Treating-to-Target

Aggressive approach may lead to bigger problems

DRUG BUST by Alan Cassels

• The people’s briefing note on prescription drugs

Portrait of columnist Alan Cassels

For most people, taking drugs for high blood pressure seems like the right thing to do, but is it? That’s the question I’m asking as I look ever more closely at what the research says about the wisdom of feeding pharmaceuticals to otherwise healthy people who have nothing other than a “high” blood pressure reading.

Let’s start with a parable of how things typically unroll.

Seventy-eight-year-old Mary McGillicutty is told she’s got “high” blood pressure. The blood pressure cuff reads 155 over 95 (millimetres of mercury, abbreviated as mmHG). The top number is the pressure on her artery walls when her heart contracts and the lower number is the pressure when her heart relaxes. Mary’s doctor wants to see lower numbers and he convinces her of the need to do so.

Dangerously high blood pressure is a risk factor for heart attacks and strokes. Lowering that pressure, through exercise, diet modification and drugs, can reduce the risk. Right now, “normal” blood pressure is defined as being at or below 120 over 80. You might be labelled a “prehypertensive” if your blood pressure is between 120 to 139 over 80 to 89. The classic “stage 1 hypertension” is when it is between 140 to 159 over 90 to 99.

Most people don’t know that the level considered “high” has changed over the years. One physician told me that, 10 years ago, he wouldn’t do anything with a patient whose pressures were 160 over 100 but now, he says, “You’d almost feel like you were committing malpractice if you didn’t give your patient a drug.”

Our doctors are ‘trained’ to get that blood pressure down ‘to target’ – as close to normal as possible – and the concept of “treating to target” is reinforced through blood pressure guidelines, cardiologists who deliver medical education to doctors and pharmaceutical sales people schmoozing our doctors’ offices with new drug samples. Some have said “treating to target” as a concept is a creation of the pharmaceutical industry, which reinforces that message because it’s a great way to get doctors to prescribe drugs and patients to swallow them.

But back to Mary. No matter what her doctor does, he can’t seem to make her numbers much lower. He tries one drug, a diuretic, and the blood pressure drops only a little; then he tries another and after a few weeks of frustration, he adds a third.

Mary’s numbers are slowly dropping but another thing is happening: she’s not feeling so well.

A few days after the third anti-hypertensive drug is added to her regime, Mrs. McGillicutty sits up in bed one morning, feeling all light-headed and dizzy. She tries to stand and falls. An ambulance is called and by that evening Mary is in surgery for a broken hip. Her life is never the same. High blood pressure now seems trivial compared to the life-altering effects of a hip fracture. She never lives in her own home again.

I only have one word for this all too-common situation: “Harrumph.”

Was this mess started with the need, nay, the very strong push to get her blood pressures to go as low as possible? Why do we push the “treat to target” paradigm on people and in so doing risk the effects of another kind of illness, “hypotension,” (low blood pressure)?

Peter Conrad, author of the 2007 book, The Medicalization of Society, points a finger at the American Society of Hypertension, claiming its pharmaceutical-funded campaigns were behind efforts to “redefine hypertension to turn it into a broader syndrome.” The rationale was like this: With blood pressure defined as being at or over 140/90, about 65 million Americans would fit that category. Lower that to 120/ 80 and guess what? Cue the cash-register sounds as you’ve increased the potential antihypertensive drug market in the US by nearly 30 million people, overnight. And that’s exactly what they did.

If you were in a business that depended on selling drugs and visits to the doctor, you couldn’t dream up anything more successful than routine blood pressure monitoring and treatment. In fact, getting our blood pressure checked is the single most common reason for visiting the physician. Why is that? Because regardless of your definition, a lot of us have hypertension. The US Centres for Disease Control conducted a large population survey in 2010 and found that “25% of a random sample of US adults had been told on two or more visits that they had hypertension.”

Luckily for us, a new research study published in mid-August by the Cochrane Collaboration (www.cochrane.org) has found something that should revolutionize how we treat blood pressure. The Cochrane Collaboration is a highly trusted source of drug information as it is independent of funding from the pharmaceutical industry and relies on ‘gold-standard’ methods for reviewing and synthesizing only the best evidence.

Also luckily for us, the Cochrane Collaboration’s Hypertension Review Group is headquartered right here in Vancouver, with UBC’s Therapeutics Initiative. The coordinating editor of this international team of researchers, who focus their research on blood pressure treatments, is Dr. Jim Wright. Over the last few years, his group has produced many major reviews of blood pressure drugs and found that using drugs to lower blood pressure can reduce deaths and illness in people over 60 years of age and that the cheapest and oldest treatments (thiazide diuretics) are the safest and most effective. Very importantly and often overlooked is the fact the main benefits of altering blood pressures with drugs are based mostly on patients who had elevated blood pressure in the moderate to severe range (greater than 160/100 mmHg). But what if it were lower?

This new review answered that vitally important question: Does drug treatment versus no treatment ‘work’ for those people who have no established heart disease and only mild hypertension (defined as 140-159 over 90-99 mmHg)? What we mean by ‘work’ is this: Did the drugs produce any statistically significant differences in the numbers of people who died, had strokes, heart attacks or total cardiovascular events?

Drumroll please… No, they didn’t.

Looking at trials totalling nearly 9,000 patients treated for more than four to five years, this review found no evidence that these mild hypertensive patients benefit from drug therapy. Further, about one in 11 patients treated with drugs experienced an adverse effect that was bad enough to make them stop the drug. Dr. Wright concludes his review by calling for better research on who should or should not be treated for high blood pressure.

Fair enough.

But what about the millions of people like Mrs. McGillicutty who are healthy and well and yet their blood pressures have become a demon that physicians feel they must exorcize at all costs? What about people’s lives being made worse from efforts to lower blood pressures ‘to target’? Almost everyone will have higher blood pressure as they get old, but does that mean we need to automatically throw drugs at it?

Mary McGillicutty is not a victim of medical malpractice, but rather of cultural malpractice. Pharma largesse is behind the push for aggressive measuring and drug treatment, almost as if they were working under the medical equivalent of cycling great Lance Armstrong’s mantra “Go hard or go home.” Aggressive medical intervention to get to lower and lower blood pressure is a cultural phenomenon and as author Lynn Payer wrote in her book Medicine and Culture, “Even as doctors regard themselves as servants of science, they are often prisoners of custom.”

Thankfully, the truth might set us free and independent research, such as that provided by the Cochrane Collaboration, may end up being a “Get out of jail free” card.

Alan Cassels is a pharmaceutical policy researcher at the University of Victoria and author of Seeking Sickness. His next book will be about the history of the Cochrane Collaboration. Follow him on Twitter @AKECassels or www.alancassels.com

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