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‘No benefit’ of lowering hypertension treatment thresholds, finds major study

There is 'no evidence' that lowering hypertension thresholds to treat low-risk patients has any benefit, a new study has found.

Researchers analysed nearly 40,000 low-risk patients across England, and found that not only was there no benefit to treating such patients with anti-hypertensive medication, it also had the potential to cause ‘harm’.

This comes after NICE said it was looking at evidence which led to hypertension thresholds in the US being ‘drastically lowered’, for its updated hypertension guidelines due in August 2019.

The latest study, published in JAMA Internal Medicine, set out to examine whether antihypertensive treatment is associated with a reduced risk of mortality and cardiovascular disease in low-risk patients with mild hypertension.

The researchers, from the University of Oxford, University of Cambridge and University of Birmingham, analysed 38,286 English patient records looking at the time period of 1998 to 2015, and comparing the outcomes of those treated with anti-hypertensives with those who were not.

They found ‘no evidence to support guideline recommendations that encourage initiation of treatment in patients with low-risk mild hypertension’.

The paper said: ‘No evidence of an association was found between baseline exposure to antihypertensive treatment and mortality or CVD.

‘There was evidence to suggest that baseline treatment exposure may be associated with an increased risk of adverse events.’

It explained that while the risk of harm was small, ‘in the context of little evidence of benefit’, GPs should be ‘cautious when initiating new treatment in this population, particularly because such an approach may affect millions of individuals’.

Study lead and Oxford University primary care health sciences researcher Dr James Sheppard said: ‘We found that, contrary to the latest US guideline recommendations, there was no evidence of any benefit to treating patients with low-risk mild hypertension.’

He added: ‘To ensure future guideline recommendations for treating low-risk mild hypertension are based on the best-quality evidence, large-scale clinical trials are now needed.’

Co-author and primary care research Professor Jonathan Mant, from the University of Cambridge, said: ‘Given that we found tangible evidence of the potential harm of treating people with mild hypertension, and no evidence of benefit, this study does raise questions over the value of initiating drug treatment in such patients.’

BMA GP Committee clinical and prescribing policy lead Dr Andrew Green warned that such moves to lower thresholds are turning 'people into patients'. 

He said: 'It is far better in these patients to concentrate on the factors that do make a difference, such as stopping smoking, controlling weight and increasing exercise.

'It is also important that clinicians realise the importance of avoiding labels such as "hypertension" in those who are unlikely to benefit from treatment, and is a salutary warning for those who would place diagnostic criteria so low that we all, as we age, get turned from people into patients.'

Earlier this year, new US guidelines were published by the American Heart Association, which included decreased thresholds for stage one hypertension, meaning that an extra 14% of people were catergorised as having mild hypertension, and bringing the country's prevelance to 46% of the total population.

This change followed the 2015 SPRINT study, which claimed that by treating patients with a target blood pressure of 120 mmHg, rather than the 140 mmHg target, mortality and cardiovascular events were significantly reduced.

But these findings were later critiqued in a study which found inconsistencies between the results of different trials focusing on lowering blood pressure thresholds.

Readers' comments (6)

  • Bornjovial

    Common sense prevails at last.
    However few caveats on this conclusion- its only 40,000 patients which for a low risk population by definition does not a high confidence interval of accuracy for the billion people worldwide who are estimated to have hypertension.
    Data from GP records is based on in clinic readings. In future validated measurements from patient held machines which can generate lot more data (?accuracy) would be used to model outcomes with a bigger dataset.

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  • I suppose that this is just using our most useful instrument the retrospectoscope! It makes you wonder what guidelines we should really be using since NICE have a habit of backing down on previous recommendations.
    Of course reducing treatments for apparent hypertension will reduce prescribing costs! Or am I just being a cynic?!

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  • assume this was not sponsored by pharma.

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  • Vinci Ho

    OMG
    How long has it taken to go round in circles before we turn back to our common sense .
    It is not surprising that the hawkish American academics would want to lower the treatment threshold in stage 1 hypertension as their whole nation is struggling to get people to lose weight , stop smoking and exercise.

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  • Vinci- is our nation any different?

    Thank goodness for this study and all the other studies which highlight the dangers of over-diagnosis and over-treatment.

    I wish NICE et al would just leave us alone to have a proper shared decision making approach with our patients, based on NNT an NNH.

    And please let's stop trying to reverse the ageing process with preventative drugs which end up causing significant adverse events

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  • Vinci Ho

    The reason I had a go on ‘US academics’ is not because we do not have our own problems in here . But we perhaps, need to re-establish British common sense and pragmatism under the heavy influence of Americanisation culturally (remember yesterday was Halloween?), politically(far right ideologies, for instance) and obviously, academically in here .
    Don’t forget it was the American colleges first bringing along the lower threshold of 10% CVD risk for statin prophylaxis in Primary Prevention.

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