Sunday, September 9, 2012

Untreated Hypertension (High Blood Pressure)

     One of the latest pieces to hit the news is that there are 32 million patients with hypertension (high blood pressure), 30 million of whom have medical insurance, who are not properly treated. By this the report means that their blood pressure is still at 140/90 or higher after being seen by a doctor (how many visits is unclear). Then the report calls for a massive effort to treat 10 million of these people to goal blood pressure in the next five or ten years.

     The problem with the emphasis on this statistic is that it completely ignores the patients, and focuses on the health profession instead. This is not dissimilar to the problem with getting patients to stop smoking, to exercise more, and to lose weight. The patients know what has to be done, but choose not to do it.

     The treatment models for smoking and obesity do not work for hypertension. Firstly, there is no moral obloquy in having high blood pressure, because the general public has no way of knowing that you are an untreated hypertensive. Secondly, until the first stroke, the patient feels no ill effects from the high blood pressure, much in the same way that diabetics feel no effect that they can ascribe to a high blood sugar. Thirdly, because of #2, it is difficult to convince most patients that they have a medical problem that requires pharmacological and/or lifestyle intervention.

     The easiest person to fool is yourself, as Richard Feynman famously remarked. When I encourage my hypertensive patients to take their blood pressure at home, close questioning reveals that most of them duplicate the behavior of my diabetics who measure their blood sugar by fingerstick at home. Both groups usually repeat the measurement several times until they get a number that satisfies them and then they record that number. With diabetics, I can use the glycohemoglobin to demonstrate this, but with hypertensives there is no way to verify their home numbers.

     What I am saying is that there has to be a massive propaganda effort to convince patients that untreated hypertension is a time bomb waiting to explode in their brain, to discuss the debilitating effects of a stroke, and to quote from the studies that have demonstrated that lowering high blood pressure significantly reduces the risk of a stroke. We still would then be left with a subset of patient who insist that lifestyle modification alone can control their blood pressure, while I try to explain that blood pressure, blood sugar and blood cholesterol all usually increase with age and that once they have hypertension the number rarely decreases of its own accord. In other words, the problem is not a lack of information transfer from the medical staff to the patient, but a lack of belief on the part of the patient that intervention is necessary.

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