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Systemic hypertension: The untold story !

Posted Nov 18 2008 12:10am

 

Is it true , once a patient is labelled as a hypertensive he remains  hypertensive life long ? Is it possible to withdraw antihypertensive drugs   permanently ?

  • Systemic  hypertension is the most common clinical entity and it forms the bulk of the physician consultations world over.
  • The anti hypertensive drugs are  one of the most commonly  prescribed medication  by the medical professionals .
  •  It is estimated , the major chunk of  revenue to pharma industry is contributed by antihypertensive  drugs.
  •  SHT , is being maintained  as a  major , global cardiovascular risk factor , by  periodically refixing the target blood pressure  to lower levels  by various committees.
  • The terminology of pre hypertension for blood pressure between 120-140 was hugely controversial    and some societies refused  to accept this entity.

Is there a case for withdrawal of anti hypertensive agents  among our patients ?

Yes , in fact there is a strong case for it.

While on the one hand there is a sustained effort ( By whom !)  to increase the drug usage , very early in the course of hypertension , there is also a silent progress in our knowledge ,  regarding withdrawl of anti hypertensive agents in all those undeserving patients .

It is estimated 42% *of the so called hypertensives especially elderly can be successfully weaned of anti hypertensive drugs with out any adverse effect.( Mark R Nelson BMJ.2002 October 12;325(7368): 815.)

What are the situations where we can successfully with draw anti hypertensive drugs?

  • The most common group of patients  are the ones, where  the anti hypertensive drugs are  started prematurely , with out giving an option for non drug life style  approach. These patients and their physicians continue to believe , anti HT drugs are sacred and essential !
  • There is another  major group of patients who have had a temporary  elevation of BP due to a stressful environment. These patients  get drugs permanently for a temporary problem  . Th ese patients need  to be reassessed.
  • Some of the elderly  patients,  with the onset of  age  related autonomic dysfunction ,these  drugs are poorly tolerated and  even have  disastrous effects .In this population  it is desirable , to wean off the anti HT drugs  and switched over to life style  medication whenever possible.

Final message

Essential or primary hypertension is not a permanent  disease, in bulk of our population. It reflects the  state of  the  blood pressure on a day to day basis  and is a continuous variable. All patients who have been labelled as hypertensives( Either by us or others ) should be constantly reviewed  and considered for withdrawal of the drugs if possible.

* Note this rule does not apply in all secondary hypertensions, during  emergencies, uncontrolled hyper tension with co existing CAD /diabetes /dyslipidemias etc .

Please refer to these forgotten Landmark articles

Does Withdrawl of Anti hypertensive Medication 

Increase the Risk of Cardiovascular Events?

The TONE study

Source:The American Journal of Cardiology, Volume 82, Number 12, 15 December 1998 , pp. 1501-1508(8)

http://www.ncbi.nlm.nih.gov/pubmed/9874055

Conclusion of TONE study

The study shows that antihypertensive medication can be safely withdrawn in older persons without clinical evidence of cardiovascular disease who do not have diastolic pressure > or = 150/90 mm Hg at withdrawal, providing that good BP control can be maintained with nonpharmacologic therapy

 

Some of the references for successful withdrawl of antihypertenive drugs

1.Nelson, M; Reid, C; Krum, H; McNeil, J. A systematic review of predictors of maintenance of normotension after withdrawal of antihypertensive drugs. Am J Hypertens. 2001; 14:98–105. [ PubMed ]
2.
Wing, LMH; Reid, CM; Ryan, P; Beilin, LJ; Brown, MA; Jennings, GLR, et al. Second Australian nationalbloodpressure study (ANBP2): Australian comparative outcome trial of ACE inhibitor- and diuretic-based treatment of hypertension in the elderly. Clin Exp Pharmacol Physiol. 1997; 19:779–791.
3.
Lee, J. Odds ratio or relative risk for cross-sectional data. Int J Epidemiol. 1994; 723:201–203. [ PubMed ]
4.
Lin, D; Wei, L. The robust inference for the Cox proportional hazards model. J Am Stat Assoc. 1989; 84:1074–1079.
5.
Veterans Administration Cooperative Study Group on Antihypertensive Drugs. Return of elevated blood pressure after withdrawal of antihypertensive drugs. Circulation. 1975; 51:1107–1113. [ PubMed ]
6.
Medical Research Council Working Party on the Management of Hypertension. Course of blood pressure in mild hypertensives after withdrawal of long term antihypertensive treatment. BMJ. 1986; 293:988–992. [ PubMed ]
7.
Alderman, MH; Davis, TK; Gerber, LM; Robb, M. Antihypertensive drug therapy withdrawalin a general population. Arch Intern Med. 1986; 146:1309–1311. [ PubMed ]
8.
Blaufox, MD; Langford, HG; Oberman, A; Hawkins, CM; Wassertheil-Smoller, S; Cutter, GR. Effect of dietary change on the return of hypertension after withdrawal of prolonged antihypertensive therapy (DISH). J Hypertension. 1984; 2(suppl 3):179–181.
9.
Mitchell, A; Haynes, RB; Adsett, CA; Bellissimo, A; Wilczynski, N. The likelihood of remaining normotensive following antihypertensive drug withdrawal. J Gen Intern Med. 1989; 4:221–225. [ PubMed ]
10.
Myers, MG; Reeves, RA; Oh, PI; Joyner, CD. Overtreatment of hypertension in the community? Am J Hypertens. 1996; 9:419–425. [ PubMed ]
11.
Stamler, R; Stamler, J; Grimm, R; Gosch, F; Dyer, R; Berman, R, et al. Trial of control of hypertension by nutritional means: three year results. J Hypertens. 1984; 2(suppl 3):167–170.
12.
Takata, Y; Yoshizumi, T; Ito, Y; Ueno, M; Tsukashima, A; Iwase, M, et al. Comparison of withdrawing antihypertensivetherapy between diuretics and angiotensinconverting enzyme inhibitors in essential hypertensives. Am Heart J. 1992; 124:1574–1580. [ PubMed ]
13.
Whelton, PK; Appel, LJ; Espeland, MA; Applegate, WB; Ettinger, WH; Kostis, JB, et al. Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomised controlled trial of nonpharmacological interventions in the elderly (TONE). JAMA. 1998; 279:839–846. [ PubMed ]
14.
Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on death from cardiovascular causes, myocardial infarction, and stroke in high-risk patients. N Engl J Med. 2000; 342:145–153. [ PubMed ]
15.
Howes, L; Krum, H. Withdrawing antihypertensive treatment. Curr Therapeutics. 1988; November:15–20.
16.
Fotherby, MD; Harper, GD; Potter, JF. General practitioners’ management of hypertension in elderly patients. BMJ. 1992; 305:750–752. [ PubMed ]
17.
Jennings, GL; Reid, CM; Sudhir, K; Laufer, E; Korner, PI. Factors influencing the success of withdrawal of antihypertensive drug therapy. Blood Press Suppl. 1995; 2:99–107. [ PubMed ]
      
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