Hypertension: Raising the Pressure

Prof Dr BM Hegde 21 September 2015

Medical students are being taught to rely on outdated, potentially dangerous drugs for treatment of hypertension

health, high blood pressure, hypertension, diabetes, chronic kidney disease,

There is something called the joint national committee (JNC) on the prevention, detection, evaluation and treatment of high blood pressure, or hypertension, in the United States. ‘JNC8’ means the report of the 8th committee—there have been seven previous ones. Experts brainstorm on meta-analyses of clinical researches and studies within a timeframe, review previous guidelines and make recommendations. JNC7 was published in 2003 and, so, everyone expected that, by 2010, JNC8 should be out. It was not to be. JNC8 got delayed for three years and came out with its guidelines only in December 2013. It recommended that patients, aged 60 years or older, start treatment if their systolic blood pressure is more than 150mmHg or diastolic blood pressure is less than 90mmHg (150/90mmHg, or just 150/90 in common parlance) and try to be within these thresholds. In patients aged 18-60 years, treatment initiation and goals should be 140/90. The same goals apply to patients with hypertension, diabetes or chronic kidney disease (CKD).

There was strong dissent from five panelists and that upset the whole drug lobby. If people are informed about the ‘normal’ BP measurements, Big Pharma will be the biggest loser as millions will need no drugs. When the JNC5 report came out, a similar noise was made, because JNC5—for the first time—recommended thiazide diuretics as the first choice drug. This was strongly resisted by the ‘thought leaders’ in the US who put forward their own guidelines. Most of them were later found to be on the payroll of Big Pharma. JNC8 committed a greater sin. They honestly reviewed the data and raised the levels for treatment by drugs. These higher levels will take millions of people out of the drug list, costing Big Pharma billions of dollars! How could that be? How can they sustain a loss? Even in JNC8, 25% of the committee members had industry connections; they were only allowed to give their opinions but not vote for the final recommendations.

The drug industry did try its best to stop the report from coming out: it is a surprise that the report did come out in 2013. Now that the report is out and recommendations made, the industry is trying various tricks, using ‘important’ medical associations—like medical unions—to block it.

The other day, I was lecturing to medical students in Pune. One student in the audience told me that they were told about the JNC8 recommendations but were told not to use that for their future practice and use JNC7 instead!

JNC8, along with the famous MRC (medical research council) study of mild-moderate hypertension published in BMJ (British Medical Journal) in 1985, makes an interesting study. What doctors read from journals becomes understandable if they have an elementary knowledge of statistics, as treatment depends on probabilistic factors. There exists what is called NNT or number needed to treat. The MRC study showed that, to save a probable one stroke in a group of 5,000 people in the next five years, one has to unnecessarily treat 850 otherwise healthy people with potentially dangerous anti-hypertensive drugs for five years; ADRs, adverse drug reactions, of these drugs could, by then, damage and/or kill 75 people!

Four randomised controlled trials published in 2012 showed no difference between the treated and untreated individuals in the incidence of coronary heart disease, stroke, total cardiovascular (CV) events, and death. About 9% of patients treated with drugs discontinued treatment owing to adverse effects. Treating mild hypertension provides little prevention of CVD in the short term.

Dear readers, there is much more than what meets the eye in this profit-oriented sickness-care industry which considers its stakeholders and shareholders dearer than the life of poor patients. The last category is only a statistic for them.

(Professor Dr BM Hegde, a Padma Bhushan awardee in 2010, is an MD, PhD, FRCP (London, Edinburgh, Glasgow & Dublin), FACC and FAMS.)

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