Kevin Lomangino is the managing editor of HealthNewsReview.org. He tweets as @KLomangino.
The American Heart Association (AHA) has faced criticism for issuing new, more aggressive guidelines that lower the threshold for high blood pressure and set lower treatment targets for millions of Americans. (We’ve written extensively about those guidelines and the SPRINT study that formed the basis for them.)
Now the AHA is facing renewed criticism for the way those guidelines are being promoted to the public.
A public service campaign called “HBP Numbers,” developed by the AHA and American Medical Association in partnership with the Ad Council, presents a number of patient stories highlighting the dire consequences of uncontrolled high blood pressure. After seeing a full page ad from that campaign in last week’s New York Times, a reader snapped a photo and sent it to me. It’s the same image and message featured on the campaign’s accompanying website — www.loweryourHBP.org— captured below.
The ad features the story of “William,” with a blood pressure of 145/90 millimeters of mercury, pictured with an unbuttoned shirt to display the scars of what is presumably bypass surgery. He’s presented as a cautionary tale about the dangers of ignoring high blood pressure.
He can also be seen in television spots like this one saying that his “memory is shot.” and “Hell, I messed up” — presumably for not getting his blood pressure checked or not following his doctor’s treatment plan.
It’s a message that’s bound to strike fear in millions of Americans who also have blood pressure readings in William’s range (146 is the mean systolic BP for Americans with high blood pressure, according this 2011 report from the CDC.)
And it’s misleading on a number of levels.
First, the imagery and promotional text — “This is what high blood pressure looks like” — directly link William’s blood pressure to the outcome of a heart attack and bypass surgery. The implication is that appropriate treatment would have avoided that outcome.
It’s a simplistic narrative carrying a message isn’t supported by the evidence, said Richard Hoffman, MD, director of the Division of General Internal Medicine for the University of Iowa Carver College of Medicine.
“As we keep lowering the threshold for diagnosing high blood pressure, the number needed to treat has increased from around 1 to about 100 – meaning you’d need to treat about 100 mildly hypertensive people with blood pressure-lowering drugs to prevent one cardiovascular event over 5 years,” said Hoffman, who’s also a HealthNewsReview.org contributor. “Considering that context, it is quite a hyperbolic message to imply that William’s blood pressure of 145/90 dooms him to bypass surgery, or that treating him would markedly reduce the absolute risk of that outcome.”
Another problem with the campaign? Nowhere is there even a nod to the potential harms that might occur from chasing the new, more aggressive treatment targets. In the SPRINT trial which helped form the basis for those targets, adverse effects — some serious — were not uncommon.
“This advertisement would be more balanced if it showed a photo of someone passed out on the ground, or in a hospital bed being treated for acute kidney failure, or making an extra co-payment at the pharmacy for an additional anti-hypertensive drug,” said Kenny Lin, MD, professor of family medicine at Georgetown University. “All of these outcomes will be more common for patients like those in the intensive treatment group of the SPRINT trial than heart attacks prevented. But unlike most drug ads, there wasn’t even any fine print on these common side effects of therapy.”
It’s true that a print or television advertisement has limited room to deliver such context, but the accompanying informational website is similarly devoid of key specifics.
There you will find plenty of warnings about the risks of uncontrolled high blood pressure – including heart attack, stroke, kidney failure, vision loss, and sexual dysfunction — but nothing about the risks of treating to a target of 130/80.
There is nothing to inform readers about the size of the cardiovascular risk reduction associated with treatment to the new targets. Nothing that answers the question, “How much do I stand to benefit?”
Concerns about these specifics were raised by the American Academy of Family Physicians when it decided not to endorse the new AHA/ACC guidelines and their more aggressive treatment targets.
Among the many reasons the organization gave for not endorsing those guidelines is that “the harms of treating a patient to a lower blood pressure were not assessed” in the literature review that informed the guidelines.
To be clear, the “HBP Numbers” campaign also features the stories of patients with much higher blood pressure levels who are obviously candidates for anti-hypertensive treatment. And the associated informational website provides some useful resources and urges patients to “Talk to your doctor” – always good advice.
Yet it is “William” and his borderline-high numbers that will resonate most with the millions of Americans who find themselves in the same gray area — where treatment to a low target may present complicated tradeoffs. And that is why his story merits our scrutiny and deserves attention from the AHA.
I believe this campaign to encourage blood pressure screening (like many others we’ve criticized on screening for prostate cancer, lung cancer, head and neck cancer, and others) has its heart in the right place. Yet good intentions aren’t sufficient to ensure a good outcome.
Physicians analyzing the evidence may disagree about the optimal blood pressure treatment targets. But they should be unanimous about the need for patients to have an informed voice in complicated treatment decisions.
That goal isn’t advanced by ad campaigns that scare patients into the clinic with dire warnings and simplistic messages.
Educating patients – not coercing them – should be the objective of this campaign and others like it.
Patients shouldn’t be frightened into making decisions that can adversely affect their health.