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.

Preventing Hypertensive Stroke

     This blog is rather short, because the basic facets and results are quite clear. The biggest risk factor for stroke in the general public is high blood pressure. The first anti-hypertensive to conclusively demonstrate a reduction in stroke risk was thiazide diuretics. They apparently work by lowering the total amount of salt in the body. We also know that thiazide diuretics are synergistic with every other anti-hypertensive medicine, in that diuretics potentiate the effect of every other hypertensive treatment. In fact, if you are on two anti-hypertensive drugs, one of them should be a diuretic, unless you have some very unusual medical condition.

     So the message of this blog is that diuretics prevent strokes. I raise this point because recent medical studies have been trumpeted in the newspapers as being more effective or more potent than thiazides in lowering blood pressure. But the question to ask your doctor is if this new and "better" anti-hypertensive treatment has been shown to lower the risk of stroke. If it hasn't, then either ask him to add a diuretic,  or see a specialist in hypertension, to see if yours is a special case.

     This is a small example of substituting an endpoint for a clinical result. We have seen similar problems in whether or not lowering cholesterol prevents heart attacks, or if lowering CPR is beneficial. To use my favorite analogy, just because you have a better "tool" for returning the arrow over the elevator to the lobby than simply pushing the lobby button, it doesn't mean that your tool will get the elevator down any faster.