It is time for an installment of my recurring screed about the detection and treatment of high blood pressure in the United States.  The spark for this piece is the recently publicized new guidelines for treatment of this important, but largely silent, medical problem.

Hypertension, the medical term for high blood pressure, characterizes the excess pressure of blood pushing against the walls of the arteries, either from excess fluid in the vessels and/or from constriction of the vessels.  Picture a garden hose: pressure in the hose increases with a greater flow of water or decreases with a larger diameter of the implement.

Respected medical bodies, including the American Heart Association and the American College of Cardiology, have now defined high blood pressure as any reading greater than 120/80. The top number (the systolic number) reflects the blood pressure when the cuff tightens the arm, and the lower number (the diastolic reading) shows the pressure in the vessel when the cuff deflates.

A few years ago, a normal blood pressure was defined as anything in excess of 140/90.  Some of the best research in clinical medicine, however, showed that this number carried the risk of higher mortality due to stroke and heart disease, such as coronary artery disease, heart failure, and atrial fibrillation.  And that treating this or a higher number resulted in a dramatic decrease in cardiovascular disease.

Treatment

Effective treatment begins with lifestyle changes–achievement of ideal weight, exercise, dietary discretion, reduction of alcohol ingestion, cessation of smoking and management of stress.  If, after three to six months into the diagnosis, the pressure is not controlled, pharmacological intervention is indicated.  A plethora of safe, effective drugs are available.  They have few side effects and are inexpensive.

Hypertension in the United States

Half of US adults have hypertension, of which 60 percent are aware of their condition.  Only half of the 60 percent receive treatment and about 20 percent achieve adequate control of blood pressure.  Almost 800,00 people percent per year suffer a stroke, and hypertension is responsible for half of all cases.  It is also implicated in about 50 percent of all cardiovascular deaths.  After diabetes, hypertension is the leading cause of kidney failure.

The Screed

Our healthcare system has lopsided priorities.  We can get prosthetic joints, expensive treatment for hopelessly ill patients with terminal cancer, and organ transplants–all at wondrous expense.  But we allow a highly treatable disease, hypertension, to go undetected and undertreated in millions of people, resulting in millions of unnecessary cardiovascular deaths.  

The neglect is partially due, I think, to our society’s infatuation with technology.  We see this in reimbursement policies for doctors–proceduralists earn 50 percent more money than “cognitive” doctors.  The latter, primary care doctors, are the medical professionals who do the day-to-day work of treating hypertension–at a huge discount compared to doctors who do the colonoscopies, heart catheterizations, joint replacements, etc.  

This situation reflects society wide values.  People circling the moon rivets the attention of the nation, while social problems that are not amenable to technological interventions go unaddressed.  It is no surprise.  As amazing as moon shots are, they are actually easier to accomplish than fixing daunting social problems.

Primary care physicians (internists, family doctors) are the only doctors who reliably measure blood pressure in office visits.  Think about your visits to orthopedic surgeons, dermatologists, ophthalmologists, etc.  Do they measure your blood pressure?  Probably not–research shows that only a small minority do.

Could we incentivize them to check BPs?  Sure.  Simply interdict reimbursement unless the medical record shows a blood pressure measurement.  And maybe BP could be checked in dental offices.

Robert F. Kennedy, Jr., the Secretary of Health and Human Services, has sweeping ambitions that range from major change in vaccination policy to reducing childhood obesity to eliminating lead in our drinking water.  As far as I know, though, he has not specifically prioritized the detection and treatment of hypertension.  The lack of attention to untreated hypertension in the US, with the attendant unnecessary disease burden, is scandalous.  This is low hanging fruit, and public health could be vastly improved with simple and inexpensive interventions.