Authors' objectives:

To summarise and critically analyse the current facts concerning the treatment of mild to moderate hypertension.

Authors' results and conclusions: Approximately 600,000 Swedes aged 40 to 70 years have a diastolic blood pressure consistently exceeding 90 mm Hg. Of these persons, approximately one half have a blood pressure between 90 and 99 mm Hg and approximately 200,000 fall within the range of 90 to 94 mm Hg. Approximately 350,000 elderly individuals have elevated systolic or diastolic blood pressure. For various reasons, it is neither indicated nor possible to treat all of these individuals. There is an increased risk for morbidity or mortality in connection with mild hypertension. All large population studies, however, have methodological problems which make the results uncertain. Treatment lowers the relative risk for stroke by 35-40% and coronary heart disease by 8-16%. The change in absolute risk expressed as relative rate per 1 000 patient years is illustrated by the following examples from two of the analysed studies:; All stroke:MRC-Trial = from 2.6 to 1.4 / Stop-Trial - from 33.0 to 17.8; All CHD: MRC-Trial = from 5.5 to 5.2 / Stop-Trial = from 24.8 to 17.2; Total Mortality: MRC-Trial = from 5.9 to 5.8 / Stop-Trial = from 37.2 to 21.3; Other diseases do not seem to be affected by treatment of hypertension. The benefit of treatment is related to the initial blood pressure level. The result is in lowering both the diastolic and the systolic pressure. The relative decrease is similar for women and men. The largest absolute decrease is seen in elderly people, as the incidence of stroke and TED is higher in elderly people, in men, and in persons who already have damaged cardiovascular systems. The benefit of treating hypertension alone in patients with a high cholesterol level or who are smokers is low. Stopping smoking would give a greater decrease. Effects of newer drugs (calcium-antagonists, ACE-inhibitors, a-blockers) on mortality and morbidity have not yet been shown. Side effects have been reported in 10-20% of cases, but is of the same magnitude in patients and placebo-groups. No studies show any difference in quality of life between different treatment regimes. Changes in lifestyle can lower the blood pressure, but not much. No effect has been shown on mortality or morbidity.

Authors' recommendations: Measurement of blood pressure values alone is insufficient for diagnosing hypertension which requires treatment. When establishing a diagnosis of primary hypertension, considerations should be given to the full clinical picture, including the presence of other risk factors such as cholesterol level, obesity, smoking habits or cardiovascular symptoms, which may later manifest themselves as vascular disease. When blood pressure elevation is moderate, repeated measurements should be taken over repetitive, standardised measurements to confirm a diagnosis of hypertension. In cases of insignificant blood pressure elevation, or where it varies greatly between normal and elevated blood pressure and the patient has no signs of organ damage, blood pressure should be viewed as a sign of risk for eventual vascular injury and not as a sign of manifest disease, and the patient should remain under observation. The patient, not the elevated blood pressure should be the focus of treatment. It may be more important to direct efforts at concurrent risk factors other than elevated blood pressure. In the absence of other risk factors, antihypertensive treatment is indicated if blood pressure is constantly and definitely elevated, or if the patient shows symptoms or other signs of organ involvement. Pharmaceutical treatment should generally be initiated using medications from the diuretic or beta blocker groups, as long as these substances are not contra-indicated. If these drugs do not provide satisfactory results they should be combined with, or substituted by, other antihypertensive agents. To avoid undesirable effects of drugs in treating hypertension, the lowest effective dose should always be used, alone or in combination. Pharmaceutical treatment should always be followed by general advice concerning a healthy life style. This increases the chances for positive treatment effects and reduces the risk for undesired effects. When a diagnosis of primary hypertension has been established, a patient's blood pressure and cardiovascular system should be checked for the remainder of their life, giving consideration to the patient's overall clinical situation. Treatment should be aimed at controlling the full range of a patient's symptoms and achieving a blood pressure which is as close to normal as possible. If blood pressure has been normal for a longer period, medication can be successively reduced, and eliminated completely if blood pressure does not rise again, or unless other symptoms return, but patients should be monitored carefully during this time. Each care provider should develop a program to care for patients with elevated blood pressure, using recommendations based on scientific literature represented by this report.

Project Status: Completed

URL for project: http://www.sbu.se/Published

Year Published: 1994

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Sweden

Organisation Name: Swedish Agency for Health Technology Assessment and Assessment of Social Services

Contact Address: P.O. Box 3657, SE-103 59 Stockholm, Sweden. Tel: +46 8 4123200, Fax: +46 8 4113260

Contact Name: registrator@sbu.se

Contact Email: registrator@sbu.se

Copyright: The Swedish Council on Technology Assessment in Health Care