Why does the definition of hypertension keep getting stricter

Great Debates
1

To my knowlege hypertenion readings have undergone at least 3 changes in the last 20 years or so, constantly getting stricter. I don’t know what the ideal readings were before that.

It used to be that anything below 140/90 was considered normal, 140/90-160/95 was borderline and anything above 160/95 was hypertension.

Then up to 140/90 was normal, I believe about 140-160/90-105 was mild and 160-180/105-115 was moderate. Then there are the severe levels above about 180/115.

Now 120/80 is normal, 120/80-139/89 is prehypertension (a few years ago a reading in that range was normal), 140/90-159/99 is stage 1 (which was considered borderline not long ago) and 160/100+ is stage two.

I have heard some say that anything above 115/75 or 120/80 should be considered hypertension. I don’t know if there are any efforts to change the guidelines again to make anything above 120/80 hypertension, but who knows.

So why have the standards gotten stricter and stricter? One argument I have heard is financial, right now by the current standards about 1/5 of the US population (60 million or so) have hypertension with another 60 million or so having pre-hypertension (120-139/80-89). So when you change the classification you encourage millions to start using medications and visiting doctors, if the standards ever change to 115/75 being ideal and anything above that being hypertension, about half the population would be considered hypertensive. But that argument makes no sense to me. Doctor and NP appointments for hypertension are cheap (usually under $100) and most of the drugs are off patent. Virtually all the CCBs, ACEIs, diuretics, beta blockers and alpha blockers are off patent and can be gotten for $2-4 a month. The ARBs are starting to come off patent and you can already get some as generics for some of those.

So I don’t see what financial incentive there would be to make the diagnosis of hypertension more strict. The doctor visits and drugs to treat it are cheap and not too profitable.

Healthwise, I’ve read every 20/10 point jump above 115/75 doubles the risk of cardiovascular disease (I don’t know if that is a compounded double or what, ie does 175/105 give 4x the risk or 8x the risk) or that prehypertension gives 3x the risk of heart attack vs a reading of about 120/80. So has medical science discovered in the last 15 years that blood pressure is a lot more important than they used to give it credit for and that is the only reason the standards have changed?

Or is medicine just getting more conservative and cautious about health readings with time and things that used to be overlooked are now taken more seriously?

Why are the standards getting stricter so rapidly?

2

I don’t have an answer, but I’ve wondered about this as well.

20 years ago, my constant 120/80 bp was smack dab in the middle of normal.

These days, depending on which chart you follow, that reading is either on the very high end of normal, or is actually considered too high.

3

120/80 with 72 pulse was and is the ideal stats. I beleive the WHO has a scale, with anything above 135 systolic and 90 diastolic being hypertension.

4

I strongly recommend reading the book “Overdiagnosed.” It deals with this question in depth. According to the book, a lot of medical research is done by Pharma companies, giving them a way to medicalize normal/borderline conditions like pre-hypertension, osteopenia, etc. This allows them to make money off a broader base of “sick” people. And doctors will often overtreat for whatever reason (they can get sued if they don’t follow “best practice,” etc).

There’s also a great book called Overdosed American, which explains how Pharma companies manipulate data to make their medications seem more effective than they really are, and it also shows how they push for broader classes of people to take medications that have not been strictly shown to be cost-effective for them. Very eye-opening.

I got my blood pressure measured recently and it was 116/70 or something like that, so I’m not worried. But who knows, maybe in 10 years that will be called pre-pre-hyptension and the doctors will pressure me to take medication…

5

  1. The medical institution is always very suspicious of drug studies performed by those who have a vested financial interest in the widespread use of a given drug.

  2. The drugs most frequently used in modern medical practice are cheap generics. No one starts off with a 100+ dollar a month drug when HCTZ is available for 4 dollars a month from walmart. The truth of the matter is that most antihypertensive drugs are just not very expensive anymore.

  3. The reason behind the changing definition of a “normal” blood pressure is due to the realization that the lower you get someone’s blood pressure, the lower their risk of cardio and cerebrovascular accidents. The only reason the recommendations aren’t lower is that doing so has been found to have an unacceptable risk of side effects like orthostatic hypotension.

In summary, the tightened recommendations on blood pressure do not reflect a desire to make money, but rather a desire to lower the rates of hypertension related disease to even lower levels than they were in the past.

6

Tell that to the doctors that continue to ignore the research that says that SSRIs don’t do anything for mild symptoms, that benzodiazepines are horribly addictive and shouldn’t be used for more than four weeks, that Tramadol is addictive–heck, tell the ones that still will recommend homeopathic medicine. Doctors seem to buy the pharmaceutical’s line hook, line, and sinker.

And medicating people for prevention but treating it like a disorder is just plain dishonest. A person with a 120/80 blood pressure is not more healthy than someone with 115/75, especially when the latter got that way with drugs that manipulate the system.

7

I remember a MAS*H episode in which Col. Potter had blood pressure in which the bottom number was just over 80 and the other doctors were very concerned and went on a crusade. Since the show was filmed in the Seventies and early Eighties, maybe that reflects the thinking even then.

I’ve been taking medicine for hypertension for at least thirty years and was told that I didn’t want the upper one to be over 130 or the lower one to be over 80.

But doesn’t it vary from person to person as to what is acceptable?

8

It still comes down to drug manufacturers making money even though the drugs are now cheap.

Maybe even more so BECAUSE the drugs are cheap.

In business terms when the new BP drugs first came out they were “rising stars.” A new pill that you could take that would lower your probability of heart attack and stroke? Lots of people would pay lots of money for that drug via their insurance if they were indeed at risk.

Fast forward to where the drugs are off patent and the price is few dollars a month. To make it worth while to produce these drugs the manufacturer requiers a much wider user base. If you are a pharma company, or are associated with one, your income from producing that expensive drug for the then smaller population of hypertension patients just fell out the bottom.

So what to do? How about converting your “Rising Star” into a “Cash Cow.” How do you do that? You can’t maintain the high price/few users business model, so instead you increase the population of users of your drug by a huge multiple. Then you would have a low price but a huge market and thereby preserve your profits.

And how do you do that? You conduct a study that shows that anyone with BP over 120/80 should use it.

Winston Churchill once famously said “there are lies, there are damn lies, and then there are statistics.” The point is you can easily twist statistics to say just about anything you want. A recent popular add said that “the Japanese, with a high incident of fish and grains in their diet suffered far fewer heart attacks and obesity.” Of course they were selling fish and grain products. The add failed to mention that Japanese also have a high incidence of dark eyes and perfectly straight black hair. Maybe if we all straightened our hair, dyed it black and wore tinted contacts we wouldn’t get fat? (Please, no offense is intended toward any Japanese by my remark.)

A Coke still costs less than 2 bucks, but Coke still makes plenty of money on them because a huge number of people drink at least one Coke a day, and an even larger number of people drink at least one Coke a month.

Imagine if that soda was a pill…… and you were in charge of seeing to it that the pill was profitable,… but no one could feel the difference on any given day if they had taken the pill or had not. You have millions to spend on marketing and on studies and on research. The only hard rules you have are that you can’t raise the price, and you can’t change the formula of the drug. the only people in a position to question your studies are other companies making the same drug (who will also benefit from your “findings,”) and doctors. But there are no docs who have your buget or resources, and if they fail to follow your guidelines they open themselves up to suits.

What would do you do?

Peter

9

Last year my hypertension cost me (or my insurer) the following:

$368 for doctors visits, including reading the lab results
$492 in lab fees for tests to make sure my HBP drugs aren’t harming my liver or kidneys
$39.96 for drugs, of which less than $7 went to the WHOLESALER. I know this because I am employed by the pharmacist.

Naturally when I look for an ulterior motive, I should start looking under the $7.

According to my doctor, and the two I had before him, the reason we treat hypertension that we would not treat before is down to three factors:

We know more about the long term effects of even moderately elevated blood pressure. With people living longer reducing your risk of a heart attack even in your 80’s might make sense.

We know more about the side effects of drugs that have been around for 20 years.

We have more drugs now which can treat patients who presented with side effects like persistent coughs, which were common with drugs available 30 years ago.

10

Wait a minute; Let’s do some math…

THE POPULATION of the USA, Canada and Europe totals up to roughly 1 billion people.

The OP pointed out that 20% are classified as having hypertension and another 20% are boarderline. That is 40% of the population which is elegible as consumers of these drugs. Let’s be conservative and call it 1/3 (33.3%)

That is over 300,000,000 (three hundred million people) times $7.00 a head
if they all knew how to get the meds cheaply, which believe me they do not. This places the current marketplace at 2.3 billion dollars or higher. Especially if the drug company can bilk the insurance company, (as happens in my case) to pay a premium for them. ( No WalMart or CVS in my town!)

If you are already an active enterprise in this market the best way to protect your market share from new start up competitors, now that there is no patent prottection, is to keep the price so low that a new break-in can’t amass enough customers at the current prices to make it attractive as a capital investment.

Meanwhile who among all those listed as receiving payment in the above post is going to challenge a study that dramatically lowers the standard and thereby raises their number of customers? Particularly if the incidents of adverse side effects are low.

I don’t have a vocabulary word for the econominc situation, but it pops up all the time in life: A situation that looks almost like a conspiracy, seems pretty much like a conspiracy, but where no one is actually conspiring. They are just individually looking after thier own interests quite independently, but it so happens that for a number of “knowlegeable” participants this includes embracing some element of “commonly accepted fact” even if it is questionable, or biased, or outright disprovable.

If you look about you will see this occuring in many situations in life, not just in the subject of hypertension standards. It is a “normal” economic situation. EX: Why do banks continue to make risky investments with your money while insiting that it is normal and necessary? Do you actually trust a banker when he tells you that is an indisputable fact of banking? OR do you believe that another way is possible and probably smarter, though it won’t make Jamie Dimon as rich?.. And that is just an obvious one.

Peter

11

My experience exactly. I’ve been around 120/80 for my whole life and thought it normal. These days I’m having doctors shake their heads and say “we’re going to have to keep and eye on that.” Maybe because I’m over 50? I was 132/80 (pulse: 48) at my last physical and I’ve been referred to a cardiologist group for all kinds of tests. What the heck is “normal?”

12

Yay my thread is resurrected.

I don’t know the exact stats, but I have heard of the claim that ‘having BP in the pre-hypertensive range doubles the risk of heart attack and CVD incidents compared to be at 120/80 or 115/75 or below’. But when you look at those stats, the doubling goes from about 2-3% in the 120/80 group up to 4-5% in the 140/90 group. So for every 100 people that is an extra 1-3 people. So people are going from a minor risk to a slightly less minor risk.

And the drugs can have side effects. Thiazide diuretics may increase the risk of developing type II diabetes (not sure if that is proven yet). CCBs and beta blockers can cause depression. Several classes can negatively effect other CVD parameters like triglycerides or LDL levels. Part of the reason I started this thread is I have a health condition caused by a hypertensive med. Not a CVD one, but I experienced some bad side effects I will have to live with.

Getting peoples vitals as close to perfect as possible comes with a cost, and the costs eventually outweigh the benefits. Is taking 2 medications and getting your BP from 140/90 down to 115/75 worth it if the only benefit is your risk of a CVD incident goes from 4-5% down to 2-3%? What about the side effects of the drugs?

Also I totally disagree about the medical institution not being swayed by groups with a financial stake. SSRIs have been proven in studies to be barely better than (or no better than) placebos for depression but they are still prescribed readily.

13

I just wanted to add that if the drug company comducts or commissions a study that shows that the drug has no benefit for those with lower blood pressure, they can just ignore it and do another study. They can do dozens of studies that show no benefit ( and these “Phase 4” studies don’t have to follow any real protocol, they can cherry-pick patients based on what they learned from the failed studies). Once they get one study tht purports to show a benefit they can submit that one to the FDA and usually get approval

14

The second part is correct, normal blood pressure in a healthy adult is more like 110/70, but the prevalence of the high salt diet/low exercise/high stress in western culture means that actually telling people that is going to be a matter of making most westerners uncomfortable.