Who Needs to Be Treated?

Before 1967, many investigators believed that high blood pressure was not truly a disease, but an adaptive mechanism. They argued that the higher pressure was necessary to maintain normal blood flow through narrowed and diseased arteries. There was a large contingent of physicians who felt that one should not try to lower blood pressure except in extreme cases. These were patients with what was called "malignant hypertension". These are blood pressures so high that serious damage to the heart, brain, eyes or kidneys, or even death, was imminent. The answer to the question "Who needs to be treated?" has changed over time. The changes were brought about by changes in the available methods of treatment, and by better knowledge of the natural history of the disease. The reason for treatment of hypertension is very different than for most diseases. The primary reason to treat most diseases is to eliminate the disease state; to cure it. If this is not possible, then the aim is to relieve or prevent symptoms. Hypertension, however, is completely without symptoms until permanent damage has begun in target organs. With current knowledge, at least 90 percent of cases of high blood pressure can not be "cured", but blood pressure can be controlled by constant therapy. Treatment must be aimed at changing the usual course of the disease, in altering its natural history. The elevated blood pressure is treated in order to prevent or delay the diseases associated with arteriosclerosis, or "hardening of the arteries".

The tendency today is to treat earlier, and at levels which once were regarded as acceptable. Serious side effects from the available medications limited treatment in the past. The effects of the medications necessary to control blood pressure frequently could not be tolerated. Persons who otherwise had no symptoms could not be expected to take medication which prevented normal sexual relations, and caused fatigue, drowsiness, or dizziness so severe as to prevent normal activities of daily living. A relatively young, apparently healthy person was asked to take medications for years, but felt better without the medicine. Before this could be justified, proof had to be shown that there was a benefit worth the cost, discomfort, and impairment of function caused by treatment.

Over the years, a number of studies were devised to discover exactly who should be treated, and whether any long-term benefit would be derived. One of the first such large studies, by the Veterans Administration Cooperative Study Group, published its initial findings in 1967. It concentrated on the effect of treatment on patients with diastolic blood pressures over 115 mm. Hg. The substantial decrease in congestive heart failure, the number of strokes, and other complications in the treated group caused the early termination of a portion of the study. The untreated group was obviously doing so poorly in relation to the treated group that it was not morally right or ethical to continue such a study. No study can ethically be done today with an untreated control group. Studies comparing different and newer methods of treatment, of course, continue.

After this study reported in 1967, there remained no doubt that treatment of severe high blood pressure is beneficial. The question remained as to whether mild hypertension really should be treated. Subsequent studies have shown that even mild hypertension should be treated. The question today is less "who should be treated", but more properly, "how should hypertensives be treated?". The damage associated with hypertension is in proportion to the height of the blood pressure and the duration of the condition. Pathological changes in the patient and the results of treatment can be assessed in a matter of weeks or months in severe hypertension. In mild hypertension, observation for years is required to evaluate the effects of treatment or non-treatment. The answers for how mild hypertension is best treated have been slower in discovery, and are still being investigated.

How is Hypertension Treated?
General
In spite of the difficulties in making a decision of which patients should be treated, a variety of effective blood pressure lowering options are available. The basic division in types of treatment available is between non-pharmacological treatment, and treatment with prescription medicines. The drugs that used to be available for treatment were quite toxic, with many side-effects. More modern drug therapy is still limited by side-effects, but there are now literally thousands of combinations of new drugs available for treatment. The goal of treatment is to prevent sickness and death due to damage to "target organs" by high blood pressure. Ideally, the treatment itself should not increase the risk of illness or death. There is no question that non-pharmacological treatment should be instituted first, and drugs only be added if the result is unsatisfactory. The necessity for the use of medication is not a reason to abandon non-drug therapy. It should always accompany treatment with medication since it is desirable to minimize the dosage of drugs needed.