Sense and Sensibility on Hypertension

Every now and then even blind squirrels find acorns.  The medical care industry, which long ago abandoned sensible fiscal and therapeutic restraint in the quest for new patients, finally treats us to a revised hypertension guideline that thoughtful people can conclude makes a great deal of sense.  It is even based on evidence, or actually the lack of it, which is itself a startling admission of reality from an industry that dances around truth with a nimble sophistry envied by even the most mendacious politicians.

The hypertension guidelines are a sharp departure from last month’s cholesterol guidelines, produced by a supposedly equally august panel of “thought leaders” who gave us guidelines that seemed to channel the The Talking Heads quite literally.  John P. Ioannidis, along with Nortin Hadler, easily one of the two or three most important physician thinkers of this or any generation, wrote that the cholesterol guideline will be either…”one of the greatest achievements or one of the worst disasters of medical history.”

If you haven’t read the hypertension guidelines, here is a useful summary:

  1. we treat too many people today;
  2. we rely too much on drugs for things that drugs cannot fix;
  3. treatment frequently does not produce health because therapy aims at a point, while the pursuit of health is a matrix; and
  4. if we are really going to improve cardiovascular health, which is strongly implicated not just in stroke, heart disease, and kidney disease, but also cognitive health, people are going to have to change behaviors because there aren’t enough pills on the planet to fix what ails us.

Cognitive health is an especially useful guidepost, because contrary to popular myth, it isn’t something that mysteriously disappears in nonagenarians.  The seemingly age-related decline is more likely the manifestation of damage done by a lifetime of incremental harms.  Isn’t it edifying to have scientists catch up to our moms?

The new guidelines leave us a redefinition of high blood pressure: greater than 150/90, except in cases where a comorbidity compels pursuit of 140/90 or lower to prevent end-organ damage.  This has implications not just for medical care but for workplace wellness, which obsesses with hypertension when it is not obsessing with cholesterol and glucose.

The hypertension guidelines yank away from workplace wellness vendors yet another reason to fine or otherwise antagonize employees who don’t show up at health fairs.  The progression of hypertension is strongly related to aging, and healthy aging is the most reliable bulwark against premature stroke, heart attack, kidney failure, or dementia.  Unless workplace wellness vendors plan to follow people into retirement, which is when the overwhelming majority of heart attack, stroke, and dementia occurs, there is no logical reason to ask any employee what his or her blood pressure or deign to tell them how to address it.

Understandably, some people will find themselves more confused than ever by this release.  Within a month, two groups of supposedly trustworthy professionals have come to the opposite conclusions on the matter of cardiovascular guidelines, one group saying we need to treat millions more people while the other group says we are treating far too many people now.  To quote Mark Knopfler of Dire Straits: “If two men say they’re Jesus, one of them must be wrong.”

The “treat less” position is braving the screen-and-prophylactically-medicate tornado sweeping the nation’s healthcare landscape.  At some point, that tornado will spin out all of its energy, and just like the real storms, we’ll be left with a littered landscape of people are worse off than before the storm and angry that they’ve been lied to and manipulated.  The hypertension guidelines show that at least one cadre of medical industry leaders is willing to forsake revenues and new patient creation in order to dodge this storm. We hope others will follow.

Vik Khanna is a St. Louis-based independent health consultant with extensive experience in managed care and wellness.  An iconoclast to the core, he is the author of the Khanna On Health Blog.  He is also the Wellness Editor-At-Large for THCB.

Al Lewis is the author of Why Nobody Believes the Numbers, co-author of Cracking Health Costs: How to Cut Your Company’s Health Costs and Provide Employees Better Care, and president of the Disease Management Purchasing Consortium.

Vik and Al will be the first authors of THCB’s new e-publishing venture.  Their jointly authored e-book, How To Survive Workplace Wellness With Your Organs, Dignity, and Finances Intact, will be released in Spring 2014.  Vik’s solo e-book venture, Your Personal Affordable Care Act: How To Make Yourself Scarce In The Dysfunctional US Healthcare System will be released in January 2014.

17 replies »

  1. If you think this is offensive you are probably better off not buying our next book “How to Survive Workplace Wellness…with Your Dignity, Finances, and Organs Intact.”

  2. Carolyn: thanks for the note and for the updated links.

    Your final paragraph raises a great issue. The cholesterol guidelines and the Canada’s HPT guidelines both arise from industry-funded “partnerships.” The HPT guidelines come out of the Joint National Commission, a body overseen by the National Heart, Lung and Blood Institute, whose work was underway before NHLBI decided to punt on guidelines writing.

    Doesn’t exactly take Holmes and Watson to connect these particular dots, does it?

  3. maybe this will help move us away from defining “quality” doctors as those who pile a bunch of medicines on someone (minimizing side effects and ignoring individual preferences) to satisfy some poorly-supported-by-the-evidence-but-recommended-by-industry-shills guideline.

  4. This is why a monkey or a computer cannot practice medicine, and why we call it “practicing” and why it is still as much an art as a science.
    Humans will simply have different risks and benefits from the treatment of these conditions such as hypertension, diabetes, cholesterol and the like.
    This is why we need to focus on primary prevention by LIFESTYLE changes, not merely prescribing pharmeceuticals.
    There will always be those patients that cannot or will not respond to non-pharmaceutical measures, but they all need to be treated individually, not just put on a particular protocol.

  5. Will do. Keep up the irreverence. Doctors take themselves far too seriously, often preventing them from seeing forest for trees.

  6. Hello Vik and Al,
    Thanks so much for including a link here to my post at The Ethical Nag (in the paragraph starting “Understandably…”) about the new cardiovascular guidelines. But I suspect you’ve included the wrong link: instead of that 2009 post about the NEJM’s former editor Dr. Marcia Angell, I’m thinking that you likely meant to link to one of my CV guidelines posts – for example: http://ethicalnag.org/2013/11/20/statin-guideline-writers/ or possibly http://ethicalnag.org/2013/11/19/statins-guidelines/

    Here in Canada, you might be interested to know that Hypertension Canada, which sets blood pressure goals used widely by docs here, has questioned new American blood pressure guidelines. Dr. Raj Padwal of Hypertension Canada told the Toronto Star yesterday that the new BP guidelines “don’t prioritize risk status — for example, whether the patient has prior cardiovascular disease or organ damage. The 2014 Canadian guidelines are already written and will NOT include an age-based recommendation for people over 60 when they are published in January.”

    This caution, of course, merely begs the question: could Hypertension Canada’s reluctance to embrace the revised U.S. blood pressure guidelines have anything at all to do with the fact that their organization is funded by Pfizer (Norvasc, Accupril), Merck (Cozaar) and other companies that make BP drugs?

    Just wondering . . .

  7. Saurabh: If you would please carry that message far and wide, you may borrow our lines as extensively as you wish. The answer to your calculus query is, of course, that it changed when the FFS system made it more compelling to be physician entrepreneurs than first class clinicians.

  8. “To quote Mark Knopfler of Dire Straits: “If two men say they’re Jesus, one of them must be wrong.”

    I’ll add this to my quiver of one liners! With due credit, of course.

    The tone of the piece brings levity to a problem which should offend physicians: over treatment. We took an oath to make sick people better not well people sick.

    When did this calculus change?

  9. VIk
    My comment was neither a nod to the JNC nor the guideline itself. It is what is, along with many other recs we use. Weak evidence encompasses a lot of medicine as you know.

    For most working adults, we used 140/90 yesterday, and we will use 140/90 tomorrow.

    Thats it.


  10. Brad,

    Thanks for your note. The recommendation related to SBP in the <60 population is a Grade E recommendation, based only on expert opinion. "however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion." That's not exactly the verbiage of a therapeutic tour de force, and we would disagree that it does not impact workplace wellness programs.

    The weak evidence basis in fact complicates their task because it will require an actual clinician to judge a patient's entire constellation of risk factors and deduce whether or not treating to that goal has merit. Deductive reasoning is not a workplace wellness core competency.

  11. The new guidelines dont change the SBP cap of 140 for individuals <60. The alteration wont have much impact on Wellness programs in the workforce given age of participants. Unchanged treatment goals.

    One notable alteration in JNC 8 drops beta blockers as first line therapy.

  12. Overtreatment is dictated by the inane guidelines for everything and no one is counting the adverse events from the over treatment.

    For instance, how many patients died from arrhythmias due to the hypokalemia from the front line guidlined hypertension treatment, hydrochlorthiazide?

    How many patients have had critical bleeding from the sc heparin prohylaxis epidemic, when combined with asa, plavix, and coumadin (sic), with mindless clicking on the CPOE gizmo?

    Who is counting, actually.