New Blood Pressure Guidelines: Good for Doctors, Bad for Patients.
Last week I went to sleep, and when I woke up an additional 30 million people had a diagnosis of hypertension, or high blood pressure. How did this epidemic occur so quickly? It turns out that the American College of Cardiology changed its definition of hypertension. Whereas previously, one had to have a pressure over 140 to be labeled with the disease, now, in their infinite wisdom, the specialist experts decreed that 130 would be the new cut off.
How did these experts arrive at so draconian a decision? While they claimed to have reviewed hundreds of studies, in fact they relied on the very small and flawed SPRINT trial, in which for a very select group of HIGH RISK cardiac patients, aggressive treatment of blood pressure lowered the rate of death and cardiac disease substantially. In fact, according to newspapers like the New York Times, aggressive treatment of blood pressure to the new targeted level of 130 would reduce death by 25% and cardiac disease by 33%. The experts quoted were giddy about how these 30 million new hypertensives would have tremendous benefit from aggressive treatment! But in fact, their conclusions are both deceptive and potentially harmful. I have discussed SPRINT in these pages before, and for a more erudite and reasoned analysis of the new guidelines and of SPRINT make sure to check the blog on my other website, where we use BRCT theaters to show the lack of evidence behind the guidelines. But here, I am going to be a bit more jaded.
SPRINT’s findings are hardly as profound as the experts suggest. In fact, over 3 years, 3.5 lives are saved among 1000 high risk people who have aggressive control compared to 1000 people with normal control, or about 1 life saved out of 1000 people treated aggressively per year (hence, 99.9% of people do not benefit). Meanwhile, among the aggressively treated group, 12 people out of 1000 with aggressive control develop severe side effects including kidney failure and life-threatening pressure drops. Countless others become fatigued, unstable, and more confused; this is what I see in my practice every day. These are hardly the drastic life-saving results that the experts and the New York Times claimed. What is worse is that in many much larger studies of aggressive blood pressure control, including in those people who are not at high risk of heart disease, or who have diabetes or kidney disease, the death rate goes up with aggressive control, and people get major side effects. In fact, two major medical organizations raised the blood pressure standards last year to 150 because of a lack of evidence that any lower pressure is beneficial and the fact that aggressive control often causes harm. Why then did the American College of Cardiology seek to push the number lower, and why did the media blindly follow their recommendations without doing any research or asking any questions?
H. Gilbert Welch, one of the smartest doctors out there, wrote a terrific op-ed in the New York Times explaining why these guidelines are off base. But for me, who practices medicine every day and who sees the results of aggressive treatment first hand, I am more cynical. Certainly, the American College of Cardiology must know that aggressive blood pressure treatment is dangerous for the vast majority of people, that the SPRINT study is flawed and selective and diverges sharply from many other studies, and that blood pressure is an inaccurate measurement that is typically higher in the doctor’s office than in real life. In fact, by making these recommendations, they are subjecting millions of people to over-treatment, over-testing, and serious harm.
Then what is their motive? I believe there are three.
Cardiologists, more than any other group of doctors, have an almost religious belief that lowering numbers must be good for you. They think so with cholesterol too, just like they think that opening blocked arteries makes good sense. Forget the fact that the evidence in all these cases shows just the opposite, you simply can’t convince them that lower is not always better.
By giving 30 million additional people a label of hypertension, this group has now created 30 million new patients who will have to see their doctor regularly and be subjected to the array of unnecessary tests (ekg’s, blood tests, stress tests) that are very profitable. As a wise doctor once told me, it is the goal of the American health care industry to make as many people sick as possible.
By having 30 million more hypertensives, the pharmaceutical industry will now be doling out even more drugs to people who don’t need them. While the new guidelines suggest that life style changes should be advocated first, the sad truth is that most doctors take the easier path and give their patients drugs, often ones that are new and very expensive. This realization is certainly not lost on the experts who framed the new guidelines.
It is not very difficult to be cynical these days. We as doctors are already being graded by clinical guidelines that verge from proven fact and that are contradictory to patient centered care. This new blood pressure guideline will be one more parameter to which we will be forced to adhere if we are going to be deemed to be “quality” doctors and if we are going to avoid getting a salary cut. If lowering blood pressure causes our patients to be tired, to feint, to have worsening memory, to lose kidney function, or to die, we will still pass the quality measures. But if our patient does better at higher pressures and prefers to keep the pressure up, we will not pass. In fact, we can push the pressure dangerously low and there is no quality measure that would tell us we are doing anything wrong.
Hence, when these guidelines are introduced, and when the media trumpets them using deceptive relative numbers (25% reduction in death, which is really 1 less person who died out of 1000 high risk people in a single small study) and does not actually scrutinize the “facts” that the “experts” give them, doctors like me just throw up our hands. Large specialty organizations push us to over-treat our patients, whether our individual patients want or benefit from that treatment or not, and then we are graded by our success in following the flawed guidelines. But this is not how medical care should be. Each individual patient is different, and blind, aggressive guidelines are antithetical to good patient care and shared decision making. However, these guidelines do enrich specialist doctors and drug companies, and so, there is a silver lining.