Hypertension treatment was all over the map
Hypertension is the second-leading cause of death in the United States and it is growing in numbers despite being relatively easy to diagnose and treat.
The prestigious Institute of Medicine reported that 73 million Americans have this deadly condition, while a similar number may be undiagnosed. Of those diagnosed, a large number are inadequately treated.
Why is there this large disconnect between ease of diagnosis and treatment and these numbers?
In the mid-20th century, hypertension, or high blood pressure, was not fully accepted as a disease. Only in that era was the connection between HBP, stroke and heart failure being recognized. In the early 1950s, one-quarter of all hospital beds were occupied due to heart failure, mostly due to HBP.
Elevated BP in the elderly was considered normal due to ???hardening of the arteries??? that naturally required more pressure to push blood through. In the 1940s, a diastolic blood pressure (the lower number) of 115 was acceptable.
A big problem was also the lack of treatment options.
The drugs available were Reserpine (still in use), the diuretic Diamox (now used for high altitude sickness and glaucoma) and a class of diuretics made from mercury compounds.
All these drugs have significant side effects with these diuretics having the potential for life-threatening organ damage.
Until fairly recently, reserpine was still used by the VA for routine blood pressure control, due in part to its very low cost and evidence that it does lower death rates. It took until 1959, when a true breakthrough occurred. The first thiazide diuretic (Diuril) was discovered.
This class of drugs is still considered a first line of treatment for all levels of HBP. At a few pennies per pill, there is no reason hypertensives shouldn???t be treated.Why isn???t it properly treated?
Doctors tend to be reluctant to treat a disease without symptoms. Many diabetics are not treated properly for this reason.
The drugs often have side effects (usually minimal). Patients tend to not comply with prescriptions that cause discomfort when they were feeling well beforehand.
The Institute of Medicine report found many doctors tend to consider only the higher number for the basis of treatment. Thus, those with a BP of 150/70 are far more likely to be treated than those with 130/95. It???s interesting that in earlier days, the higher number was largely ignored and treatment centered on the diastolic number. In fact, both numbers must be treated properly.
In the current era of treatment, we have excellent guidelines for care. In the mid-1970s, the National Heart, Lung and Blood Institute, a part of the National Institutes of Health, published its first report by the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure.
This committee of experts evaluated current research and came out with detailed recommendations as to treatment options. Every few years, when changes in understanding of the disease or advances in treatment become available, the committee prepares a new report. The seventh report was published recently.
We now have numerous drugs to treat hypertension.
The mainstay of treatment is the use of diuretics, largely thiazides. These drugs help excrete salt from the blood. Since the body tries to maintain the concentration of salt in the blood at a constant level, the more salt the more water is necessary to keep the concentration steady.
The more volume, the harder the heart has to work to push blood through the system. Diuretics lower the volume allowing for less pressure to be needed.
Beginning in the 1970s, many new classes of drugs have been introduced.
In spite of all these choices, for most patients a diuretic is best initial therapy. In certain patients, salt retention is not the problem, but chronic excessive production of stress hormones is.
The recommended treatment for this is a beta blocker, such as propanolol, which blocks the effect of these hormones on the heart.
However, in most cases, one drug is not enough to fully control the problem, and others are added. Neither doctors nor patients should allow inadequate treatment due to the fear of taking ???too many drugs.??? The consequences are far too disastrous.
Charles Barta retired to Green Valley after 10 years as a medical director for several health care insurers. Before that, he was physician-in-charge of Kaiser Permanente of Colorado and a private internist in Las Cruces, N.M. He had previously held a management position in the Medical Systems Division of Pfizer. His column is published Sundays.