A good argument can be made that we could save more lives and prevent more morbidity by aggressively diagnosing, treating and controlling hypertension than with any other condition given the knowledge and tools at our disposal at this time. Hypertension is not a sexy to address as things like breast cancer, colon cancer or diabetes, but it is extremely prevalent,we can diagnose it easily, treat it effectively, and we have great data that this treatment saves lives and prevents morbidity from strokes, heart attacks, congestive heart failure and kidney failure.

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) tells us that hypertension affects more than 50 million Americans and more than 1 billion persons worldwide. It is estimated that in people with Stage I Hypertension (the mildest type with Systolic BP of 140-159 or diastolic BP of 90-99 at the time of diagnosis) we only need to treat 11 people for 10 years to prevent one cardiovascular death. If look at people with either known cardiovascular disease or any organ damage from high blood pressure it only takes treating 9 people for 10 years to prevent a death.

The bad news is that despite this terrific data, and despite better and better drugs to treat hypertension we are doing a miserably poor job of controlling hypertension in America.  After great progress in the 1970’s and 1980’s we have made little progress in the control of hypertension.  In the late 1970’s only 51% or Americans with Hypertension were aware of the diagnosis and only 10% were controlled.  By the late 1980’s this had dramatically improved to 73% awareness and 29% controlled.  Since then there has been little continued progress.  Data from the early 1990’s and from 1999-2000 show little further improvement, and there is not much evidence we are doing better now.  Effective control of only 30% of patients with a disease that is nearly 100% controllable and where effective control can prevent death and terrible diseases like stroke, heart attacks and kidney failure is a disgrace. We should and can do better.

The JNC-7 report states the goals succinctly:

Goals of Therapy

The ultimate public health goal of antihypertensive therapy is the reduction of cardiovascular and renal morbidity and mortality. Since most persons with hypertension, especially those age >50 years, will reach the DBP goal once SBP is at goal, the primary focus should be on achieving the SBP goal. Treating SBP and DBP to targets that are <140/90 mmHg is associated with a decrease in CVD complications. In patients with hypertension and diabetes or renal disease, the BP goal is <130/80 mmHg.

This sounds simple.  It really is most of the time so why are we failing miserably? Here is what I think:

1. As a population Americans, both patients and physicians just don’t believe treatment of hypertension is important.  Every day I hear patients say, “I’ve always had borderline blood pressure.”  “I just don’t want to have to take a medication for the rest of my life.”  “My blood pressure is only high at the doctor’s office.”  As physicians we need to be believe the data, be firm in our advice, and not let patients convince us to ignore this serious disease. As patients we need to recognize that when we have high blood pressure it needs effective treatment, and though non-pharmaceutical measures can help, medication is often needed.
2. Hypertension is asymptomatic, meaning patients feel fine even though their blood pressure is high, and it is gradually causing damage to their blood vessels, heart, and kidneys.  We need to emphasize to patients that they cannot ignore the objective evidence of their disease.  It needs treatment.
3. Once diagnosed patients drop out of site.  At our office we have had an electronic medical record for 12 years, and have a virtual disease registry to try to track down and arrange follow up on our patients with high blood pressure who have not been in for evaluation and treatment, as well as find patients whose last blood pressures were high but did not come back for reevaluation.  I understand the argument for asking patients to be responsible for their own follow up care, but when we have the tools to help, we should use them.
4. Too many Americans do not have health insurance, and spending one’s limited money to treat an asymptomatic disease that is not likely to cause problems in any given short period of time is difficult.  I’d argue that we have inexpensive meds that work great for most patients, and there may not be any disease more important to treat than hypertension.  Hypertension treatment should really be at the top of the list of health concerns on which to spend limited resources.

So what should you do as a patient?  Everyone should get a blood pressure check every year or two.  It is free, easy and painless. Just do it.  If your blood pressure is borderline or high don’t wait.  See your physician and get it evaluated.  If your physician seems to not address a blood pressure over 140 systolic on repeated measurements seriously, ask them why?  If they still ignore the problem, consider a different physician or get a second opinion.

 As physicians we need to refocus on the diagnosis and aggressive treatment of this silent killer.  We cannot accept suboptimal control, and need to develop tools to try to manage both our individual patients as well as our patient panel as a whole using a chronic disease management model of care.