Reprinted from ANNALS OF INTERNAL MEDICINE Vol. 78, NO. 1, January 1973 Printed in U.S.A. Changing Attitudes to Hypertension DOCTOR LANGFELD'S REPORT, in this issue, on the de- ficient care of hypertensive patients is one of several indicating that essential hypertension is still poorly managed in this country. Despite conclusive evidence to the contrary, many if not most physicians still consider essential hypertension to be a benign disease for which reassurance rather than treatment is needed. The persistence of this therapeutic nihilism is sur- prising in view of the fact that there are few chronic diseases for which medical treatment is more rational or better documented than for essential hypertension. All epidemiological data on the subject, such as the life insurance statistics (1) and the Framingham Study (2, 3) make clear that the risk of cardiovas- cular complications is directly related to the level of blood pressure: the higher the level, the greater the risk. Such a linear relationship should lead to the con- clusion that the level of blood pressure is causally related to cardiovascular damage, because, if it were not, no such relation would exist. Confusion has arisen from a failure to distinguish between casual and basal blood pressure. Physicians have been overly impressed by the exceptional patient with high pressures who survives without cardiovas- cular damage for many years. Usually these patients are women beyond the menopausal age with labile hypertension who often have nearly normal levels of blood pressure at home or during hospitalization. Phy- sicians reassure themselves for doing nothing about their hypertensive patients by overemphasizing these exceptional cases. The more representative epidemio- logical studies, however, indicate clearly that even mild elevations of blood pressure, especially in per- sons below age 45 years and in men at all ages, car- ries a high risk. Therefore the physician is not justi- fied to dismiss lightly the prognostic implications of an elevated blood pressure. Hypertension and hypercholesterolemia are the leading risk factors in coronary artery disease. Hy- pertension is by far the most important risk factor in stroke. According to the Framingham Study, con- gestive heart failure is six times more common in hypertensive than in normotensive individuals. Hy- pertension is a leading cause of renal failure in mid- dle and old age. Well-controlled, prospective, therapeutic trials, which compared results of treatment with antihyper- tensive agents against no treatment, have supplied definitive evidence that reducing blood pressure will prevent much of the cardiovascular damage associ- ated with hypertension (4-6). The Veterans Admin- istration Cooperative Study showed that in male pa- tients with diastolic blood pressures in the range of 90 to 115 mm Hg the risk of developing cardiovas- cular complications over a 5-year period was reduced from 55 to 18 percent with the effective use of anti- hypertensive drugs. The greatest benefit of treatment was seen in the subgroup with diastolic blood pres- sures of 105 mm Hg or higher. Strokes were reduced by a ratio of four to one, fatal or permanently crip- pling strokes by a ratio of 12 to one. Such compli- cations as congestive heart failure, acceleration of hypertension, progressive renal damage, and dissect- ing aneurysm were seen only in the control group and were completely prevented in the treated patients. The only complications not significantly affected by the treatment were those due to coronary artery disease. In view of the gradual development of athero- sclerosis, treatment may have been started too late, and in these cases earlier institution of antihyper- tensive drugs might have favorably influenced this complication as well. Many hypertensive complications can be repro- duced in animals. One example is the strain of Wistar rats in which hypertension develops spontaneously. In these rats antihypertensive drug treatment will completely protect from development of cardiovas- cular abnormalities, including left ventricular hyper- trophy, arterial disease, and nephrosclerosis (7). Such studies show clearly that the cardiovascular compli- cations of hypertension are the direct result of the elevated blood pressure and can be prevented by re- 141 ducing pressure to normal levels. What is needed to reverse the present toll of need- less disability and death from uncontrolled hyperten- sion? The first requirement is to convince physicians that the complications of hypertension are prevent- able. The second is to identify the large number of patients with hypertension requiring treatment who are presently unrecognized. The third is to motivate patients to accept and continue with treatment even though they have no symptoms. The first objective can be met by an intensive edu- cational effort in the medical profession, the second by organized screening programs, and the third by cooperation between the profession and the public media to bring about a change in the public attitude toward hypertension. Admittedly, these objectives are difficult to achieve, but much more can be done than is being done now. Hypertension is such a ubiquitous disease that effective identification, diagnostic study, and long- term treatment will impose a heavy load on the exist- ing system of medical care. 11 has, therefore, been proposed that physician assistants, nurse practition- ers, and allied health persons who have received spe- cial training in hypertension could take on much of the routine in screening, diagnostic study, and super- vision of follow-up care that is presently done by physicians. The physician would have a more super- visory rather than direct role in patient care, although he would necessarily be involved in diagnosis, initia- tion of treatment, and management of unusual prob- lems. There is a precedent in the coronary care units, where it has been shown conclusively Ithat specially trained nurses can effectively collect and interpret clinical data and make appropriate therapeutic de- cisions within a limited sphere of medical practice. Much of the diagnostic study and follow-up care of hypertensive patients is routine. For most patients with hypertension an elaborate diagnostic study for Specialists in internal medicine can and should curable hypertension is not justified by either the ex- lead in bringing about the necessary changes in our pense or the chances of finding a curable condition. Furthermore, treatment seldom needs to be compli- system of health care so that hypertension will be cated. Initially, model clinics could serve as proving grounds for developing the most efficient methods of detection and delivery of optimal care, employing effectively treated. These changes call for well-in- nurse specialists, physician assistants, and other allied formed support and active participation of all phy- health personnel to the fullest possible extent. sicians in internal `medicine. (EDWARD D. FREIS, M.D., Veterans Administration Hospital and George- town University Hospital, Washington, D.C.) References 1. SOCIETY OF ACTIJARIES: Build and Blood Pressure Study, vol. I. Chicago, Society of Actuaries, 1959 2. KANNEL WB, GORDON T, CASTELLI WP, et al: Electrocardio- graphic left ventricular hypertrophy and risk of coronary heart disease. The Framingham Study. Ann Zntern Med 72: 813-822, 1970 3. KANNEL WB: Current status of the epidemiology of brain infarction associated with occlusive arterial disease. Stroke 2:295-318, 1971 4. HAMILTON M: Selection of patients for antihypertensive therapy. In Antihypertensive Therapy: Principles and Prac- tice, an International Symposium, edited by GROSS F. New York, Springer-Verlag, 1966, p. 196 5. VETERANS ADMINISTRATION COOPERATIVE STUDY GROUP ON ANTIHYPERTENSIVE AGENTS: Effects of treatment on morbiditv in hypertension. I. Results in patients with diastolic blooh pressure averaging 115 through 129 mxn Hg. JAMA 202: 102% 1034, 1967 6. VETERANS ADMINISTRATION COOPEIUTIVE STUDY GROUP ON ANTIHYPERTENSIVE AGENTS: Effects of treatment on morbiditv in hypertension. II. Results in patients with diastolic blood pressure averaging 90 through 114 mm Hg. JAMA 213 :1143- 1152, 1970 7. FREIS ED, RAGAN D, PILLSBURY H III, et al: Alteration of the course of hypertension in the spontaneously hypertensive rat. Circ Res 31:1-7, 1972