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PRO & CON.
Should mild hypertension be treated routinely with drug therapy?
Dr. Stevo Julius is professor of internal medicine at the University of Michigan, Ann Arbor, and is the Heutwell Professor of Hypertension.
YES Hypertension is a slowly progressive disease that starts early in life and typically leads to cardiovascular mortality and to other diseases. We should intervene in this relentless process by treating even mild elevated blood pressures using the only approach that really works--early, routine, pharmacologic intervention.
Others call for counseling and believe that lifestyle modification should be first-line therapy But patients don't listen to such advice, especially patients with mild hypertension. They often believe that they do not have a lot to fear from high blood pressure. Nondrug interventions may work with zealots but not with typical patients. And only an effective intervention can stave off hypertension in its early stages, before target organs are damaged and cardiovascular disease progresses.
Clinical studies appear to indicate that the same benefits can be attained with lifestyle modifications, but sometimes the data do not apply to the real world. The Dietary Approaches to Stop Hypertension study showed that a healthy diet can lower blood pressure in hypertensive patients. But the study participants' food was prepared for them every day in a hospital kitchen at a cost of $20,000-$40,000 per patient per year. Such data tell us nothing about what people are willing to cook for themselves.
In addition, studies that show benefit 5 years out fail to shed light on what happens after that time. Invariably patients go back to old habits and regain the weight they lose.
It's true that many patients with mild hypertension never require treatment and will see their blood pressure return to normal spontaneously But we need research to determine which patients fall into this category and which are at risk of deteriorating. Instead, researchers ignore the pharmacologic needs of mild hypertensives, and our leaders have washed their hands of the problem.
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