The mass confusion that reigns in the medical field has never been exemplified better than the following letter, written by Dr. Richard Donze, a doctor of osteopathy in Philadelphia, Pennsylvania. His letter, which is excerpted from my book, A Report on Hypertension (copyright 1985) clearly gives you an idea of the frustration the average doctor faces when it comes to treating high blood pressure. This is a direct word-for-word quotation from his letter. -- K. Donsbach, D.C., N.D., Ph.D.
"Recognize the game? It's called 'Treating Hypertension.' Physicians and patients are the contestants, and Simon is the state of the art medical wisdom.
"The stakes are very high. If you win, you beat hypertension. Then you possibly avoid a heart attack or stroke. If you lose, you could have these problems and perhaps die. On the other hand, you can win and still have a heart attack; in fact, winning might even make it more likely. You might also develop gout, impotence, or a lot of other fun things. Great game, isn't it?
"Oh -- there's one more monkey-wrench. The rules change whenever Simon says. Unfortunately, Simon has been saying a lot lately.
"We're not talking about the malignant hypertension that pushes the optic disc through the iris, or even the moderate hypertension that makes us take two or three steps of stepped-care in one leap. No, we're talking mild hypertension. The 90-104 diastolics. (Our old friends -- the rent payers) This is the hypertension we see most often and still can't get a handle on.
"Drug companies are avid watchers of this game since they provide some of the most important equipment. Their representatives often ask me, 'Doctor, how do you treat hypertension?' I never seem to have the answer they're looking for: If I say start with diuretics, they tell me Europeans use beta-blockers or central agents as monotherapy; if I say start with beta-blockers or central agents, they tell me diuretics are still the cornerstone of stepped-care. Usually I laugh and tell them my approach depends on the last thing I've read. They think I'm kidding.
"Life was simple after HDFP. The Hypertension Detection and Follow-up Program was the five-year study that told us in 1979 that all levels of hypertension benefited from treatment. Even people with mild high blood pressure given special attention, the 'stepped-care' group had decreased cardiovascular mortality. This was a dramatic finding, since perhaps 70% of all hypertensives are mild, and we could therefore offer them a statistically significant reduction in their incidence of cardiac and cerebral events. How nice to have been able to leave the limbo of 'borderline hypertension,' the land of 140/90. The 90s do better at 86 or 84, so let's treat them.
"Then came MRFIT in September 1982, and suddenly special intervention wasn't so special anymore. The Multiple Risk Factor Intervention Trial showed that some mild hypertensives with resting ECG abnormalities actually had more deaths than those who supposedly were treated less aggressively. This raised lots of questions. Are diuretics harmful for some patients? Were there problems with electrolytes or lipids? MRFIT demanded another serious look at treatment philosophy.
"A special issue of the Annals of Internal Medicine in May, 1983 dealt with nutrition and blood pressure control. Dr. Norman Kaplan from the University of Texas wrote the leadoff article. (I first saw him in a medical school education film giving a 'diuretics for the rest of your life' speech to a hypertensive woman.) In the Annals article, he talks about redefining high blood pressure with a detailed benefit risk analysis. What are the risks of long-term anti-hypertensive therapy? Apart from potential electrolyte, glucose, lipid, and uric acid disturbances, how about the effects of turning an asymptomatic person into a 'patient,' one who squirms in the waiting room, catecholamines working overtime, wondering if the 'silent killer' is advancing.
"Kaplan suggests putting high blood pressure into a context, so that if glucose, cholesterol, and ECG are normal, and the person doesn't smoke, isolated hypertension might not be so much of a threat. For such a patient, it might be more appropriate to start with careful surveillance instead of medical treatment, and try non-drug therapies -- weight reduction, relaxation, and exercise. (Simon now says, don't treat the 90-diastolics.)
"Other articles in this Annals issue explored the notion that salt restriction may be effective in perhaps only 30% of all hypertensives. One article suggested that salt restriction can actually hurt some people. (Simon says bring back the salt shaker?)
"And it hasn't stopped there. Other articles have appeared preaching the alternate message -- no salt and stepped-care for mild hypertension. Still more papers question that. On and on. Simon says this. Simon says that.
"Two months ago I'm treating 140/90, now I'm letting 150/94 slide! Hypertension isn't labile. The treatment is!
"What are we supposed to do, we family docs in the trenches, while the generals debate data base and double blind? I knew that uncertainty came with the territory; I didn't know it was the territory.
"So here we are, poised after acting out our last set of instructions, hoping, at least, that we do no harm. As we hold our position, we wonder. We pray. We wait to hear what Simon will say."
Richard Donze, D.O.
Family Health Service
Methodist Hospital,
Philadelphia, Pennsylvania
When Do You Treat Hypertension?
The alternative practitioner is the best choice when it comes to treating high blood pressure. I have spent considerable time researching the hypertension morass and have compiled it all in my new book, High Blood Pressure. In order that you not think that this is a commercial for said book, I am offering a copy free to any DC who will request a copy and send a one dollar bill to cover postage, to Professional Products, 424 Calle Primera, San Ysidro, California 92703. It will offer you some of the best reasons and documentation available for alternative methods in this commonly mismanaged condition.