This topic is currently caught up in a tangle of controversies and guideline wars.
British Medical Journal. 2012.
By Paul Goldfinger, M.D., F.A.C.C. Board Certified cardiologist/internist, Editor of Blogfinger.net, and Dean of the Blogfinger Offshore School of Medicine in Ocean Grove, NJ. Closed on Sunday mornings until noon.
PART I: WHAT ARE THE ISSUES?
We wrote a series of this type before, but there are some important issues to discuss now based on changes of guidelines for the diagnosis and treatment of high blood pressure, i.e. hypertension.
Hypertension is a condition which threatens huge numbers of people around the world. The prevalence among adults in the U.S. used to be quoted as 32%, but since the new guidelines came out with new definitions, the number is now estimated to be 46%. And that number goes up with age, so that 76% is the prevalence in adults ages 65-74; and rises to 82% in ages 75 and older.
The measurement of BP is obtained using an electronic or mechanical device—a sphygmomanometer. 120/80 is the classic normal, but even that is controversial. The top number is called the systolic, while the bottom is diastolic. If either number or both is consistently elevated, then a diagnosis of hypertension is obtained. But there are different degrees of severity, and the risks of the disease go up as the numbers go up.
What is clear is that bringing the blood pressure to normal will reduce the risk of devastating vascular problems such as heart attack, heart failure and stroke.
Where the guidelines differ is in the cutoffs for making the diagnosis of hypertension, cutoffs for choosing various therapeutic approaches, and cutoffs having to with target readings when therapy is established.
But the world-wide healthcare establishment has yet to agree about how to correctly diagnose and treat hypertension. And the matter has other ramifications:
a. Many people with the disease have no idea that they have a problem
b. Of those who have been diagnosed and treated, a large percent have failed to reach desirable BP goals. And many who know that they have a problem are in a state of denial and do not go for evaluation or they receive inadequate followup, or they do not reliably and correctly take their medication.
In addition, physicians often fail to deal with hypertension properly, as defined by guidelines. In fact, some doctors ignore guidelines altogether, deciding their approach based on instinct and ignorance.
I have always thought that guidelines were a great idea since most doctors don’t have time to read all the research, so why not take the advice of experts? But there is a caveat: The doctor-patient relationship must be preserved, and the physician must be allowed flexibility in his decisions. However, if guidelines become inviolable laws, then doctors will rebel, and quality care will decline. In medicine, one size does not fit all.
c. There currently is a war of sorts, between the Americans and the Europeans regarding guidelines which determine how to diagnose and treat this important disease. No, it’s not like the D-Day invasion, but it is bad enough that both sides have published their own guidelines: the Americans in 2017 and the Europeans (let’s include Australia in this group) in 2018.
For years, the National Institutes of Health took on the task of issuing hypertension guidelines in the form of the Joint National Commission reports. The last time they did so (JNC8) was in 2014, but then, probably for political reasons, they retreated to their Bethesda headquarters, turning the job over to a combined committee from the American Heart Association and the American College of Cardiology (disclosure: I am a “Fellow” of both organizations. That title is gender neutral.)
And the Europeans have the European Society of Cardiology and the European Society of Hypertension.
To tell the truth, I not only prefer their croissants, their wine, and their beachwear, but I also prefer their hypertension guidelines. However we will get into that later.
d . And why can’t they totally agree? It’s because there have been hundreds of credible research trials on the subject done around the world, many recently, and because there are some philosophical differences between the two sides. And because medicine is a mixture of art and science, and no matter how much doctors try to practice “evidence based” medicine, there always is room for good judgement, style, and experience.
And don’t forget the incursions into medical practice by the bottom-line oriented health corporations, government, “Big Pharm,” and insurance companies; and by many physicians themselves who have been coerced into leaving private practice to become puppets of their employers—large hospital “health” systems.
Along the way, some of these doctors have compromised their standards in exchange for less stress, less administrative duties, more time off, and more cookbook medicine that can torture and break the traditional doctor- patient relationship. And the growing use of physician extenders to replace doctors introduces perhaps more efficiency and more money, but, in my opinion, greater chances for mistakes in patient care. As the hypertension guidelines become more complex, the involvement of physicians gets less.
I’m going to try to penetrate the layers of complexity of all this for you . You would be surprised if you knew how deep those layers go.
Feel free to comment by looking down and finding the comments button.
See you soon for Part II (I hope I can remember my Roman numerals.)
THE MARVELOUS WONDERETTES. And if you think that medicine and music don’t mix, just walk into an OR sometime during major surgery.