Drug use for management of mild hypertension called into question

William B. White, MD, FASH, FACP, FAHA

From the perspective of a hypertension specialist, there are a number of concerns for the Cochrane Collaboration analysis on ‘mild hypertension’. Most importantly, this analysis simply does not have definitive information to lead to the conclusions being made by the authors. Hence, the results of the Cochrane analysis should not lead to any changes in clinical practice with regard to the management of hypertension.

Although the literature search and the pooling of data appear to be correctly performed in the Cochrane analysis, several problems still remain. First, of the four studies included in the review, one did not really even qualify based on the authors' own criteria of ‘mild hypertension’ defined as 140 mm Hg to 159 mm Hg/90 mm Hg to 99 mm Hg — the Systolic Hypertension in the Elderly Program (SHEP). Secondly, other studies included in the review were from the era in hypertension treatment when higher dose diuretics and beta-blockers were the primary drugs utilized. Side effect rates leading to discontinuation (9%) are higher with these drugs than many present day therapies; hence, this finding is not representative of the rates seen with the wide variety of antihypertensive medications used in 2012. Thus, the conclusion that treatment of ‘mild’ hypertension may cause more ‘harm’ than benefit is probably incorrect.

Although the number of patients in the analysis may seem high (nearly 9,000), the number of CV events, that included MI, stroke and death, was actually small, as was the duration of observation (<5 years) for this particular population. Because of these two issues, the review did not have the statistical power needed to determine whether pharmacologic intervention conferred a benefit or not.

The authors also contend that many patients without CVD and stage I hypertension may benefit more from non-pharmacologic interventions, such as diet, exercise and smoking cessation. Although these lifestyle modifications may be effective, adherence to them remains a problem in clinical medicine. In my long-term experience as a physician, many patients are not able to continue these interventions beyond a few months and soon find themselves with significantly elevated BPs once again.

Clinicians should be concerned with not treating ‘mild’ or stage I hypertension with antihypertensive medications as BP often becomes more severely elevated with age, thus increasing the risks for stroke and congestive HF. This is of particular concern as hypertension is an asymptomatic disorder and many patients will not visit a doctor until a complication has become manifest.

I have substantial concerns that if recommendations stemming from the Cochrane analysis are heeded by doctors and patients that some patients might simply stop their antihypertensive treatment, which could lead to stroke, progression of kidney disease, HF and even death. Thus, it is critical for patients to consult with their prescribing physicians before making any changes to medication regimens.