MUMBAI: It's a potential bombshell in healthcare. A new study suggests that people with mild hypertension — a reading of 140/90 mm — should not be popping pills daily to control their condition. In India where every fifth, if not every fourth, grown-up is a hypertensive, this radical thought could further raise blood pressure.
Has all the pill-popping been in vain? ACochrane Review published recently has concluded as much: there was no reduction in deaths, incidence of heart disease or strokeamong 9,000 patients who took medication for four to five years. The prestigious journal said it had reviewed data from four randomized trials conducted in the United Kingdom, Australia and the United States to arrive at its conclusion.
Patients who were reviewed had systolic blood pressure between 140 and 159 mm Hg and diastolic reading between 90 and 99 mm Hg. This is classified across the world, including India, as mild hypertension. There have, of course, been allegations from health activists that the definition of hypertension has been manipulated so that the pharmaceutical industry can sell its medication to the maximum number of patients.
But hypertension or elevated blood pressure cannot be taken lightly. It can, over a period of time, wreak havoc with one's system. It increases a person's risk for heart disease, stroke, kidney disease and even blindness. Predictably, most doctors here are upset with the Cochrane review.
"It's a review and not an actual study on the effects of medication," said endocrinologistShashank Joshi, author of a pan-India study on the incidence on diabetes and hypertension. Many western reports on the review suggest that newer medications were not included. The UK Blood Pressure Association's professor Gareth Beevers said in his statement: "There is a danger that some journalists and patients will take this review as evidence that hypertension in general is not worth treating. If lots of patients with severer grades of hypertension with existing CVD stop their tablets, there could be disastrous consequences."
The fear is shared by Indian doctors. Dr Anoop Misra of Fortis Hospital in Delhi felt it was too early to consider changing the course of therapy for mild hypertension. "The trials considered in this review were done only up to five years, while the consequence of mild hypertension may appear only after a decade or later," he said. Moreover, he felt Indians may have different results with drug treatment of mild hypertension. "I suspect our results are more positive than those seen in Caucasians," said Misra, who is also associated with Diabetes Foundation of India.
"The patient might have some other underlying disease condition, family history of stroke or heart attack etc. We can't risk a patient's life. Starting medication in the initial stages will prevent serious damage in the long run," said MP Sharma, head of internal medicine, Rockland.
In India, the hypertension picture becomes more serious when one considers the epidemic of diabetes; their combination is certainly more dangerous than either occurrence in isolation. Diabetes affects 61 million Indians, according to 2011 figures. "Given the burden of diabetes and hypertension in the country, we should have more vigorous and aggressive treatment," said cardiologist N O Bansal, who heads the department in JJ Hospital's medical school.
Moreover, in India, a sizeable number of patients don't know that they are suffering from hypertension. Dr Shashank Joshi, a consultant at Mumbai's Lilavati Hospital, said, "The rule of halves still holds true in India. Approximately half of the patients are undetected, half of those detected are not treated, and half of those treated have failed to get their disease in control," he explained. In other words, the epidemic in India is still silent and undetected in many patients. The question of overmedication hence doesn't arise, feel experts.
While some feel overmedication can cause side-effects, Dr Bansal said there was no disputing the fact that anti-hypertensive medication helps reduce stroke, kidney and heart failure among patients. "We know that these medications don't help reduce the burden of ischemic heart disease because many factors contribute to heart disease," he said.
Cardiologist Ganesh Kumar from L H Hiranandani Hospital in Powai was among the few who agreed with the Cochrane review. Stating that many patients in India with mild hypertension were indeed being subjected to medication, he said, "Many patients suffer from white-coat hypertension, that is their blood pressure goes up by merely waiting in the waiting room of a doctor (who wears a white coat)." Hence, blood pressure readings should be repeated over a three-month period before the patient is put on medication.
There is also the role of exercise and diet. The lead reviewer of the recent Cochrane Review, David Cundiff, has been quoted as saying: "Patients focus on exercising, smoking cessation, and eating a DASH (diet against systolic hypertension) or Mediterranean diet." Dr Kumar concurs: "If a person reduces five to 10 kg, then his\her blood pressure will come down by 20-30 mm Hg. He says the first approach should always be diet control and weight reduction. "Some reports from the West have shown that just controlling diet and increasing exercise can bring down blood pressure under control for three to four years."
Has all the pill-popping been in vain? ACochrane Review published recently has concluded as much: there was no reduction in deaths, incidence of heart disease or strokeamong 9,000 patients who took medication for four to five years. The prestigious journal said it had reviewed data from four randomized trials conducted in the United Kingdom, Australia and the United States to arrive at its conclusion.
Patients who were reviewed had systolic blood pressure between 140 and 159 mm Hg and diastolic reading between 90 and 99 mm Hg. This is classified across the world, including India, as mild hypertension. There have, of course, been allegations from health activists that the definition of hypertension has been manipulated so that the pharmaceutical industry can sell its medication to the maximum number of patients.
But hypertension or elevated blood pressure cannot be taken lightly. It can, over a period of time, wreak havoc with one's system. It increases a person's risk for heart disease, stroke, kidney disease and even blindness. Predictably, most doctors here are upset with the Cochrane review.
"It's a review and not an actual study on the effects of medication," said endocrinologistShashank Joshi, author of a pan-India study on the incidence on diabetes and hypertension. Many western reports on the review suggest that newer medications were not included. The UK Blood Pressure Association's professor Gareth Beevers said in his statement: "There is a danger that some journalists and patients will take this review as evidence that hypertension in general is not worth treating. If lots of patients with severer grades of hypertension with existing CVD stop their tablets, there could be disastrous consequences."
The fear is shared by Indian doctors. Dr Anoop Misra of Fortis Hospital in Delhi felt it was too early to consider changing the course of therapy for mild hypertension. "The trials considered in this review were done only up to five years, while the consequence of mild hypertension may appear only after a decade or later," he said. Moreover, he felt Indians may have different results with drug treatment of mild hypertension. "I suspect our results are more positive than those seen in Caucasians," said Misra, who is also associated with Diabetes Foundation of India.
"The patient might have some other underlying disease condition, family history of stroke or heart attack etc. We can't risk a patient's life. Starting medication in the initial stages will prevent serious damage in the long run," said MP Sharma, head of internal medicine, Rockland.
In India, the hypertension picture becomes more serious when one considers the epidemic of diabetes; their combination is certainly more dangerous than either occurrence in isolation. Diabetes affects 61 million Indians, according to 2011 figures. "Given the burden of diabetes and hypertension in the country, we should have more vigorous and aggressive treatment," said cardiologist N O Bansal, who heads the department in JJ Hospital's medical school.
Moreover, in India, a sizeable number of patients don't know that they are suffering from hypertension. Dr Shashank Joshi, a consultant at Mumbai's Lilavati Hospital, said, "The rule of halves still holds true in India. Approximately half of the patients are undetected, half of those detected are not treated, and half of those treated have failed to get their disease in control," he explained. In other words, the epidemic in India is still silent and undetected in many patients. The question of overmedication hence doesn't arise, feel experts.
While some feel overmedication can cause side-effects, Dr Bansal said there was no disputing the fact that anti-hypertensive medication helps reduce stroke, kidney and heart failure among patients. "We know that these medications don't help reduce the burden of ischemic heart disease because many factors contribute to heart disease," he said.
Cardiologist Ganesh Kumar from L H Hiranandani Hospital in Powai was among the few who agreed with the Cochrane review. Stating that many patients in India with mild hypertension were indeed being subjected to medication, he said, "Many patients suffer from white-coat hypertension, that is their blood pressure goes up by merely waiting in the waiting room of a doctor (who wears a white coat)." Hence, blood pressure readings should be repeated over a three-month period before the patient is put on medication.
There is also the role of exercise and diet. The lead reviewer of the recent Cochrane Review, David Cundiff, has been quoted as saying: "Patients focus on exercising, smoking cessation, and eating a DASH (diet against systolic hypertension) or Mediterranean diet." Dr Kumar concurs: "If a person reduces five to 10 kg, then his\her blood pressure will come down by 20-30 mm Hg. He says the first approach should always be diet control and weight reduction. "Some reports from the West have shown that just controlling diet and increasing exercise can bring down blood pressure under control for three to four years."
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