Letter by Lowe Regarding Article “How the Times Have Changed: Antihypertensive Agents”

To the Editor:

Dr Bloch’s commentary (Bloch MJ. How the times have changed: antihypertensive agents [published online February 18, 2020]. Cardiology Consultant. https://www.consultant360.com/exclusive/cardiology/hypertension/how-times-have-changed-antihypertensive-agents.) is great and very simply put, stating what all physicians in medicine must have realized by now and must agree with.

Appropriate treatment of hypertension and the full spectrum of hypertension are critical to the well-being of the general public and is virtually the most important public health goal for the entire country, society, and mankind.

The early treatment of mild hypertension in youth is critically important to their longevity and cardiovascular health. The aggressive treatment of moderate hypertension can easily be obtained with the appropriate medication regimen. And we have wonderful drugs for severe life-threatening malignant hypertension that patients can actually take without too many adverse effects.

I tell every one of my patients that nothing has been more studied and more proven in the history of medicine than the early and prolonged treatment of hypertension over time.

I still frequently see new patients to my practice—who are 45 to 75 years old with systolic blood pressures ranging from 135 to 145 mm Hg and diastolic blood pressures ranging from 80 to 95 mm Hg—who have been able to avoid taking medications via many diverse reasons. The most important of which is because they were not previously informed of the scope and ramifications of the disease process. This takes time, and the time the physician spends with the patient is critical for education and implementation. Long-term adherence is proven to guarantee beneficial results—a longer and healthier life.

When they tell me, “Oh, my blood pressure is always like that,” or “I’ve had hypertension since I was 25 years old,” I cringe at the loss of vascular compliance and the development of cardiac stiffness, both of which are ominous signs for the future. And I realize, as a physician, I have lots of work to do to convince them that taking medication is the right thing for them both in the short and long term. The longer they have gone without treatment or under treatment, the more irreversible a component of that loss of compliance is. If they had spent too much time with significant hypertension, the less reversible their vascular compliance. Conversely, the sooner they start treatment for hypertension, the more reversible the lack of compliance is.

We as a country and society should acknowledge that investment in primary care is the most important way to realize these changes.

Franklin Lowe, MD
Family Medicine Physician
Private Practice
Los Alamitos, California

The Author Replies:

I would like to thank Dr Lowe for his thoughtful letter. I couldn't agree with you more; the deck is stacked in many ways against those of us on the front lines of treating cardiovascular risk generally and hypertension in particular. Since blood pressure elevations are mostly asymptomatic, without extensive public education about untreated or undertreated hypertension, it is difficult to motivate patients to make the lifestyle changes needed and take their medications consistently. We also often deal with the “tyranny of the urgent” in the office, where the discussion of chronic issues like hypertension are often superseded by patient concerns about acute issues. That being said, I remain hopeful that over the next decade we will be able to make greater strides in blood pressure control rates in this country.

Michael J. Bloch, MD
Associate Professor
University of Nevada School of Medicine

Medical Director
Renown Vascular Care
Renown Institute for Heart and Vascular Health

President
Blue Spruce Medical Consultants, PLLC
Reno, Nevada