Correspondence

The Hypertension Paradox

N Engl J Med 2009; 361:2195-2197November 26, 2009

Article

To the Editor:

In the Shattuck Lecture on the hypertension paradox (Aug. 27 issue),1 Chobanian points out that the number of people with uncontrolled hypertension is increasing. Nonadherence to treatment is a possible explanation for this finding, since estimated adherence rates are 51 to 79%, depending on the number of daily doses prescribed.2 Nonadherence is a recognized cause of adverse outcomes, particularly among patients with cardiovascular disease.3 In a recent editorial on osteoporosis in the Journal, 4 Khosla wrote that treatment success increasingly depends not so much on the drugs available to us but rather on our ability to engage our patients and ensure that they take the medications we prescribe. In my opinion, his statement is perfectly well suited to describe the situation concerning the treatment of hypertension.

Urs Schwarz, M.D.
Via Leoni 5, Breganzona, Switzerland
dottori.schwarz.hoey@bluewin.ch

4 References

1
Chobanian AV. Shattuck Lecture: the hypertension paradox -- more uncontrolled disease despite improved therapy. N Engl J Med 2009;361:878-887
Full Text | Web of Science | Medline

2
Claxton AJ, Cramer J, Pierce CA. A systematic review of the associations between dose regimens and medication compliance. Clin Ter 2001;23:1296-1310
CrossRef | Web of Science

3
Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005;353:487-497
Full Text | Web of Science | Medline

4
Khosla S. Increasing options for the treatment of osteoporosis. N Engl J Med 2009;361:818-820
Full Text | Web of Science | Medline

To the Editor:

In his article, Chobanian did not address the complexity of the management of hypertension in the geriatric population, although the majority of patients with hypertension are elderly. The low control rates of hypertension are largely attributable to inadequate treatment of systolic hypertension.1 Earlier research2 showed that treatment of systolic hypertension in the elderly resulted in impressive reductions in the incidence of stroke, coronary heart disease, and congestive heart failure. Study data3 also indicate that treatment of systolic hypertension (systolic blood pressure ≥160 mm Hg) in older patients is strongly recommended, whereas recommendations for treatment when systolic blood pressure is 140 to 159 mm Hg are less strong. More recent studies4,5 suggest that reaching a goal for systolic blood pressure at the expense of a reduction in excessive diastolic blood pressure may increase morbidity and mortality, particularly in cases of isolated systolic hypertension. It would be important to take these compelling study outcomes into account when developing treatment strategies for elderly patients with hypertension, particularly systolic hypertension.

Asit Baran Shil, M.D.
University of Southern California Keck School of Medicine, Los Angeles, CA
shil@usc.edu

5 References

1
Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report. JAMA 2003;289:2560-2572
CrossRef | Web of Science | Medline

2
Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991;265:3255-3264
CrossRef | Web of Science

3
Chaudhry SI, Krumholz H, Foody JM. Systolic hypertension in older persons. JAMA 2004;292:1074-1080
CrossRef | Web of Science | Medline

4
Ungar A, Pepe G, Lambertucci L, et al. Low diastolic ambulatory blood pressure is associated with greater all-cause mortality in older patients with hypertension. J Am Geriatr Soc 2009;57:291-296
CrossRef | Web of Science | Medline

5
Oates DJ, Berlowitz DR, Glickman ME, Silliman RA, Borzecki AM. Blood pressure and survival in the oldest old. J Am Geriatr Soc 2007;55:383-388
CrossRef | Web of Science | Medline

To the Editor:

In his recent Shattuck Lecture on hypertension, Chobanian states, “From the prehypertensive range upward, the effect of blood pressure on cardiovascular risk is progressive and continuous. . . . Thus, patients with prehypertension should be targeted for lifestyle interventions that reduce blood pressure. . . .” Other investigators have even begun to explore the value of treating such patients pharmacologically.1 Given these characteristics of prehypertension (i.e., increased risk, leading to recommendations for blood-pressure reduction), it is hard to understand what is “pre” about it. I believe that the term is misleading, because it implies that it is solely a precursor of hypertension, but the epidemiologic evidence of added risk shows that it is much more than that. On the basis of these considerations, I suggest that the term “prehypertension” be eliminated and replaced with “stage 1 hypertension,” while bumping up the current stages 1 and 2 to stages 2 and 3.

Aaron Spital, M.D.
Elmhurst Hospital Center, Elmhurst, NY
aspital@att.net

1 References

1
Kaplan NM. Prehypertension: is it relevant for nephrologists? Clin J Am Soc Nephrol 2009;4:1381-1382
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Author/Editor Response

As Schwarz indicates, nonadherence to medications is a problem for the control of hypertension and cardiovascular diseases. Approximately half of hypertensive patients discontinue medications in the first 6 to 12 months of therapy; treatment adherence involves not only patients but also clinicians and the quality of their interactions.1 However, this does not negate the importance of unhealthy lifestyles in promoting population-wide rises in blood pressure, leading to an increase in the prevalence of hypertension in the United States and most other parts of the world.

Shil raises issues regarding the management of systolic hypertension in elderly patients. Although the control of hypertension in the geriatric population is admittedly an important and complex problem, it was not the focus of the lecture, and space considerations precluded a full discussion of the topic. However, my views on the subject have been summarized in another publication.2

Spital disagrees with the designation of “prehypertension” for persons with blood pressures in the 120–139/80–89 mm Hg range and instead would replace the term with “stage 1 hypertension.” The prehypertension terminology has been the subject of considerable discussion and debate since its introduction in 2003.1 It identifies persons who are at greater risk of cardiovascular disease than those who have lower blood pressures.1 Other than for patients with chronic renal diseases, diabetes, or certain cardiac conditions, no data are yet available for this group regarding the benefits or risks of therapy with antihypertensive drugs. Until such evidence becomes available, it is appropriate to classify such persons as prehypertensive and restrict therapy to appropriate healthy lifestyles that reduce blood pressure and minimize age-related increases.

Aram V. Chobanian, M.D.
Boston University Medical Center, Boston, MA
achob@bu.edu

2 References

1
Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289:2560-2572
CrossRef | Web of Science | Medline