Treatment for symptom-free high blood pressure? It's not usually worth the stress

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I've come about a friend of mine ... Go on. He's a fit, 40-year-old TV producer who went to his GP with a sprained ankle ... RICE Sorry? RICE. Rest, Ice, Compression, Elevation. Would have sorted it without troubling the doctor. Yes, well she said, "While you're here, we might as well check your blood pressure."

That's what we call opportunistic screening. You go in with one problem and we decide to investigate you for something completely unrelated without your consent.

It seemed like a good idea at the time. Until she said, "Ooh, it's a bit high. 140/104."

It could have been worse.

She said anything over 140/90 was abnormal, and sent him off with a low- salt diet and an exercise programme, to return in a month.

And what was the blood pressure then?

140/104. And the same again a month later.

Tell me, how did your friend feel over these two months?

His ankle got better, but he became obsessed with his blood pressure. He had nightmares of his heart exploding and his work and marriage suffered.

That's fascinating. Studies have shown that labelling people who feel perfectly well with the stigma of high blood pressure can increase absenteeism, trigger depression and lead to self-imposed restrictions at work and play.

Why didn't the doctor warn him of this first?

Because doctors aren't terribly good at recognising the psychological side-effects of medicine. Also, the harm of labelling applies to all of medicine, not just hypertension, so it tends to get taken for granted.

So why do it at all?

Labelling can be ethical, especially if the patient asks for a diagnosis. But, for a doctor to go forcing a label on someone who hasn't got any symptoms and hasn't asked for it, we've got to be sure that the benefits of treatment outweigh the anxiety of the diagnosis.

So presumably there's concrete evidence that the two tablets a day my friend is now taking for the rest of his life will improve his lot?

Er ... not as such.

Meaning?

Meaning that if your friend was elderly or his blood pressure was higher, then it might be worth treating him to reduce the risk of stroke and heart disease. But he falls into the category of "mild hypertension in middle age" where things are a bit murkier. The biggest trial was published in 1985 after 17,534 mild hypertensives underwent 85,572 years' worth of treatment either with placebo or anti-hypertensive drug. Alas, there was no difference in rates of death or heart disease in the two groups.

A complete waste of time then?

The only benefit was a minuscule reduction in strokes (850 patients would have to be treated for a year to prevent one stroke). On the downside, side-effects were common in both the treatment group (eg, gout, diabetes, impotence) and the placebo group (10 per cent experienced impotence).

So why is my friend being treated at all?

Some cardiologists have criticised the trial, claiming the patients were mainly worried, well, middle-class men from the Home Counties who didn't really have hypertension at all, but their blood pressure went up a bit when they saw doctors. Others believe that the trial wasn't long enough and that the drugs used have now been superseded by better ones with fewer side-effects which, in time, will be proven to work.

So he's being treated on a hunch?

Like most of medicine, yes. Most strokes and heart attacks occur in people with mild hypertension, we just don't have the evidence that treatment prevents them. But with 10,000 people suffering a stroke each year before retirement, you can construct a compelling argument for treatment.

And against it?

Two million English people are currently labelled with hypertension, so that's a lot of psychological damage to prevent relatively few strokes. It's also very expensive. Your friend is likely to live, and thus be on two tablets a day, for another 35 years. That's 25,568 tablets, enough to go twice round the perimeter fence of my surgery. Each year, his chance of avoiding a stroke is one in 850, so his estimated benefit over 35 years is 850/35 or 25:1 against. Not great odds.

So is he likely to stick it out?

No. Thirty per cent of hypertensives don't cash in their prescriptions, probably because they feel well and don't see the point. It's estimated that of all the hypertensives in the UK, only half are known about. Of these, only half are prescribed adequate medication and only half of these take it as directed.

So only an eighth get effective treatment?

Yes. A recent study found that 21 per cent of stroke victims were on anti-hypertensive drugs at the time, suggesting they weren't getting the correct dosage.

Or that they don't work.

Perhaps. But hypertension is only one risk factor in many that can roger your arteries. Smoking is by far the worst. If you have high blood pressure plus high cholesterol or diabetes, then I'd opt for treatment. But if you have mild hypertension and nothing else, you could be better off without the label.

Thanks for your advice, Dr Phil, I'll pass it on to my friend. Oh and while I'm here, I haven't had an erection for three months ...

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