Till now, any blood pressure value above 140/90 (systolic/diastolic pressures) was considered "high" and the person was put on medication to lower it. But the expert committee (called the Joint National Committee JNC-8) appointed by the National Heart, Lung, and Blood Institute of USA has recommended that persons older than 60 years should wait till the BP reaches 150/90 before beginning treatment. It went through all the published research and found no additional benefit to lowering the blood pressure below 150/90 in this age group in terms of coronary heart disease, stroke, heart failure or death. On the other hand, it noted that aggressive BP treatment in this age group does have several potential adverse consequences (such as impotence, dizzy spells, light headedness, weakness). If the recommendation of JNC-8 is followed, lakhs and possibly crores of BP patients will be spared the expense of treatment.
The issue of what constitutes "high" BP has always been problematic. The World Health Organization guidelines in the mid-1950s put it at above 160/95. But over the years, the limit has steadily crept downwards. For example, JNC 4 report of 1988 set the limit at 140/85, JNC 6 report of 1997 reduced it to 130/85 and JNC 7 report of 2003 set it still lower at 120/80. Several reputed medical practitioners have complained that the steady lowering of the limits was due to pressure from powerful drug companies which stand to make huge profits if more people are declared hypertensive and put on medication. One fact which supported this complaint was that spending on BP drugs in the USA went up from $3 billion (19 thousand crore rupees) in 1999 to $16.3 billion (one lakh crore rupees) in 2004, a tremendous growth of more than 5 times in 5 years. Another fact which supported the contention was that most of the members of JNCs were paid consultants, paid speakers or grant recipients of one or the other drug companies. Even the World Health Organization solicits and gets huge donations from drug companies and so there are questions about its recommendations also.
The fact that JNC-8 has increased the BP limit and thus cut into the profits of drug companies may suggest that the influence of the drug companies on the medical profession is waning. But there are other indications that drug companies continue to wield enormous clout. Let us look at some of them.
1. Evidence has been building up over the years that the BP limits set by JNCs was too high, but the JNCs kept ignoring it. Finally, JNC 8 was forced to acknowledge it. But it raised the limit only for senior citizens. There is strong evidence which shows that there is no additional benefit to lowering the BP below 150/90 even for younger patients if they had no previous cardiovascular disease, diabetes, or renal disease. A significant number of such patients suffer from negative side effects due to BP medicines. JNC 8 skips this evidence and does not recommend that they be not given BP medication. Such patients are expected to spend about $40 billion (two and a half lakh crore rupees) every year on BP medication in USA alone!
2. There are three basic varieties of drugs to reduce BP, those that increase urination (to make the body get rid of unneeded water and salt), those which widen blood vessels and those which slow the heart. Diuretics, which increase urination, are much cheaper than the others and according to the largest BP study ever (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial funded by the US government), as effective and safer than the other drugs. There is less profit in diuretics. JNC 8 report recommends them equally even though the cheaper diuretics are clearly superior.
3. Even though the JNC 8 report is only mildly anti - drug lobby, the American Heart Association and the American College of Cardiology whose expert members formed JNC 8 have essentially disowned the report! It seems likely that the vast majority of doctors in the USA will continue to aim for lower and lower BPs and prescribe more drugs to achieve this goal, thus ignoring strong evidence to the contrary. It is not known what reaction doctors in India have for the JNC 8 report or what course they will take in treating BP.
C V Nagaraj, MGP