If you want to understand how medicine is really practiced, try answering this simple question: When should otherwise healthy 60-year-olds be started on medication to control their blood pressure?
If you answered, “it depends on which experts you ask,” then you're on the right track.
The initial step in treating a mild case of high blood pressure — or hypertension — is advising the patient to lose weight, exercise more and change their diet. If this fails, as it frequently does, the next step is medication.
All medications used to treat hypertension have potentially serious side effects. The question is when do the benefits of treating hypertension outweigh the risks of the medicines used to treat it?
Updated guidelines dealing with this issue were recently published by a panel of experts in the Journal of the Medical American Association (JAMA). They employed an “evidenced-based approach” meaning they chose and reviewed the studies they felt were most likely to give useful clinical information. The problem is that no study is perfect and sometimes the results can be inconclusive or even contradictory. Trying to derive hard and fast rules from such a mass of data is often more art than science. They recommended treatment for healthy patients under age 60 if the pressure is greater than 140/90. The panel also concluded patients 60 and older do not benefit from treatment unless their blood pressure is greater than 150/90.
This has generated significant controversy. This seemingly small change actually affects millions of Americans who were previously labeled hypertensive but are now no longer considered candidates for beginning treatment. For those in this age group, this represents a significant relaxation of previous treatment guidelines at a time when many feel hypertension is undertreated. In fact, the CDC estimates that half the adults in the U.S. with hypertension are poorly controlled.
Many have disagreed with this interpretation of the relevant studies. In fact several members of the panel have stated that the panel had reached the wrong conclusion. In the Annals of Internal Medicine they published their own interpretation of the same data and concluded that the cutoff for treatment should remain at 140/90 even for those over 60 years old.
A recent editorial in American Family Physician agreed that the panel came to an incorrect conclusion.
So who is correct?
I have no idea.
The point is that if even the experts looking at the same studies cannot reach a consensus, how can individual practitioners know what is best for their patients? In medicine such seemingly straightforward questions often have no clear-cut answers. Patients frequently have the idea that most medical decisions are straightforward and can be practiced by anyone who can check the boxes on a checklist. The reality is that caring for a patient means making many decisions where what is the best option for a given situation is simply unknown.
If a “simple” decision such as when to start blood pressure medicine can be so uncertain, imagine the uncertainty involved if your situation, like that of many patients, is complicated.
Unfortunately, dealing with such uncertainty on a regular basis is how medicine is actually practiced.