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1992 Interview with hypertension expert, Dr. Michael Alderman

Posted by medconsumers on December 12, 1992

Michael H. Alderman, M.D. is an epidemiologist, internist, and the chairman of the department of epidemiology and social medicine, Albert Einstein College of Medicine, Bronx, New York, A member of the panel that authored the new report (1992) from the National High Blood Pressure Education Program, Dr. Alderman is interviewed by Maryann Napoli, Center for Medical Consumers.

Q: The National High Blood Pressure Education Program seems to be taking credit for the country’s reduction in heart attacks and strokes, implying that publiceducation and medical treatment did it. Can you comment?

A: The treatment of blood pressure has contributed to the saving of lives. [But] it is important to know that the incidence of stroke has been declining since the early 1950s, before any antihypertensive drugs were invented, and well beforeany of them were used widely. Heart attack rates began to decline probably in the 1960s, again, well before anthypertensives were widely used.

Q: Why did the report recommend that all children over age three years have their pressure measured annually? It’s more frequent than the recommendation aimed at adults (every two years) who are far more likely to have hypertension.

A: That was a regrettable oversight in the report. [Instead], they should have recommended that kids have their blood pressure measured every five years until age 30 or 40 years.

Q: But what are they proposing doctors do with a kid who has high blood pressure?

A: I don’t know. I don’t think I’d do anything. It’s terra incognita. I don’t think any pediatrician would recommend drug therapy….if a fat child has high blood pressure, there would probably be much more urgency to help the child lose weight.

Q: In writing about elevated cholesterol, it was apparent that, though non-drug approaches are emphasized as the first step in treatment, drug therapy is inevitable because diet and exercise have only minimal effects. Is this also true for hypertensives?

A: No. Weight reduction however achieved can prove sufficient. It can have the same effect as drugs. For example, a 10 lb. weight loss in a 160 lb. man does the trick.

Q: what about salt reduction? Isn’t it true that this will only benefit about 10% of hypertensives?

A: Salt reduction for some people helps. It probably doesn’t help the majority. No one knows exactly. But, you really have to make a major reduction in your salt intake. [The usual advice of] putting away the salt shaker–that’s trivial–that just accounts for only 15-20% of the average person’s sodium intake. You’d have to cut the sodium about 30-40%, and that’s hard to achieve in people who can’t just eat fresh foods. As soon as you get into canned foods or store-bought bread or milk, you’re eating a lot of salt.

I’m not against trying, and, if it works, terrific. There are skinny people who don’t have any room to lose weight and maybe for them salt reduction is a good idea. Hypertension is not a disease confined to fat people.

Q: There has been an ongoing controversy about the value of treating mild hypertension. Your latest article cites 14 randomized clinical trials showing that treatment lowers the incidence of stroke and heart disease, where do the mild hypertensives fit into this treatment success story?

A: You’re asking a very complicated question. Patients at the same blood pressure level can have vastly different likelihoods of having a stroke or heart attack, depending upon a whole other set of characteristics In short, blood pressure itself is a rather poor predictor of outcome.

For clinical trials involving mild hypertension [140-159/90-99], you must enroll many, many thousands of participants because their rates of stroke and heart attack are so low. You need thousands of participants to find out if the treatment is doing any good.

The studies do show a benefit, but it’s realized by only a small fraction. Most of these people [with mild hypertension] were never at risk of having a stroke or heart attack. So they couldn’t possibly benefit from treatment, and they don’t. Some, who were going to have a stroke or a heart attack are spared because the treatment lowered their blood pressure, and that’s great. But this is only about 1-2% of the whole group.

And then, there were some people who, despite the treatment, will go on to have a stroke or a heart attack. You see, undergoing treatment doesn’t eliminate the incidence of stroke or heart attack, it just reduces the incidence. So any large group of people with the same measurement will have these variations.

The higher the blood pressure, the greater the likelihood of a stroke or heart attack. For example a 7 mm Hg increase in diastolic measurements causes a 42% increase in the likelihood of a stroke for the group as a whole. For an individual, the chances of having a stroke in the next 15 years is probably in one in 1,000. If this individual were to lower his or her blood pressure 7 mm Hg., there would to 42% reduction of an infinitesimal risk. And that’s the problem–that’s why treatment of people at so little risk has virtually no chance of doing them any good, they never were going to have a stroke anyway.

So the trick is how to identify the ones who will benefit [from treatment] and distinguish them for those at extremely low risk.

The idea is not to focus only on the blood pressure measurement. What’s important is the totality: does the patient have a bad family history of premature heart disease, high lipid values, diabetes, evidence of kidney disease or peripheral vascular disease, and, of course, heart disease, or obesity. It’s not so hard to identify the higher risk from the lower risk group.

This would put some reason into it [the approach to hypertension], rather than the mindless treatment of everyone’s elevated blood pressure measurements, which has precious little to do with the likelihood of a bad outcome.

Toscanini died at age 90 with a lifelong blood pressure measurement of 240/120. He never was treated because they didn’t have antihypertensive drugs. Had they been available, he would have been treated for a lifetime with pills that probably would have made him feel not as good as he felt with his terribly high blood pressure.

By contrast, Franklin Roosevelt died at the age of 60 of stroke after five years of heart failure and a somewhat lower blood pressure than Toscanini’s.

So blood pressure is just a factor, and it’s only one factor.

Center for Medical Consumers(c), December 1992

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