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EDITORIALS: Bruce M Psaty and Curt D Furberg British guidelines on managing hypertension BMJ 1999; 319: 589-590 [Full text]

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What about non-medical remedies first?

Angela Hey   (8 September 1999)

hypertension is a neceesity and not to be reduced

Fazlur Rahman   (14 September 1999)

Hypertension guidelines

N J Sharvill   (15 September 1999)

Mortality preferred to ''''major disease end points''''

Michael Stewart   (21 September 1999)

What about non-medical remedies first? 8 September 1999
Angela Hey, Consultant Areva International Send response to journal: Re: What about non-medical remedies first?	In the article on managing hypertension in the UK I am amazed that there was no attempt to bring down people's blood pressure by (a) reducing salt intake (b) encouraging daily exercise - strengthening, cardio and stretching Whereas the medical profession clearly is trained to dish out drugs there is a body of scientific evidence - see www.pritikin.com that show that diet and exercise are very effective at reducing hypertension. I wish the British medical profession would become more aggressive in preventative medicine and in treating the whole person. Its not a question of money its one of attitude. As a Californian on a somewhat misty visit to the UK both in east London suburbs and in Yorkshire I was the only one out jogging before work and people looked at me as if I was a freak from another planet. No wonder there's lots of hypertension. Angela Hey, PhD
hypertension is a neceesity and not to be reduced 14 September 1999
Fazlur Rahman, physician chennai Send response to journal: Re: hypertension is a neceesity and not to be reduced	Heart circulates blood with perfusion pressure necessary to infuse the needy tissues and organs. The blood pressure is not uniformly the same throughout the body but meant for those organs and tissues under stress and strain. Blood pressure increases in response to the demands of the various stressful parts of our body to protect them by providing extra nutrition. Attempting to reduce the blood pressure is absolutely not possible for the protective mechanism of human system always out maneuvre the drugs. The struggle between the heart's obeisance to the natural demands and the drugs' anti biological effects will in due course exhaust the heart musculature leading to its failure.
Hypertension guidelines 15 September 1999
N J Sharvill Send response to journal: Re: Hypertension guidelines	Dear Sir I am becoming increasingly concerned that the expert guidelines we are advised to follow are not based on the people I look after as a GP, and that the details given in the guidelines are not patient friendly. Specifically I would like to know the numbers needed to treat, and when they say deaths prevented I assume they mean deaths postponed as we all die. How long are they prevented for and what do the patients die of if it is not a consequence of their hypertension and could we not have prevented that also? We have also recently received guidelines from the British Heart foundation advising that blood pressure should be reduced to below 125/75 in a diabetic with proteinuria. I find this almost beyond belief as I feel that if I prescribed sufficient medication the side effects would probably be intolerable and I also question whether the number needed to harm would be less than the numbers needed to treat. This information is not, to me as an ordinary GP, easily available. I am also concerned that all trials seem to add yet more treatment when most of them are conducted on single interventions. The wisdom follows that they all can be added to give 'extra' benefit. Sometimes I wonder if the added value after an MI of Aspirin, a B Blocker, a statin, an ace inhibitor and spirinolactone must make death impossible! The most telling comment in the accompanying editorial was that no declaration of interest was published. From the early MRC hypertension trials showing a moderate benefit in some patients in treating hypertension we now have a bandwagon of multiple interventions at great cost. In my experience as a GP actively involved in reaching hypertension targets considerable anxiety and side effects are being generated by this drive. Finally over the years have there not been trials showing no reduction in mortality with various anti-hypertensive agents? Why do these not recieve the same exposure. Yours sincerely Dr N J Sharvill Balmoral Surgery, Deal, Kent
Mortality preferred to ''''major disease end points'''' 21 September 1999
Michael Stewart Send response to journal: Re: Mortality preferred to ''''major disease end points''''	In their editorial on the new British Hypertension Society guidelines for managing hypertension, Psaty and Furberg (1) demand evidence that recommended drug therapies reduce major disease end points, such as myocardial infarction, stroke, and heart failure. Whilst this would be an improvement on evidence that they lowered blood pressure, it is insufficient to justify their use. If a drug were shown to reduce cardiac deaths but had no effect on all cause mortality, I for one would be reluctant to take it, particularly if the displaced mortality was in the form of increased suicide and homicide - presumably as a consequence of the drug's side effects. In reading reports of randomised trials of drugs claiming success, I first look for the effect on all cause mortality. If that is not significantly negative, or worse still not even revealed, I pass on. It saves a lot of reading. The area of medicine in which treatment has become completely detached from clinical end points is of course HIV. Drugs with the most devastating and frequent side effects are now administered to symptomless mothers and babies for no better reason than that they reduce the incidence of scoring positively on an 'HIV test'. Michael Stewart Statistical Consultant 2 Lesley Court, Strutton Ground, London, SW1P 2HZ 1. Psaty B, Furberg C. British guidelines on managing hypertension. BMJ 1999; 319:589-590. (4 September) no competing interest.