Health News Review

Dr. Iona Heath, a retired general practitioner and member of the UK’s Royal College of General Practitioners, writes in JAMA Internal Medicine‘s “Less Is More” column about “Waste and Harm in the Treatment of Mild Hypertension.” (subscription required for access to full text)

This is a topic that receives very little attention.

After all, who can argue with attempts for early intervention against “the silent killer”?  Well, evidence is not a bad argument, writes Heath, a leading voice against disease-mongering.


  • “The 2012 COCHRANE Review on “Pharmacotherapy for Mild Hypertension”1 concluded that antihypertensive drugs used in the treatment of otherwise healthy adults with mild hypertension (systolic blood pressure [BP], 140-159 mm Hg, and/or diastolic BP, 90-99 mmHg) have not been shown to reduce mortality or morbidity in randomized clinical trials”
  • “The Cochrane Review also reports that antihypertensive drug treatment for mild hypertension caused 9% of patients to withdraw owing to adverse effects. Each of these patients has experienced the harm of an adverse effect for no established benefit. The waste in terms of the costs of medication and investigations and the time of both patients and health care professionals is enormous.”
  • In view of the mounting evidence of both waste and harm, it is well time that we returned to the higher threshold of 160/100mmHg for the pharmaceutical treatment of hypertension in otherwise healthy people. The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure provides a timely opportunity for achieving this, but, with the probable degree of industry entanglement, it seems a remote possibility. However, sooner or later the pharmaceutical treatment of mild hypertension seems likely to be consigned to what the novelist Amitav Ghosh has described as “medicine’s vast graveyard of discredited speculations.”

This is worth noting:  I could not find one mainstream news organization that reported on Heath’s article.  Why not? Too contrarian? It’s just mild hypertension?

We have news organizations that publish stories about journal articles on case series of 1 to 4 patients and make sweeping proclamations based on these.  Then why not this?


On a Forbes blog, Dr. Peter Lipson challenges Heath’s stance, concluding: “One Cochrane report combining four studies is not about to change the way most of us practice medicine. Given the disease burden caused by high blood pressure, none of us should rush to raise our treatment thresholds. While Dr. Heath raises some interesting points, her call for significantly raising the treatment threshold (to 160/100) should be discarded until stronger evidence supports her ideas.”


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Peter A. Lipson, MD posted on May 28, 2013 at 12:40 pm

Her opinions aren’t simply out of the mainstream: they ignore the bulk of data available. I’ll have to pull down the full text of the Cochorane review and the piece referenced above, but RCTs aren’t the only story. Larger studies, although not RCTs, show a clear trend toward the benefit of lowering blood pressure to the current JNC recommended levels. Most of these are cohort studies, etc, but the trend is clear and overwhelms the relatively small cochorane review (11 RCTs).

Ken Leebow posted on May 28, 2013 at 3:43 pm

Dr. Nortin Hadler, author of Rethinking Aging, has been discussing this issue for a while.

DHN posted on June 7, 2013 at 10:07 am

I’m late to this party, but feel compelled to add: it is mistaken to cite and use observational data, which are hopelessly biased, in determining treatment thresholds. The data from roughly 9000 subjects in RCTs clearly and conspicuously trumps all observational data. This is the purpose of performing RCTs. No need to go backwards here—we have our best answer.

ed posted on June 26, 2013 at 5:03 pm

Dr. Heath is correct. Dr. Hadler and H Gil Welch have covered this. High blood pressure is a strong risk factor for early death. But as we’ve seen with B vitamins for hyperhomocysteinemia and fibrates/Zetia/niacin for hyperlipidemia, pharmacologically adjusting risk factor levels sometimes has no benefit.
If one sticks to what is rigorously proven, doctors would have a lot less to offer. I prescribe many drugs not because of rigorous proof, but because of peer pressure (to maintain my favored place in society).
– skeptical doctor in minnesota