The Hypertension Guideline War Is Not A Fake War

The war over the new blood pressure guideline is not a fake war or a childish dispute. It is a real war over genuine differences in how we should think about health and disease and prevention.

The publication last November of the new US blood pressure guideline sparked a vigorous and important debate. A central part of this debate is whether the new guideline went too far, since millions of people who were deemed to have “normal” blood pressure were labelled as “hypertensive.” All at once the number of US adults  labelled as “hypertensive” jumped from 72 million to 103 million, which translates to an increase from 31.9% to 45.6%, according to one reasonable estimate.

Original illustration by Max Husten

In a recent blog post one clinical trial expert, Milton Packer, sensibly pointed out that “the whole idea of a numerical threshold was silly. The risk associated with hypertension is not binary. It does not become real when you exceed a certain number, and it does not fully subside when you are below it. The risk is continuous; the higher the number, the higher the risk.” He further observed that the new guideline relies on data from the highly controversial SPRINT trial, “but no one really understands the blood pressures in that study” and the new guideline “applies its recommendations to people who were not even represented in the SPRINT trial.”

Packer then focused on one part of the guideline debate. On one side two medical specialty groups, the American Heart Association and the American College of Cardiology, (who developed the new guideline) broadly endorsed the new guideline. On the other side, two primary care groups, the American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP), refused to accept the new guideline. Instead, the AAFP and ACP published their own guideline for adults over age 60 recommending that physicians start treatment only in patients with systolic blood pressure of 150 mm Hg or above. In a statement the AAFP explained that the AHA/ACC guideline was not based on a rigorous systematic review of the evidence. They also expressed concern about the strong reliance on the SPRINT trial and conflicts of interest among the committee members of the AHA/ACC guideline.

By way of explaining this divergence Packer notes, undoubtedly correctly, that “primary care physicians really dislike it when specialists tell them what to do.” But Packer misses why this is not a trivial debate. He says that he is “entertained” by the claims that the war is “fake” “since there is no magic number that describes the risk associated with high blood pressure, there has been nothing to fight about.”

He asks: “Why do children get into mud fights?” His answer: “Because they enjoy acting like children.”

I agree with Packer that there is no one simple answer to this question. There will never be a “magic number” that is proven to be “right” by science. Any threshold inevitably involves tradeoffs and compromises.

But I couldn’t disagree more that this is a silly mud fight between children. I think this dispute is deadly serious and is packed with meaning.

On the one hand, the specialist view represented by the AHA/ACC guideline weaponizes the medical system to seek and destroy disease. High blood pressure, in this view, is an enemy that must be wiped out at any cost. But this view fails to sufficiently account for the inevitable collateral damage. It downplays the adverse side effects of treatment (or overtreatment), and it almost never takes into account the adverse effect of telling an otherwise healthy people that they have a serious disease. It focuses on the reduction of relative risk and brushes off the small reduction in absolute risk. This is why the NNT (number-needed-to-treat) increases as the absolute level of risk goes down.

For specialists these limitations are not a big deal, since they are focused on the disease and not the entire patient. (Of course I am aware that the vast majority of specialists are not insensitive brutes, but this is also an inescapable element of specialization.) Paternalism is ubiquitous in medicine, and specialists are far more susceptible than primary care doctors.

On the other hand, the primary care physicians look at blood pressure within the larger perspective of the whole patient and the public health context. This doesn’t mean that primary care doctors aren’t aware of the relationship between blood pressure and risk, or that they are uninterested in cardiovascular risk prevention. But this is not their exclusive interest, and they are finely attuned to the adverse effects of overtreatment, since they are the ones who will deal with the patients who fall when their blood pressure drops too far or who mix up all the pills they nearly invariably take as they grow older.

From a primary care perspective it is crazy to think that nearly half the adult population has a disease that needs to be treated. In case you haven’t been looking, our healthcare system is already bigger by far (by percentage of GDP) than any other healthcare system in the world. Does it really need to grow larger? Is this what we want to do, turn everyone into a patient?

Furthermore, there is a far more urgent blood pressure problem that is not being adequately addressed, even by the standards of the American Heart Association. According to the AHA’s own recently released statistics, only 84.1% of people with hypertension (under the old definition) were aware of their condition, only 76% were under current treatment, and barely half (54.4%) had their hypertension under control. Why focus on bringing in even more and lower risk people into the “hypertension” diagnosis when there are still so many higher risk people who are being inadequately identified and treated?

There is a another important perspective that needs to be considered here. This perspective is not about specialty versus primary care but is instead about medical care (primary or specialty care) versus public health. From the public health perspective it is inevitably a losing proposition and a rearguard action for doctors to treat mildly elevated blood pressures with medicine or even individual lifestyle advice. Instead we need broad public health measures to help bring about a culture that encourages and steers people toward lifestyles that incorporate healthful food and exercise habits. In this case the focus is on doing something positive and healthy, rather than fighting a disease.

As I’ve asked before, do we really want to turn the entire world into a hospital? No matter how it is dispensed, taking a pill is not a positive experience. By contrast, cycling to work, to take a favorite example of mine, can be a life-affirming experience for many.

 

 

 

 

 

Comments

  1. Milton Packer says

    Larry
    You are absolutely right. This is not a fake war.
    You have very eloquently described the lens of the specialist as well as the lens of the primary care physician. These two worlds should be working together, but over the years, they have grown further apart. The reasons for the chasm are multifactorial and include professional pride, income disparities, difference in perceived mission, and a mutual lack of sensitivity and respect. Sadly, the patients are caught in the middle, not knowing which side to trust (if either). I am not optimist that this war will end soon. There are many fronts, not only inside of cardiovascular diseases, but in many other disciplines. If this conflict continues, the public will undoubtedly suffer. It already has.
    Milton Packer

  2. Steve Marks says

    Just like what was done with Diabetes.. The ‘norm’ average B.S. reading a couple of decades ago was 140 ( morning reading ) and by ‘dropping it’ down to 125, and re-labeling everyone over that number as ‘PRE-DIABETIC’ just to have them take unnecessary and dangerous insulin or pills! I have run into 3 types of Physicians these past 10 years. Those who are ‘indoctrinated’ to anything ‘new’ ( often just out of school a few years and very young practitioners.. Then their are those who wait for solid proof and stick with the proven, and lastly… Those who are way outdated, usually because of age..

  3. James Stein says

    Talk about behaving like the kids in a midfight! You are egging them on.

    I’ll remind you that the concept of shared decision making in guidelines really came of age in cardiology guidelines (cf the 2013 lipid guidelines) and page 6 of the AHA-ACC HTN guideline, before any thresholds are even mentioned, states “Adherence to recommendations can be enhanced by shared decision making between clinicians and patients, with patient engagement in selecting interventions on the basis of individual values, preferences, and associated conditions and comorbidities.” The importance of shared decision making is mentioned 5x in the guidelines!

    I don’t know a single cardiologist, nephrologist, or internist that just treats to a number. We all consider patient wishes (though we might try to influence the patient more the farther they are their goal or the higher their ASCVD risk), costs, side-effects, and potential drug interactions.

    To weakly disclaim in parenthesis that disregarding limitations of new thresholds is an “inescapable” element of being a specialist is pure hogwash and to buys into the specious arguments of weaponist generalist (the parallel to the so-called weaponized specialist). There is no connection. There never has been and it is an insult to entire professions.

    If you want to know who “weaponizes” guideline thresholds leading to overtreatment and absurdly aggressive med recommendations, blame insurance companies and graders of health systems who score us based on how many patients with X reach Y goal, and the hospital administrators who build systems built on overtreatment or on non-patient centered care (in the name of quality of care, ironically). Maybe pharma too. Don’t criticize the doctors. Jeez.

  4. James Stein says

    2/2. “On the other hand, the primary care physicians look at blood pressure within the larger perspective of the whole patient and the public health context.” Yes, because as an evil cardiologist, I don’t care about the whole patient or public health. And also, why does treating mild HTN mean we can’t also pursue lifestyle interventions? That is a complete false dichotomy. Indeed, the guidelines call for those as well, and most docs who treat hypertension spend a lot of time trying to help patients lose weight, exercise more, and eat a DASH-style diet. Finally, no one likes turning people into patients. But no one likes heart attacks, strokes, heart failure, and kidney failure either. Decades of improvements in medications, treatment guidelines, and lifestyle changes have lead to a progressive decline in CVD-related death rates and events. Each advance is met with the same half-baked criticsms.

  5. “Decades of improvements in medications, treatment guidelines, and lifestyle changes have lead to a progressive decline in CVD-related death rates and events”: The rate of CVD deaths peaked and started its rapid decline before much in the way of much-touted medications and treatment guidelines were in use. So the latter are not the cause of the former.

    As for “lifestyle changes” I’m open to persuasion but my guess is that the only one that’s been a big deal is the preaching against cigarettes. If so, the effect on CVD is essentially a side-effect of a campaign against a major cause of lung cancer.

  6. James in Oz says

    According to the website. “NNT”. the Mediterranen Diet – and it needs be stressed that it includes social and Family support is more protective than statin meds by a factor >2.5…
    Neither of my previous cardiologists mentioned “diet” apart from “cholesterol”.
    But guess what type of drug they prescribed !

  7. richard cooper says

    I am in with the evil specialists writing above. This original post is – well – benighted. Why is it that the opponents of the SPRINT message somehow forget that they are forcing an active choice on to patients – Why don’t they ask: Would you rather faint (the main adverse event, and only a 2% excess), have a stroke or die? Take your pick . . Look again, all cause mortality reduced by up to 25% – does that not somehow weight the answer on this question?

    To say SPRINT couldn’t measure BP is just a stupid dodge of the real question. The trial results are 100% consistent with all BP trial experience of 60 years, and the epid data. As was the case with statins. Nothing mysterious here. Lower is better, and actually in older people, a whole lot better.

    European primary care doctors 20 yrs ago screamed about a guideline of SBP 140 . . same arguments, same self-motivated desire to avoid taking on the burden, ie, doing the right thing.

    If all of these specialist recommendations are misguided, why have stroke and CHD fallen > 80% since 1968? Maybe those recommendations are on to something . . maybe we could prevent even more people from having a devastating stroke – or should we really be more worried about a faint, that leaves no residual, or a mild elevation in Cr, reversed by changing dose? Or making people such unhappy “patients” by taking a pill once a day . .

    Medicine is supposed to be reliant on science. You have to justify why you ignore evidence. Look again at benefits of treatment and tell me it’s an evil plot.

    • “why have stroke and CHD fallen > 80% since 1968?” If the peak was in 1968 then it certainly isn’t statins that should take the credit, is it?

      Why do doctors insist on making these false implications?

      • Perhaps because of the landmark VA hypertension trial published in 1967. BTW, the entry criterion was a DBP of 115-130 for that trial! We’ve come a long way.
        JAMA. 1967;202(11):1028-1034. doi:10.1001/jama.1967

  8. Any person’s pressure will vary widely through an active day. One measure tells nothing. There is no single pressure representative of any single individual.

    Compounding that uncertainty is the fact that the measurement of brachial blood pressure leaves a great deal to be desired. The technique varies so much from clinic to nurse to machine so as to render that one measurement’s accuracy undependable.

    Beyond even this is the fact that the brachial artery supplies the musculoskeletal complex from forearm to fingers. The aorta most directly supplies the heart itself, the brain, liver, and kidneys. Brachial pressure does not directly reflect aortic pressure.
    Which would it make more sense to keep track of – if you could?

    Probably the most appropriate and simple fall-back for the treatment of definitive hypertension is to institute rigorous lifestyle changes… and then, if needed, slowly and carefully titrate medication(s) until hypotensive lightheadedness is effected – then back off a bit.

  9. Nice post, thanks for sharing.

  10. What irritates me the most is the assertion that the only negative impact of drug treatment is potential lightheadedness.
    I was prescribed a medication with serious potential side effects even though my blood pressure fluctuates between 128-136. My cholesteral is around 103
    WHY do I need this unnecessary medication????????????

  11. James B. Seward, MD; Professor of Adult and Pediatric Cardiology; Emeritus Mayo Clinic says

    James B. Seward, MD
    A BIG UNSOLVED PROBLEM
    Blood pressure (BP) is a nonlinear number, which does not fit the definition of “causality” (“cause is a multi-variable (not a single number) that must be present in each and every person suffering from the disease”). To make an informed decision you need a small number of highly related data (nonlinear variables related to the same outcome…e.g., Heart Failure, etc.). BP is a consequence associated with a myriad of other associated disease processes..e.g., AF, Stroke, HF, etc.). An association will never define cause. A causal multi-factor must be defined experimentally and not defined by a statistical or empirical assumption. The hypertension WAR is the result of not understanding or capturing “individualized cause-and-effect”… We need to compute “causal RISK factor” and NOT independent risk factors such as BP, AF, HF, etc.). The 100 year hypertension WAR is the result of using the wrong ammunition (a strategy that cannot resolve the hypertension WAR, which cannot be resolved by using BP as START-Point or END-point of the WAR. Treating BP can affect some defined battles will not definitively win the WAR.

    Non-linear problems (or WARS) are most appropriately managed by understanding probabilistic RISK (i.e., Bayesian network probability), which can be expressed a “Absolute Risk [start-point]” and incrementally monitored by “Absolute Risk Reduction [change related to treating the start-point”]; RisK should be ideally Individualize (each individual has a unique Risk State… and assisted quantitative monitoring of the RISK STATE)

    The world of medicine will have to make a monumental change on how it addresses chronic diseases…treating independent risk factors is insufficient ammunition… as you know every chronic disease is increasing in incidence (HF, AF, stroke, etc., etc. etc.). there are TWO absolute necessary strategies #1. employ individualized quantitative CAUSE-and-EFFECT Methodology to battle non-communicable disease. #2. build a NEW MEDICAL TAXONOMY the completely changes how we manage the chronic disease WAR, which is currently using the wrong ammunition

  12. It’s FAR WORSE than a fake war. It’s an obvious and dangerous MONEY GRAB by the pharmaceutical industry! PERIOD. Suddenly, almost half the adult population of the entire United States needs to be medicated with DANGEROUS high blood pressure medication. I know this well. I was prescribed two different high blood pressure medications and both caused horrible side effects (muscle weakness with one and water buildup in my feet so bad I couldn’t get my shoes on with another). And that was at the 140/90 level. Mind you, a person on here is correct in that physicians and their assistant DO NOT take blood pressure correctly! That’s a FACT. I’ve had it taken by dozens and NONE follow the prescribed conditions of sitting for 5-10 minutes before taking a reading and that’s just for starters. I found my trying to “meditate” to lower it, I was actually raising it because I was breathing shallow. Taking deeper breaths lowered my reading at home (doing it correctly) by over 20 points! I kid you not. This is CONSISTENT. My average blood pressure now is between 117/74 and130/84 and you can be certain caffeine and stress and other factors cause the variation and that’s NOT using ANY blood pressure medication, neither of which had any observable effect on my blood pressure at the time, but BOTH caused awful side effects. I
    ‘m sure it made the medical industry some more MONEY and given the health costs in the USA are 2x higher than the rest of the world as it is, I’m sure that makes someone in Big Pharma very happy. They don’t give a crap if my shoes fit or not or I have muscle weakness. They just want to force me to take those pills so they get their money. Period. Given the above results, I no longer trust doctors as far as I can spit. I’ve been lied to, ignored and tested over and over for various conditions over the years and it’s UNBELIEVABLE how many times the doctors get it WRONG. They act like gods and are nowhere NEAR as smart or educated as they pretend to be. I’m an electronic engineer and I would never take the attitude they have towards humans being so much dumber than they think they are. I’ll give a personal example.

    12 different specialist doctors and two primary ones over two years could NOT figure out I needed a mucous thinner and decongestant when I had pain near the corner of my left eye after wearing contacts at an amusement park. I had TWO CT scans done and even though the first doctor could plainly see fluid build-up in my left cheek, he said that shouldn’t cause pain by my eye. His exact words to me were, “I don’t know what this, but I can tell you this much. It is NOT a sinus problem!” That awful advice gave me pain by my eye for TWO YEARS! Not even Vicodin (which you could actually get for pain when doctors prescribed it back then; now it’s another BS political stance against drugs that have nothing to do with heroin abusers, but that’s another story) had any effect on this pain. It was AWFUL. I had a doctor try to burn an eyelash near my eye out (it grew back so I suffered for nothing). Finally, an allergy doctor actually LISTENED to what I said and told me I had a sinus problem. He had me hold my nose on one side and snort. Fluid came flying out of my cheek into my nose like a squirt gun the pressure was so bad! He diagnosed this without any CT scans and told me specialists can’t think outside their basic diagnostics. I had no sinus infection. Just sinus back pressure combined with overly sensitive nerves lead to hypersensitivity near my eye on the skin. Three days of prescription strength Sudafed and Mucinex (Pseudoephedrine and Guaifenesin) and I was 100% pain free! UNBELIEVABLE! I’m thankful for ONE doctor that knew SOMETHING. The other 12 doctors were MORONS. Not ONE suggested even TRYING Sudafed even ONCE! (I probably took a normal dose before I even went to the doctor, but clearly it wasn’t strong enough to get the fluid out). After that, I at least need Guaifenesin to keep my sinuses clear and sometimes Pseudoephedrine when it gets bad, but they keep it under control.

    Now I’m told I should stay away from Sudafed (so the eye pain can come back) since it might raise my supposedly high blood pressure. The same blood pressure that reads 117/74 at home most of the time after I sit and take it properly. This with EVERY SINGLE doctor taking it WRONG (immediately after you sit down and them stressing you out about it when you came there for something else. So yeah, it was high every single time after the first because they make so nervous and worried about it). So I’m going to take pills for a non-existent condition? No, I no longer even trust doctors. They are only interested in moving you along like an assembly line. Who cares if you have a drug reaction? It’s not their problem. I’m sure any doctors reading this are probably mad as hell, but they should be looking in the mirror because 12+ doctors is no accident or not small statistic! It’s an OUTRAGE. And we pay these people 2x-3x as much as they do in Europe and they get better outcomes. I wonder why.

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