptics often cite the "French "Paradox" -- cardiovascular mortality is exceptionally low in France despite the fact that the French diet is quite high in animal fats and alcohol, and that French doctors do very little to treat hypertension.

There is much evidence from around the world, however, that hypertension has serious health consequences -- at least for the non-French -- and that modern antihypertension drugs work, both to lower hypertension and to prolong life. These studies have consistently shown that blood pressure can be reduced in large groups of people and that when this is done, for example, the chance of getting a heart attack or dying from one fall dramatically. In light of what we now know from these studies, there is no excuse for the fact that many doctors simply do not focus on treating their hypertensive patients.

Sorting Through the Maze of Antihypertension Drugs
Today, modern medical science offers a confusing number of new and different antihypertensive drugs, each claiming to be better or more effective for a particular type of patient. It is comforting to remember, however, that it is hard to make a wrong choice; most antihypertensive drugs, even those that are now obsolete, have a good track record.

Antihypertensive drugs range from so-called angiotensin converting enzyme inhibitors (ACE inhibitors) to calcium antagonists, angiotensin II receptor blockers (ARBs), beta blockers and low-dose diuretics, alone or in combination. Because they are easy on the heart and the kidneys, ACE inhibitors are a good place to start. For patients who respond slowly to these drugs or who experience bad side effects, the best second choice is a calcium blocker in sustained release form.

Whether to move on to beta blockers and/or diuretics is an individual decision that should be made together with your own doctor. The same goes for the issue of trying to lose weight or reduce the amount of sodium in your diet, which are helpful for some people.

Conclusion
Hypertension is a very serious condition that is not taken nearly seriously enough by today's doctors. The situation is similar to that of cigarette smoking, another huge public health problem that doctors were slow to take seriously. As of the start of the new millennium, the medical profession worldwide has good antihypertension treatments at its disposal, yet has not treated more than one-half of those who need it. Until this changes, it is up to individual patients to bring up the subject of high blood pressure with their own doctors and, when necessary, to insist on proper treatment.
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