Questioning the Need to Treat Millions with Hypertension

Patient engagement and shared decision making for hypertension

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Two recent studies raise questions on both the accurate diagnosis of hypertension (HTN) and the need to treat HTN in mild cases in a low risk population

 

"Benefits and Harms of Antihypertensive Treatment in Low-Risk Patients With Mild Hypertension"

"Comparing Automated Office Blood Pressure Readings With Other Methods of Blood Pressure Measurement for Identifying Patients With Possible Hypertension "

Published in JAMA the articles identify both overdiagnosis and over treatment of millions of individuals currently diagnosed as hypertensive.

The first study did a review of means to measure blood pressure accurately looking at in office manual blood pressure measurement versus automated office based measurement and lastly comparing to ambulatory blood pressure measurement.  The results indicated a significant overestimation of measurements due to “white coat” effect The white coat effect is related to measuring BP in the medical setting rather than the at home.  Further inaccuracy was questioned due to human rather than machine measurement.

The second study looked at the risk benefit analysis of treating mild HTN in low risk population.  They concluded

This prespecified analysis found no evidence to support guideline recommendations that encourage initiation of treatment in patients with low-risk mild hypertension. There was evidence of an increased risk of adverse events, which suggests that physicians should exercise caution when following guidelines that generalize findings from trials conducted in high-risk individuals to those at lower risk.

 

Patients should be aware of the means of which blood pressure measurements are obtained which frequently overestimate disease and the questionable benefit of treating HTN in a low risk population. Stay tuned , further research is needed.

If you are being treated for borderline HTN and are low risk it is time to ask your doctor what is the best course of action for you.

NEW ENGLAND JOURNAL of MEDICINE MISSES the MARK


WHOOPS

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Extremely misguided and unscientific recommendations by a recent New England Journal of Medicine, Nov 22, 2018, article  suggests we  move beyond evidence based medicine (EBM) to a new paradigm described by Thomas Lee, MD as "interpersonal medicine"(IP).  The article describes the need for caregivers to respond to the individual circumstance and capabilities moving beyond EBM.   While every caregiver already understands that tailored individual care is the hallmark of fulfilling the fiduciary obligation to every patient, we must redouble efforts to base those tailored decisions on a very strong foundation of objective science and EBM.  We must decry the use of anecdotal and experiential care which risks offering therapies and interventions which offer no improvement over placebo but subject the patient to risk of harm without any proof that there is a benefit.



I applaud every effort to engage in shared decision making and encouraging patient engagement but only through EBM.  We return to the days of snake oil and witch doctors when we move away from science and EBM.  We currently do not practice EBM in the vast majority of patient encounters ( a fact admitted in the article) Please see previous articles I have written on the topic.  The decades of work of Iaoniddis highlight that 85% of the published research is either biased,  invalid  or non-reproducible proves this.  Understanding the importance of care coordination, psychological implications of the caregiver patient relationship, communication and understanding the impact of social determinants is critical but only if founded on EBM.



The author touts the benefits of "intuition" and "instincts" in care-giving which is frankly heresy and anathema.  We have over thirty years of data proving that  our medical instincts and intuition are more often wrong than right and that is why we need clinical decision support, artificial intelligence and other technology solutions so that science based decisions trump anecdotal medicine.  The work of Kahneman highlights the cognitive biases which pollute objective decision making.  When obtaining informed consent research shows that physicians routinely underestimate risks and overstate benefits when communicating with patients.



One major point of agreement is that science will not solve our biggest problems in health care but rather addressing prevention and the social determinants of health.  I have written most recently on the benefits of social prescribing and link workers/community health workers as a evolving solution to preventative care.  Still the practice of medicine should be EB, scientific, not intuitive, instinctive or anecdotal.



Creating good health policy should be based on science not anecdote.  Patient surveys identify preferences but do not create cures for disease



Lets embrace

  • Shared decision making

  • Informed Consent

  • Enhanced communication

  • Prevention through the social determinants of health

  • Clinical decision support, artificial intelligence, technology 

  • EBM



Lets de novo reject

  • intuition

  • instinct

  • anecdote based care

  • interpersonal medicine which moves beyond EBM

nicolas argy copyright 2018

nicolas argy copyright 2018