Hypertension: Take these pills or face the consequences

Hypertension: Take these pills or face the consequences

Neil Chesanow has written an excellent review of treating high blood pressure. He reports that 3.8 billion prescriptions are written each year in the United States, but over 50% of them are filled incorrectly or not at all. It is very clear that successful treatment of hypertension requires a change in patient thinking and does not create a new revolutionary breakthrough in medical care. We have the tools, but they are not being used.

New guidelines were recently written by the American Heart Association that lower the blood pressure treatment goal to 130/80 for most patients. The first step is an honest assessment of diet and exercise with the goal of preventing overweight or obesity. If blood pressure remains high despite these measures, medication will be ordered as well as laboratory tests to check for other associated conditions. Doctors are provided with step-by-step instructions. Generally, they prescribe diuretics first, then lisinopril, an ARB, or a calcium channel blocker such as amlodipine. Three or even four medications may be required. It's all cut and dry and works very well. Why is there a problem?

The first obstacle to successful treatment is mistrust of doctors. I've read that most patients don't trust their doctor and can even hate them. They continue to make office visits but have no intention of doing what they are told. They come because their spouse insists, or because their mother goes there, or because “the last doctor was worse.” Sometimes this distrust is a family or even community problem. Sometimes it is triggered by a cold attitude from the doctor or a feeling of disinterest. The doctor may be very caring or compassionate, but he is harried and tormented by an impossible schedule.

Another obstacle is the fear of side effects. Men talk about the effects of blood pressure medication “on their gender.” They tell stories of friends who have “lost their masculinity.” Older women may fear dizziness and a catastrophic fall without access to help. Younger women may have “heard that these make you fat or cause your hair to fall out.” The internet whispers that “these pills will make hair grow on your pancreas.” “You should throw them away and use turmeric or at least see a naturopath.” Unfortunately, this alternative health care guy is probably more glib and superficially persuasive than your doctor.

The “sick role” is also important. High blood pressure is generally a disease without symptoms. It is the long-term consequences: stroke, heart failure and kidney failure that are catastrophic. If you agree to take a long-term medication, you must accept that you are “sick.” This is very different from taking an antibiotic for ten days for an ear infection. It's natural to ask, "I feel good, why do I need this pill?"

After four decades of doctoral work, I have come to the conclusion that the decision not to take medication is generally made very consciously, not because one is forgetful or “just stupid.” A contract between doctor and patient is important to correct this situation because the dollar cost and health consequences of untreated hypertension fluctuate.

Inspired by Scott W Younkin