New blood pressure guidelines are promoted with scars and scare tactics

Kevin Lomangino is the managing editor of 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 —— 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.

A ‘hyperbolic message’ that ignores the harms

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 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.”

Key questions unanswered

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.

Education, not coercion, should be the goal

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.

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Comments (3)

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bev heywood

January 28, 2018 at 8:48 am

This campaign for more aggressive HBP treatment echoes the tradition in the profession of ignoring any and all drug side effects and interactions. Rarely do you see that emphasized either in training or in practice, nor any of the nuances such as treating the very elderly for high blood pressure. This must be remedied.

Maggie Francis

January 29, 2018 at 3:52 pm

Hi Kevin, I work for the American Heart Association and was part of the development and dissemination of the high blood pressure information you mention here. While important in the context of the conversation around new hypertension guidelines, your commentary is fundamentally flawed for a couple of key reasons.
You open with criticism of a new public service campaign sponsored by the American Heart Association and others, intended to raise awareness of risks of high blood pressure. You quote Dr. Lin:

“…unlike most drug ads, there wasn’t even any fine print on these common side effects of therapy…”

These aren’t drug ads. They are public service announcements to support an integrated awareness campaign, created to inspire people with high blood pressure to take action. We want consumers to take action by talking with their doctor and sticking with, modifying or returning to the lifestyle habits that will help them more successfully manage their blood pressure. This campaign features real people, like William, who volunteered to tell their stories in the hope of helping others. The social marketing literature is full of examples of similar evidence-based campaign approaches that resulted in successfully raising awareness and changing behavior. This one follows in that honored tradition (“Sophisticated Lady”, “Your Brain on Drugs”, “Truth”) featuring distinctive approaches intended to leverage the impact of humor/scare/startling facts/celebrity with relevance (there is a reachable audience who can/will care) and resonance (whether the audiences can understand and personalize the message). In this case, the market research told us that most adults did not consider controlling high blood pressure as urgent until it was connected with real consequences, many of which the patients didn’t know or had dismissed. Good public service advertising is good advertising.

You then pivot to a false assumption that the new public service campaign – and the hypertension guidelines themselves – were specifically created to increase medication use. Not true. According to two separate analyses of the joint 2017 Hypertension guidelines, less than 3 percent more adult Americans will actually need to take anti-hypertensive medication. The guidelines clearly and unequivocally emphasize that preventing and managing high blood pressure comes through lifestyle change – increasing physical activity, reducing dietary sodium, adhering to a DASH-like Mediterranean diet, limiting alcohol and avoiding tobacco use.

At the American Heart Association, we are not promoting a drastic change in physician prescribing practices. Rather, we are encouraging a “back-to-the-basics” approach to care that involves getting an accurate blood pressure measurement to begin with, increasing focus on lifestyle change, and partnering with patients to create a workable plan for keeping each individual’s blood pressure at a healthy level.

The idea that treatment involves more than medication may be a paradigm shift for some in the healthcare industry and for some patients alike. But whatever the route to improving blood pressures, the “side effect” we’re striving for is a scientifically proven reduction in cardiovascular disease, related deaths and disability.

    Kevin Lomangino

    February 2, 2018 at 1:06 pm


    Thanks for your comment and for explaining some of the thinking that went into this campaign. I know that it is difficult to create messages that are effective and that you are trying to improve public health.

    I will not respond in detail to every point that you raised but overall, I think your comments demonstrate thinking that is well-intentioned but does not serve the public good and may well cause harm. I hope you will consider this perspective for future campaigns.

    Fear may well be an effective motivator for an advertising campaign. However, getting people into their doctors’ offices and screening for blood pressure is not an end in and of itself. That’s simply the start of a process where patients may or may not decide to take further action depending on their individual circumstances. If patients have been scared into screening by inflammatory and unrealistic media messages about the risks, they are not in a good position to make these complicated decisions. They will be acting out of fear, and not from a careful and dispassionate evaluation of their circumstances.

    You said that “most adults did not consider controlling high blood pressure as urgent until it was connected with real consequences.” And that is exactly my point: a BP of 145/90 is NOT urgent and should NOT be directly connected to the outcome of bypass surgery – as the expert comments from my post demonstrate.

    Lastly, we agree that some percentage of Americans will have to take more drugs to reach the blood pressure targets. I don’t know how many thousands or millions of people that represents, but those people should be warned, somewhere, that this is not a slam dunk decision. The benefits for someone like William would be modest at best and would have to be weighed against the potential harms that Dr. Lin describes. There was plenty of room to include that message in the campaign website. The information that’s provided has to be balanced — otherwise it’s just promotion.


    Kevin Lomangino
    Managing Editor