“Diagnosis creep” conjures up an image of a final year medical student on the far end of the spectrum, sounding a bit like cousin “bracket creep”, much beloved by economists and politicians alike.
In November 2017 the American College of Cardiology and the American Heart Association took over from the National Heart, Lung, and Blood Institute and issued new guidelines that changed the classification of hypertension.
For 14 years the previous guidelines had recommended a target of less than 140/90. The new recommendations define stage 1 hypertension as a systolic of 130-139 or diastolic of 80-89. As a result of this some 46% of the USA adult population can be found to have high blood pressure. For the under 45s this will triple the number of males and double the number of females diagnosed with hypertension. The good news is that few of these new patients will be recommended for drug treatment.
A diet low in sodium and high in potassium, along with regular exercise and restricting alcohol intake to less than two drinks per day for males and one for females results in a 4-5 mm Hg lower reading. Going the “whole hog” with decreased saturated fats and increased fruit, vegetables and grains gets an 11 mm Hg reduction.
Such an approach may seem fanciful to an older generation of patients and their doctors but is increasingly seen as both doable and desirable amongst millennials.
The North Coast Primary Health Network has set the local health community a challenge: design and implement a model that works for improving exercise levels in the community. On Saturday 12 May, Professor Paul Glasziou comes to the North Coast to advise on this challenge. Professor Glasziou has a long established international reputation in the evaluation of Evidence Based Medicine. The PHN hopes to use his expertise to find a program that works, is acceptable to patients and is affordable to the funders.
The new BP guidelines also place greater emphasis on patient home blood pressure monitoring, but recommend the accuracy of the device is validated.
The guidelines note that more than one medication is often required and that pills containing a combination of drugs improve patient compliance. They also recommend that psychosocial stress, which is correlated to socioeconomic status, be evaluated.
For patients in the lower BP range, medication is only indicated if the patient has a raised cardiovascular risk on one of the many tools available.
Elderly patients with high systolic and low diastolic also benefit from a lower BP. The task is to lower the systolic reading without causing postural hypotension and precipitating the associated risk of falls and fractures. While difficult to achieve, improvements in control can be made through careful monitoring.
Masked hypertension where the blood pressure is normal in the surgery but high at home would seem as rare as hen’s teeth to the average GP. However, it is a significant problem and, perhaps unsurprisingly, carries the same risk as sustained hypertension.
Conversely, patients with “white coat hypertension”, where the readings are normal outside the surgery carries no increased risk.
The new BP recommendations have been criticised by Australian reviewers, Bell, Doust and Glasziou. They are concerned that the new definition increases anxiety and depression in patients by being labelled as having a disease. They also note a hypertension diagnosis makes it more difficult to get affordable health insurance in societies that do not have universal health coverage, such as America.
Their main concerns, however, are the increased cost and potential side effects of drugs in treating mild forms of hypertension. This is understandable and it will be hard not to think of “medication creep” the next time the cardiovascular drug rep visits.
