Saturday, March 17, 2007

Hypertension 42: The Facts Can Be Harder To Take Than The Prescription Medications

Remember the study quotes in Hypertension 41? No, that study does not apply to me. I’m worse.

The study quoted in Hypertension 41 involved people with mild Hypertension. Very generally that would mean people with a systolic pressure under 160. For those people, the best approach might be to avoid medications, and instead exercise five times a week, avoid salt, and eat a lot better. Stroke and heart attacks appear to be the negative outcomes. Eyesight problems and kidney damage are extremely rare.

The study that applies to me is located in the Cochrane Library ( That site features medical studies and information. The abstracts, quoted here, are copyright the Cochrane Library, and are available free of charge. If you want the actual studies, there is a small fee. Thank you for this service, Cochrane Library!!!

The study I was pointed towards? C Mulrow, J Lau, J Cornell, M Brand, Pharmacotherapy for hypertension in the elderly. Cochrane Database of Systematic Reviews 1998, Issue 2.

One view of the studies I have been advised of, from someone who has read the entire studies, not the abstracts:

“The drug treatment increased average overall survival over 5 years from 87% to 88.8%. Drug treatment increased stroke-free, heart attack-free and heart failure-free survival over 5 years from 82% to 87%. Stated another way this means that 20 patients have to be treated with drugs for 5 years to prevent one heart attack, stroke or hospitalization for heart failure. Withdrawals due to adverse effects was similar to mild hypertension, about one withdrawal for every 10 patients treated.

“You asked about other outcomes such as loss of vision or kidney damage. These events are very infrequent with elevated blood pressure so would not change the above evidence.

“I believe that all patients who are being considered for long-term preventive treatment should be informed of the evidence and make their decision regarding treatment based on an understanding of the evidence.

“I hope this helps…and you are welcome to post this on your website.”

And, a further addition from the same very helpful & kind person:

"Over many years I have come to the realization that we always present medical information focusing on the empty part of the cup. That is why I presented the fact that if you don’t do anything you have an 82% chance of not being harmed by your hypertension in the next 5 years. If you do what you are doing in taking drugs to lower your blood pressure you can increase that to 87%. I would hope that that gives you a more comfortable perspective than what you had before. In other words your cup is pretty full and taking your pills fills it up even more. It should also provide the realization that the drugs are only modestly effective and you could have a good or bad outcome independent of what you do."

The kind and helpful person is, actually, Jim Wright, Coordinating Editor, Cochrane Hypertension Group. He provided this information, including directing me to the study quoted below, in his role as Coordinating Editor.

Thank you Jim!!

Want to read the facts for yourself? Okay, be pushy! Some of it is confusing for a layperson, so feel free to help me out if I’ve gotten anything wrong. But in terms of facts, here we go!

Most fascinating for me: only four of the fifteen studies kept track of patients who dropped out. Of the four trials, the drop out rates due to negative side effects was as high as one in four. That is, one person out of four left the study because of the negative side effects of the medications. There was no indication of how drop-outs impacted on the statistical analysis.

What does it come down to?

If you have "mild" Hypertension, where your systolic pressure is generally always under 160 "points" (does anyone really know what the actual measurement means?), avoid all the medications. You can do just as well by committing to lifestyle changes: exercise regularly (ohmigod), less salt (Lots a luck--my first Biblical pun), lose weight. In my experience, the common negative side effects of the medications, with their resulting impact on your quality of life, are not worth it. You really are better off not popping pills and taking the easy way out.

If you have moderate to severe Hypertension, as I do, it is a more difficult question. Basically, it does seem to come down to a 5% improvement in your chances of not croaking (or suffering a less serious health risk, like the kind you might get from watching Fox News too much). That's tough. 5% is more significant, and you'd feel pretty stupid if you then did have a stroke, eh? In that situation, it depends on a case by case situation--how bad the side effects are, for example, for you in particular. Of course, that also depends on whether you are grabbing your life situation by the neck and not just being a sit on the couch wuss. Are you exercising, losing weight, less salt, watching less aggravating television such as President Bush news conferences (well okay, maybe his press conferences do have a surreal entertainment value).

Here is a portion of the abstract.

General abstract:
Medications to treat high blood pressure are effective in preventing serious complications, such as stroke or heart attack, in elderly people. Hypertension (high blood pressure) is common among elderly people and increases the risk of serious problems such as heart disease and stroke. Several medications are used to try to lower blood pressure and reduce the risk of complications, but relatively few studies have examined treatments for hypertension in people over 60 years of age. The review found that medications to lower blood pressure were highly effective in preventing complications such as stroke and heart attack in elderly people. However, effects of treatment in very old people or people with other problems like diabetes are not clear. More research is needed.

Fifteen trials including 21,908 elderly subjects were identified. The average prevalence of cardiovascular risk factors, cardiovascular disease, and competing co morbid diseases was lower among trial participants than the general population of hypertensive elderly persons. Most subjects were 60 to 80 years old. Most trials were conducted in Western, industrialized countries and evaluated diuretic and beta-blocker therapies. Event rates per 1000 participants over approximately 5 years indicated that antihypertensive drug therapy was beneficial. Cardiovascular morbidity and mortality was reduced from 177 to 126 events (95% CI of the difference 31 to 73). Cardiovascular mortality was reduced from 69 to 50 deaths (95% CI of the difference 9 to 31). Total mortality was reduced from 129 to 111 deaths (95% CI of difference 4 to 28). The data from the three trials restricted to persons with isolated systolic hypertension indicated a significant benefit: cardiovascular morbidity and mortality over approximately 5 years was reduced from 157 to 104 events per 1000 participants (95% CI of the difference 12 to 89). Numbers of participants who dropped out of trials secondary to adverse drug effects were often not reported. The four trials that did report this data showed a wide variation in drop out rates ranging from no significant differences between treatment and control groups to as many as one out of four patients dropping out due to side effects of treatment.

Authors' conclusions
Randomized controlled trials establish that treating healthy older persons with hypertension is highly efficacious. Benefits of treatment with low dose diuretics or beta-blockers are clear for persons in their 60s to 70s with either diastolic or systolic hypertension. Differential treatment effects based on patient risk factors, pre-existing cardiovascular disease and competing co-morbidities could not be established from the published trial data.

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