Letters Managing hypertension

Professional judgment is key in treating hypertension

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e1033 (Published 14 February 2012) Cite this as: BMJ 2012;344:e1033
  1. Michael Schachter, senior lecturer in clinical pharmacology1
  1. 1Imperial College London, St Mary’s Hospital, London W2 1NY, UK
  1. m.schachter{at}ic.ac.uk

I don’t know if medieval theologians really did discuss how many angels could dance on the head of a pin, but as someone involved daily in managing hypertension, I believe that much of the debate about treating the condition is in the same category.1 Some points are worth making.

We now have a large repertoire of treatments for hypertension and radically new ones are unlikely in the foreseeable future.

The choice of diuretics is open to endless debate, and head to head trials in thousands of patients over five years are unlikely to be performed. The diuretics now proposed are even more likely to cause hypokalaemia than the thiazides and monitoring for this is mandatory; drugs like co-amilozide are useful in this context.

White coat hypertension is not benign, but we have no evidence based approach for dealing with it. Even if we did have such evidence, patients may not want to follow our advice—many do not share their doctor’s keenness for drugs.

Most patients will ultimately need two or more drugs to reach target blood pressure. The concept of starting treatment with low doses of two drugs is appealing and probably economical.

The demotion of conventional β blockers is probably justified. We don’t have enough data on vasodilator β blockers (carvedilol and nebivolol) to know whether they should be exempt from this and probably never will.

As Voltaire said 300 years ago: “A long dispute means both parties are wrong,” and this is probably the case here. Meanwhile lots of people need treatment, although many may dispute this. We will need to use professional judgment in many cases, before of course that sort of behaviour is banned.


Cite this as: BMJ 2012;344:e1033


  • Competing interests: None declared.