49- Definitive Article on Blood Pressure Control in the AHA Journal Hypertension: The Huge Disconnect Between Usual Care and Optimal Medical Therapy
All treatments are not Equal
Hypertension is the title of the journal on high blood pressure published by the American Heart Association. It contains this review on resistant hypertension by leading experts on treating high blood pressure. They recommend an ACE inhibitor (lisinopril) or ARB (losartan), a calcium channel blocker (amlodipine), and a fluid pill (hydrochlorothiazide) as the first three medications to use to control your blood pressure. Most people need between 2 and 3 medications to get there. I take two with no side effects whatsoever. My blood pressure was 160/100 ten years ago and now I have the blood pressure of a young girl. 108 million people in the US have hypertension—almost half the adult population. Only 44% of Americans have their pressure controlled to 140/90 or less. Over time, that failure generates a lot of misery and increased medical cost.
Kaiser Permanente uses focused teams and this recommended approach to achieve blood pressure control in 90% of their patients. High blood pressure is the most common serious chronic disease in the country. It reflects the presence of abnormal arteries and makes them more abnormal. Achieving control is important for you. The improved control rates at Kaiser help their patients live longer healthier lives. Kaiser is making a big difference.
These first recommendations reflect practice broadly if you look at the most prescribed drugs in the country. Lisinopril is the third most widely prescribed medication with almost 100 million users. Amlodipine is fifth with 75 million users. Losartan is ninth and HCTZ is 13th with 40 million users. If the first three recommended medications don’t achieve blood pressure control, these experts recommend changing the fluid pill to a more powerful one like chlorthalidone or indapamide. Here there is a huge disconnect between usual care and optimal medical treatment. Chlorthalidone is 161st with only about 4 million users. Indapamide doesn't even make the list. If the fluid pill change does not solve the problem, the fourth drug recommended is spironolactone which is 63rd with 12 million users. There are no real competitors for spironolactone as the fourth drug. It interferes with the biology that causes high blood pressure in the first place. It lowers the top number on the blood pressure by 25 points. It is very powerful in lowering the pressure and helps restore arterial health.
Meanwhile, other inferior medications and drug classes are widely used for uncomplicated hypertension. For example, 76 million Americans are on metoprolol which is the 6th most frequently prescribed medication. 22 million are on carvedilol and 19 million are on atenolol. That is 117 million Americans on beta blockers. Sure, beta blockers as a drug class are used for other things, but there are just 18 million people with heart artery disease and 5 million with congestive heart failure. That is just 23 million. Far too many people are taking beta blockers for uncomplicated high blood pressure and that has consequences.
One of the foremost leaders in high blood pressure science has taken this issue head on. Dr. Franz Messerli. He says, “ beta-blockers should no longer be considered appropriate for first-line therapy in uncomplicated hypertension.” We treat high blood pressure to reduce the number of strokes and heart attacks. Dr Messerli makes a compelling case that beta blockers do not reduce these catastrophic events. In diabetic patients, beta blocker use is actually associated with higher mortality. High blood pressure generally has no symptoms . Beta blocker side effects include fatigue, erectile dysfunction, weight gain, and an increased likelihood of diabetes. Patients who have high blood pressure and take metoprolol may weigh 37 pounds more than patients who don’t take it. Many patients stop treatment because of these side effects and that is a barrier to success. Stopping beta blockers suddenly may cause side effects as well. These medicines should be tapered. If an individual feels well and you give him a problem, you have needlessly created an obstacle to progress. That said, these medications have an important role to play in managing heart artery disease and heart failure.
11 million people are on clonidine. This is not a great drug for high blood pressure. Stopping it suddenly may be dangerous and cause distressing symptoms. Fatigue, dizziness, and dry eyes may occur. There are alternatives that don’t have these problems. If you are on clonidine, there are better choices, and you should discuss a change with your doctor.
You should be able to see easily that all treatments for high blood pressure are not equal. You can control your blood pressure with minimal effort and side effects, and the leading experts agree on a better way. Controlling your high blood pressure to goal is a critical element of optimal medical treatment (OMT). These numbers don’t lie. Too many people are not receiving OMT. Please subscribe if you find this kind of information valuable.
Thanks Joseph. Your comment means a lot to me. I know you are very knowledgeable in this part of medicine!
Very comprehensive over view, excellent!