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Patient's 'big picture' is key in treating hypertension

From the May 1995 ACP Observer, copyright © 1995 by the American College of Physicians.

by Sylvia Wrobel

Hypertension is just part of a patient's larger medical picture, and cannot be considered in isolation from other problems, according to Joseph L. Izzo Jr., FACP, chairman of the department of medicine at Millard Fillmore Hospital in Buffalo, N.Y.

"If you focus only on your patients' target blood pressure, you may be missing the boat," Dr. Izzo said during a Meet the Professor session on drug therapy for hypertension. Physicians should instead focus therapy on the organs that can be damaged by hypertension. For example, Dr. Izzo said he finds it very difficult to justify treating a relatively healthy patient with borderline blood pressure. It's more reasonable and more cost-effective to monitor the patient, periodically to assure that kidneys and brain, heart and blood vessels are not being affected, he said.

This big-picture view, espoused by the most recent Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure, may help physicians decide which patients don't need immediate treatment, Dr. Izzo said. The committee defined the goal of therapy as reducing morbidity and mortality by the least intrusive means possible. It did not focus on lowering blood pressure in all patients.

Very high blood pressure levels clearly contribute to micro and macro vascular change, Dr. Izzo said. But there is very little evidence that lowering blood pressure alone in mild essential hypertension--systolic blood pressure of 140 to 165 and diastolic blood pressure of 90 to 100--offers clinically significant protection to the target organs.

And in some patients lowering blood pressure may actually cause more problems that it cures. For example, an 85-year-old with atherosclerosis may need that surge produced by hypertension. Aggressive treatment may even contribute to the "J-curve" in which lower blood pressure begins to be associated with increased morbidity and mortality.

Focusing on hypertension as a physiological process also can make a difference in what medication (if any) physicians use to treat an individual patient, Dr. Izzo said. A wide array of compounds can lower blood pressure, and different classes of compounds inhibit different physiologic systems. Physicians should understand the physiologic phenomena underlying an individual patient's hypertension because it allows more effective treatment and more effective protection of target organs.

Expanding on the Joint National Commission recommendations, Dr. Izzo said physicians also "have to take into account any diseases or medical problems, family history and risk factors, especially for cardiovascular disease, as well as lifestyle and personality of individual patients." He aggressively treats hypertension in a diabetic patient or in a patient with renal disease.

This focus also means he is less likely to restrict his interventions to blood pressure. The most valuable contribution of the Framingham study, he says, was the understanding that cardiovascular disease results from a number of interacting factors, among them systemic hypertension, glucose intolerance, hypercholesterolemia, left ventricular hypertrophy and smoking. The presence of other risk factors also dramatically amplifies the risks of hypertension.

Faced with what Dr. Izzo calls the average American patient--a little hypertension, a little high cholesterol, smoking--where do physicians begin? He's one of a growing number of hypertension experts who believe in starting with efforts to control cholesterol because it's the biggest problem, then try to control the blood pressure. "We don't need algorithms to keep numbers in line," he said. "We are looking to optimize a multisystem environment for long-term outcome."

And what about smoking? It is a challenging problem: Smokers find it difficult to stop, and physicians find patients' smoking impossible to counteract. Unlike cholesterol and other factors that magnify the ill effects of hypertension, target organ effects of smoking not appear to be fully treated or blunted by current drugs. Beta blockers, for example, offer no protection against stroke and cardiac endpoints in smokers, according to a Medical Research Council trial, Dr. Izzo said.

Lifestyle or behavioral modification have been recommended in the last two Joint National Committee reports as a first step in control of hypertension. Dr. Izzo said that physicians "need to remember your patients are not organisms with hypertension. What do they need in life? What are they willing to put up with? And what are they willing to change?"

He encouraged physicians to keep at the difficult task of effectively modifying patients' lifestyles. However, he warned that physicians could unknowingly create a contingency relationship with the patient. In that situation, the patient may drop out of treatment because of the guilt associated with failing to lose weight, stop smoking or follow other of the physician's recommendations.

"Make your lifestyle recommendations in parallel with treatment," he suggested. "Then you can allow the patient to reduce the amount of medication he has to take in exchange for successful lifestyle modifications, creating a win-win situation."

Dr. Izzo recommends the American Heart Association's new book, "Hypertension Primer," which he says brings together information from many fields that are changing how physicians view and treat hypertension. The books costs $34.95 plus $3 shipping and profits go to the heart association. Information: 214-706-1574.

Sylvia Wrobel is director of health sciences news and information at Emory University. She writes frequently on medical issues.

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